Corrective Action Plans

May 3, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports and timekeeping records to Wade Stables P.C for review. We did not have the grant in our financial software as we were beginning a migration to new software during the early stages of the grant; therefore, we tracked that grant on an excel spreadsheet that annually was provided to our auditors. Most of the staff assigned to the grant were full-time staff, so time allocation was easily tracked. For the few staff that were part-time we had designated codes in our Electronic Medical Record to identify work done on behalf of the grant. In response to Finding 2022-001- B Allowable Costs, we agree with the Statement of Cause citing the exponential growth of the organization regarding preparedness for a first-time grant award of this size being our largest challenge. Initially we were informed we had not received the grant then, due to additional COVID funding, we were invited to participate in the grant with a very short turnaround to finalize budgets and hire staff. Our salaries are consistent with the positions designated in the grant and in a few cases our staff salaries exceeded the allowable costs; therefore, those allowable costs were used to calculate the drawdown. MTBH did not have an established de minimis rate; therefore, we used the 10% designated rate associated with the grant. The interactive Budget Narrative Form template, required per SAMHSA guidelines, had 10% built into the template. If afforded future opportunities to secure a SAMSHA grant, we would be better positioned to execute the financial management in our SAGE software to segregate costs for the purpose of tracking the expenditures associated agency grant operations. Currently all agency expenditures have transferred into SAGE by our Vice President of Finance, Jenny Haught MBA, which would also be the Responsible Official to fiscally manage future grants. Respectfully, Angela Caraway, VP of Clinical Operations

Action Item Title 2022-002 – Financial Management and Internal Controls Compliance Requirement Allowable Costs/Cost Principles Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining the activities allowed or unallowed and the allowability of costs as described in subpart E, Cost Principles of 2 CFR Part 200. Identified root cause It is the first year for the Corporation to be subjected to a single audit compliance requirement. However, since the Commonwealth of Puerto Rico (the Commonwealth) filed for Title III under the PROMESA, all the instrumentalities of the Commonwealth had to reduce their staff as part of the Fiscal Plan to reduce expenditures. This has disrupted the segregation of duties, which is a key control. Grantee resolution plan Written Policies The Corporation received federal funds for the first time in 2022. For the purposes of purchases or acquisitions, the Corporation is governed by Law of the General Service Administration for the Centralization of Government Purchases in Puerto Rico, Law No. 73 of 2019, which establishes the uniform purchasing process for acquisitions by the Commonwealth. The Corporation will adopt regulations for the use and disbursement of federal funds and comply with the federal regulations. Completion Date Written Policies By June 30, 2025 Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov

Management Response #2022-009: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: The following action plans have since been implemented: • During the fourth quarter in 2022, finance team delineated and expanded positions whose primary responsibility is to monitor and manage all grant activities. • During the fourth quarter in 2022 a new process was implemented to track grant related activities. Prior to any drawdown, the expenses are pulled from the G/L and reviewed. The expenses are entered into a spreadsheet and totaled based on the applicable federal award which has been assigned a client ID in the accounting system. The finance team is notified of the amount due to be drawn for each federal award. That amount is entered into the accounting system as an accounts receivable entry. This process has been formally documented. • Project Budget Reports have been created for each federal award. These reports include the budget, expenses for each month and the revenue (drawdown) incurred for each month. The reports will be reviewed and reconciled by the grants administration staff and finance monthly to ensure all agree with the allocated costs and costs and are in compliance with grant regulations. Once approved by both teams the reports will be routed for signatures. This process was launched in July 2022. • Supporting documentation for all draws will be maintained on a shared network drive so that an adequate audit trail will be established. This drive will be backed up on a regular basis by the Information Technology team. Responsible Party: Tamara Barnes, CFO

CONDITION: During my sample review of the District’s completion of its federal grant program ‘Quarterly Cash On Hand Reconciliations’ for the 2021-2022 4th fiscal quarter for the ESSER II and ARP ESSER grants, I noted that the amounts reported to date for ‘total disbursements’ could not be ascertained from the coding of these expenditures in the District’s general ledger (See Finding 2022-005) and did not reconcile to the separate spreadsheets maintained by the School District. This is a repeat finding (2021-006) from the previous fiscal year. CRITERIA: Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance, to allow for the proper completion of the ‘quarterly cash on hand reconciliations’. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to effectively access the necessary federal expenditure totals, by individual grant program, to document and support amounts reported as ‘total cash disbursed’ on the quarterly cash on hand reconciliations. This procedure will enable the District to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations. This is a repeat finding (2021-005) from the previous fiscal year. CRITERIA: The Pennsylvania Department of Education (PDE), through the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts requires School Districts to utilize specific funding source codes for federal program expenditures. In addition, Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to 1) enhance internal controls for tracking and monitoring federal program expenditures and 2) comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to enhance its internal controls for tracking and monitoring federal program expenditures and to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN March 11, 2024 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2022-001 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2022-001 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will review the accounting and financial procedures, system of internal controls and policies. If HUD has questions regarding this corrective action plan, please call (803) 873-2377. Sincerely yours, Dwayne Legrant President Omni Property Management and Development Managing Agent

FINDING # 2022-018No finding in prior yearThe DCA staff responsible for the LIHEAP cash management function retired prior to this audit period without a proper transition of these tasks and there was also a delay in refilling the position. As recommended, the DCA has reviewed current procedures and controls regarding cash drawdown approvals and has developed a Policy Memo that details the Payment Management System (PMS) drawdown procedures going forward. For each request made, a Contract Administrator will produce a Business Object report for all transactions to be included in the drawdown and will send the report to the Program staff for review and approval that the amounts contained in the report are correct. Once the Program staff review is complete, the approved Business Object report will be forwarded with a cover email to the Division Fiscal Unit staff responsible for drawing down the funds in PMS for final processing.COMPLETION DATE/CONTACT PERSON March 27, 2023Fidel Ekhelar(609) 815-3905Fidel.Ekhelar@dca.nj.gov

GRYC acknowledges and agrees with the finding and is in process of reviewing and analyzing allcontracts and amendments to ensure that the SEFA includes all federally awarded programs. GRYCwill start implementing this recommendation during the year ended June 30, 2023, and plans to filethe 2023 Uniform Guidance report timely.

FINDING 2022-005Contact Person Responsible for Corrective Action: Lynn Leininger, Business ManagerContact Phone Number: (260) 367-3677Whitko Community Schools concurs with the finding and will implement internal controls for all grantrequirements and reporting compliances of the Education Stabilization Funds. All reporting will be a jointeffort between the Business Manager preparing the reports with the assistance of the business officepersonnel. Supporting paperwork and calculations will be maintained to support all report informationsubmitted. Prior to submission of Education Stabilization Funds, all information will be reviewed andsigned by the Deputy Treasurer to insure reporting compliance.The completion date for this corrective action will be May1, 2023.INDIANA STATE

Finding Number: 2022-002Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 fiscal yearwhich resulted in several vacancies, including the Director of Finance position, for a significant portion ofthe year. As a result, many of the reports that are standard practice in our organization were not beingcompleted. In addition, the filing of certain documentation to support expenditures was not being doneconsistently. The Director of Finance position was filled in the fall of 2022. As a result, documentationof allowable expenditures is being addressed for the fiscal 2023 audit.In addition to turnover, the organization transitioned to a new general ledger system with a new chartof accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certaindata pertaining to the federal programs was not being captured. Management has informed all staff ofthe requirements to track federal programs within the general ledger accounts.Anticipated Completion Date: June 30, 2023Responsible Contact Person: Erica Tkachyk, Director of Finance

FINDING 2022-005Contact Person Responsible for Corrective Action: William LutherContact Phone Number: (812) 330-7700Views of Responsible Official: We concur with this finding. This finding has been remediated as of the completion dateshown below.Description of Corrective Action Plan:All Education Stabilization Funds applicable to the reporting in this finding have been expended as of the completion datebelow. We will continue to submit all future Education Stabilization Funds annual reports with evidence to support thesubmission.Completion Date: September 30, 2022

FINDING 2022-010Subject: COVID -19 - Education Stabilization Funding - ReportingFederal Agency: Department of EducationFederal Program: Education Stabilization FundAssistance Listings Numbers: 84.425D, 84.425UFederal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425D210013,S425U200013Pass-Through Entity: Indiana Department of EducationCompliance Requirement: ReportingAudit Findings: Material Weakness, Modified OpinionContact Person Responsible for Corrective Action: Chad Yencer, SuperintendentContact Phone Number: 76+5-348-7550Views of Responsible Official: We concur with this findingDescription of Corrective Action Plan:Internal Control:1. The grants specialist/data specialist will compile the information for state reporting in the ESSER grants.The grants specialist will maintain documentation to support the data being presented.2. The corporation treasure will review all compiled financial data for the reporting period and verify it foraccuracy prior to submitting to the superintendent.3. The Superintendent will review the information, supporting documentation and verify accuracy prior tosubmitting to the IDOE reporting.Anticipated Completion Date: July 2023

FINDING 2022-002Contact Person Responsible for Corrective Action: Allison Pund and Melissa BoeglinContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ensurereporting compliance requirements are met. The corporation will assure one individual is completing the reports andanother is verify the reports.Anticipated Date of Completion: March 2023

Finding Number: 2022-001Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryU.S. Department of EducationFederal Program: COVID-19 -Coronavirus State and Local Fiscal Recovery FundsCOVID-19 - Education Stabilization FundSupporting Effective Instruction State Grants (formerlyImproving Teacher Quality State Grants)Assistance Listing: 21.019, 84.425C and DPass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:211838-01 (3/3/21 ? 12/31/24) 211815-01 (3/3/21 ? 12/31/24)211875-01 (3/3/21 ? 12/31/24) 201873-01 (3/13/20 ? 9/30/22)201787-01 (3/13/20 ? 9/30/22) 202233-01 (3/13/20 ? 9/30/22)191360-01 (7/1/18 ? 9/30/21) 201067-01 (7/1/19 ? 9/30/21)210781-01 (7/1/20 ? 6/30/22) 221052-01 (7/1/21 ? 6/30/23)Compliance Requirement: ReportingType of Finding Significant Deficiency in Internal Control over Compliance, OtherMattersRecommendation:We recommend that the Board review its policies and procedures to ensure that ReimbursementRequests and the detail & accompanying reconciliations used to prepare it are retained for auditpurposes.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding. Action taken in response to finding: Procedures to ensure that the documentation to supportthe monthly submission of the Financial Status Report have been modified accordingly.Name(s) of the contact person(s) responsible for corrective action: BCPS grant accountants;Accounting Manager.Planned completion date for corrective action plan: For immediate implementation andongoing.

MANAGEMENT WILL WORK WITH THEIR CONSULTANT AND DEVELOP WRITTEN POLICIES AND PROCEDURES OVER THEIR FEDERAL AWARDS IN ACCORDANCE WITH THE REQUIREMENTS OF THE UNIFORM GUIDANCE.

Corrective Action Plan: After monthly reconciliations, financial statements will be delivered to AJAC Directors monthly. AJAC Accounting Department will hold monthly close calls to collaborate with AJAC Directors to ensure accuracy of financials. Anticipated Completion Date: Completed

Corrective Action Plan: After monthly reconciliations, AJAC Directors will review all appropriate reimbursable direct expenses related to each grant or contract agreement. After an expense has been included on a reimbursable request, the transaction will be marked appropriately in the accounting software to ensure that transactions are submitted for reimbursement correctly. All necessary reclasses will be performed in the accounting software to match the reimbursement request (invoice). Anticipated Completion Date: Completed

Corrective Action Plan: After monthly reconciliations, AJAC Directors will identify all appropriate indirect expenses specific to each grant or contract agreement and request reimbursement for actual indirect expenses up to the 10% de minimis rate. All items identified as being reimbursable to a specific grant or contract will be reclassed in the accounting software to match the reimbursement request (invoice). Anticipated Completion Date: 09/01/2024

Corrective Action Plan: AJAC Directors will develop and implement policies and procedures for appropriate methods of calculation that ensure benefit allocations are aligned with wage allocations at an employee level. Invoicing will reflect actual benefit expenses up to a predetermined amount or percentage that is unique to each individual grant or contract agreement. Anticipated Completion Date: Completed

Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.

During 2022, there was a change in accounting staff which led to difficulty in tracking and preparing the SEFA. Once management became aware of the issues, changes have been made to internal processes to allow for proper SEFA tracking moving forward.

The County has identified federal grants subject to the Uniform Guidance and will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.

The University concurs with the finding. As a result of this finding, the University created a new fund code within their general ledger chart of accounts for the purpose of classifying these funds as federal funds. The University performed the appropriate reclassifying journal entries within their general ledger utilizing the newly created fund code to recognize the $138,700 as federal revenue and expenditures.

Significant Deficiency in Internal Control over Compliance and Compliance Recommendation: CLA recommends that The Organization move away from using a cumulative profit and loss report and instead run monthly general ledger details by program as support for their monthly reimbursement requests. This will enhance clarity of costs attributable to each monthly period and reduces the chance that costs will be missed when requesting for reimbursement. Any reconciling transactions can be clearly tracked an Excel file of the general ledger detail by program. In addition, CLA recommends that The Organization emphasize to program management staff the importance of filing reimbursement requests each month and in a timely manner to reduce administrative and financial burden. There is no disagreement with the audit finding. Action taken in response to finding: The organization has modified our approach to making monthly reimbursement requests by including monthly general ledger details by program to ensure we have appropriate support and to increase clarity of costs attributable by month. Since fall/winter 2023, we have increased training to financial and program management staff around the importance of filing reimbursement request in a timely manner and we intend to increase the size of the financial support staff to further help minimize timely delays in reimbursement requests. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 4/1/2024

Epidemiology and Laboratory Capacity for Infectious Diseases Cash Management Significant Deficiency in Internal Control over Compliance For the audited period and until August 2023, the procedure of the program and the Department of Health was "advanced" and was as follows: 1. The Epidemiology program worked with the validation of the voucher and recovered the director's signature for the punch of the "certificate". Once the validation and signature were in place, the cash request was processed. Once the cash request was remitted or the credit notice was registered, the receipt was delivered to the Tax Intervention area. 2. The Fiscal Intervention area works on the approval of the payment on the vouchers. Vouchers were worked on a first-come, first-served basis. This intervention process can take a week or more. The program had no control over the timing of payment approvals. This created a weakness when it came to cash management compliance. The program did confirm that the money was available at the time the payment was approved but had no control over the date the payment was approved. However, due to the nature of our funds and the volume of invoices, the Treasury Department asked us to change the modality for terms of cash requests from "advanced" to reimbursement. This began to be implemented as of September 2023. This method of reimbursement makes it easier for the program to have better control over cash management. With this method, the program requests the funds on the days that the Treasury Department makes the payment rolls. Once the petition is created on the same day of the print run and approved by the Program Director, it is submitted to the Office of Federal Affairs to prepare the request for funds to the federal government. The Office of Federal Affairs has the flexibility and agility to process such a request within two days. This helps us to meet the requirements of cash management.