Corrective Action Plans

Reporting Recommendation: We recommend that the Foundation update its policies and procedures to ensure formal documented review and approval over financial and performance reports. Procedures must include documentation and proper sign offs from preparer and reviewer of the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procedures updated to reflect a formal sign off for all electronically submitted reports to prove proper reviews were completed. A sign off email will be included in the files going forward. Name of the contact person responsible for corrective action: Ellen Goury Planned completion date for corrective action plan: 6/30/2024

Finding 2023-001 – Allowable Activities and Costs of Provider Relief Fund Significant Deficiency in Internal Control over Compliance Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Federal Grantor: U.S. Department of Health and Human Services Pass-Through Entity: None Criteria: Per 2 CFR 200.430(i), personnel costs charged to federal grants are required to be supported by documentation including time records. Per 2 CFR 200.303, a non-federal entity must establish and maintain effective internal control over Federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Condition: Our audit procedures over the calculation of COVID patient days used to allocate the payroll cost to the PRF/ARP federal program disclosed the amounts were not properly calculated. Cause: The Medical Center has controls in place to review the calculation; however, the control did not operate to identify an error in the calculation of COVID patient days. Effect: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Questioned Costs: None Perspective: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Medical Center implement additional internal controls over compliance in order to properly identify any errors in calculation. Management’s Action Plan: The Medical Center will implement additional internal controls over compliance. Such controls will include verification of all calculations used by two parties, the Director of Finance and CFO as well as signoff on calculations. Name of Person Responsible for the Plan: Mallory Ginn, CFO Anticipated Completion Date of the Plan: 7/31/2024

Contact Person Responsible for Corrective Action: Abby Doyle, Chief Deputy Auditor Contact Phone Number: (574) 235-9668 ext. 7201 Views of Responsible Official: We concur with the audit finding with respect to the failure of having processes and procedures in place to prohibit from contracting with or making subawards under covered transactions to parties that are suspended and debarred or whose principals are suspended or debarred. Description of Corrective Action Plan: Currently, the County requires all new vendors to complete the attached “Vendor Registration Form”. On page 5 the vendor acknowledges they have not or are currently not suspended and debarred. A new step that Procurement implemented as of July 14, 2023 was verification of vendor’s status on sam.gov and attaching the screenshot to the LOW system. Procurement will update their vendor policy to specifically include this step in 2024. On July 14, 2023, County Attorney issued a statement enforcing the following verbiage to be added to all contracts. Debarment and Suspension 1. Contractor certifies, by entering into this Agreement, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from or ineligible for participation in any Federal assistance program by and Federal department or agency, or by any department, agency, or political subdivision of the State of Indiana. The term “principal” for purposes of the Agreement means an officer, director, owner, partner, key employee, or the person with primary management or supervisory responsibilities, or a person who has a critical influence on or substantive control over the operation of the Contractor. 2. Contractor certifies, by entering into this Agreement, that is does not engage in investment activities in Iran as more particularly described in IC 5-22-16.5. 3. Contractor shall provide immediate written notice to County if, at any time after entering into this Agreement, Contractor learns that its certifications were erroneous when submitted, or Contractor is debarred, suspended, proposed for debarment, declared ineligible, has been included on a list or received notice of intent to include on a list created pursuant to IC 5-22-16.5, voluntarily excluded from or becomes ineligible for participation in any Federal assistance program. Any such event shall be cause for termination of this agreement as provided herein. 4. Contractor shall not subcontract with any party which is debarred or suspended or is otherwise excluded from on ineligible for participation in any Federal assistance programs by any federal department or agency, or by any department, agency or political subdivision of the State of Indiana. Next, the County Attorney provided guidance to all departments to verify vendors prior to engaging in a contract. Below is the verbiage from the County Attorney to staff on July 14, 2023. The state has asked us to verify that the entity we are contracting with is not debarred by visiting the following websites and running a search: https://sam.gov/content/exclusions https://www.in.gov/idoa/procurement/supplier-resource-center/supplier-responsibilities/ Termination for Failure of Funding Notwithstanding any other provision of this Agreement, if funds for the continued fulfillment of this Agreement by County are at any time insufficient or not forthcoming through a failure of any entity to appropriate funds or otherwise, then the County shall have the right to terminate this Agreement without penalty by giving written notice documenting the lack of funding, in which instance this Agreement shall terminate and become null and void on the last day of the fiscal period for which appropriations were received. County agrees to make its best efforts to obtain sufficient funds, including but not limited to, requesting in its budget for each fiscal period during the term hereof sufficient funds to meet its obligations hereunder in full. For public works projects: Compliance With E-Verify Program. Pursuant to IC 22-5-1.7, Consultant shall enroll in and verify the work eligibility status of all newly hired employees of Consultant through the E-Verify Program (“Program”). Consultant is not required to verify the work eligibility status of all newly hired employees through the Program if the Program no longer exists. Consultant and its subcontractors shall not knowingly employ or contract with an unauthorized alien or retain an employee or contract with a person that Consultant or its subcontractor subsequently learns is an unauthorized alien. If Consultant violates this Section, County shall require Consultant to remedy the violation not later than thirty (30) days after County notifies Consultant. If Consultant fails to remedy the violation within the thirty (30) day period, County shall terminate the contract for breach of contract. If County terminates the contract, Consultant shall, in addition to any other contractual remedies, be liable to County for actual damages. There is a rebuttable presumption that Consultant did not knowingly employ an unauthorized alien if Consultant verified the work eligibility status of the employee through the Program. If Consultant employs or contracts with an unauthorized alien but County determines that terminating the contract would be detrimental to the public interest or public property, County may allow the contract to remain in effect until County procures a new contractor. Consultant shall, prior to performing any work, require each subcontractor to certify to Consultant that the subcontractor does not knowingly employ or contract with an unauthorized alien and has enrolled in the Program. Consultant shall maintain on file a certification from each subcontractor throughout the duration of the Project. If Consultant determines that a subcontractor is in violation of this Section, Consultant may terminate its contract with the subcontractor for such violation. Pursuant to IC 22-5-1.7 a fully executed affidavit affirming that the business entity does not knowingly employ an unauthorized alien and confirming Consultant’s enrollment in the Program, unless the Program no longer exists, shall be filed with County prior to the execution of this Agreement. This Agreement shall not be deemed fully executed until such affidavit is filed with the County. Lastly, the Commissioner’s Assistant will check incoming contracts from departments to ensure proper documentation is attached that verifies the vendor has been checked through sam.gov and in.gov. Once the contract has been approved by the Commissioners, the Auditor’s office will then upload the contract and supporting documents onto Gateway. Completion Date: June 24, 2024

Single Audit Finding 2023-003 Federal Agency Name: Program Name: Finding Summary: Responsible Individuals: Status: United States Department of Agriculture Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Corrective Action Plan The Organization did not have an adequate internal control policy in place to ensure the reserve account was separately tracked and a documented review and approval over the reserve fund occurred. Sharlene Knutson, Administrator We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2024

We recommend Arbor Place to implement internal controls over reporting and allowable costs to ensure all financial records are complete and accurate.

In June 2023, following the completion of the 2022 Single Federal Audit, APS immediately implemented additional policies, procedures, and controls to ensure that all subrecipients submit programmatic and financial reports in a timely manner and that these reports are reviewed by the Principal Investigator/Program Manager and Grant Administrator through a new reporting form. This form logs electronic signatures from both the sub-awardee and APS staff. In addition, APS implemented a procedure to review the single federal audit of each sub-awardee annually. APS will review and monitor award amounts and for the required filings annually to ensure that the award amounts are accurate and updated timely to meet all reporting requirements set forth under the Transparency Act. APS implemented the corrective action plan on June 5, 2023. Management's contact responsible for the implementation of the Corrective Action Plan: Name: Jane Hopkins Gould Position: Chief Financial & Operating Officer Telephone number: 301-209-3276

The department concurs with this finding and plans the following: The NH DDS will have written policies and procedures in place that ensure the validity (non-expired) of medical licenses for providers, as well as the suspension & debarment status of providers. Policies will be in place for pre-hire interested parties, as well as more than annual re-reviews. Aside from written policies and procedures, we will develop a spreadsheet to be completed for each individual review done and we will maintain a documents folder to retain electronic proofs in. Proofs will be retained for 6 years. At this time, the Administrator meets with the Professional Relations Officer every two weeks. Discussions and oversight of these policies, procedures, spreadsheet completion and proofs documentation can be done on, before and after these reviews.

(SSA 4513) The department concurs with this finding and plans to work on the following areas to make reviewing and understanding of the reports an easier process: NHDDS will make sure that line 7 on the 4513 report is checked appropriately on all future reporting. NH DDS will update all process directions for all fiscal reporting. For these directions, NH DDS will update all spreadsheets used for reporting purposes, add labels to column headers and link to cells when able for better understanding of our business processes and where amounts are pulled from. NH DDS will keep all backup documentation needed for these directions, to review all current open grant years. NHDDS will create “Mock” documents of each reporting process to help in any further reviews. (SSA 4514) Administrator runs a leave report for a 1-month time frame. Put in alpha order and date order. In an excel spreadsheet, staff are in alpha order. Leave time is added to each individual staff member for a time frame of 3 months (quarterly report). The total for each individual staff member is then populated to a second spread sheet which is broken out by position categories and each position total is then populated to the 4514 report. • On Duty Hours (column A) are the number of days worked in a quarter, times 7.50 hours per day. • Holiday/Leave Hours (column B) are the number of Holidays (7.50 hours per day) during that quarter plus the amount of leave (hours and minutes) per individual staff member during that quarter. • Total Hours (column C) is the amount of column A, plus column B, equals column C. • Total Part-Time Personnel-Is the number of hours the physician worked during that quarter. A report is run in Virtual Time Clock for the quarterly time frame and hours are entered into Part-Time, Medical Consultants (h.) Prior to completing the quarterly report, the excel spread sheet, sheet 2, will be reviewed to ensure cell equations are correct to eliminate formula errors used to calculate quarterly hours. When emailing the Administrator, the quarterly report for signature, the following statement will be in the body of the email to certify cell equations were reviewed prior, to eliminate formula errors: “I certify that I reviewed the SSA-4514 prior to completion, to ensure that cell equations were correct to eliminate formula errors.” Sent to the Administrator for signature then sent off to Region. Sent emails will be saved in an outlook folder for future reference and proofs that reports were sent.

Corrective Action Planned: The identified payments relate to postage expenditures recorded in the Child Support Enforcement Grant. Postage expenditures are controlled in the State's mailing system through mail codes. Agencies send approved postage budgets to the Department of Administrative Services (DAS), who then creates a new mail code or adds additional funding to existing codes in the system. All mail processed through the mailing system is charged to these individual mail codes. A monthly expenditure report from the mailing system is interfaced with NH First, and the DAS uploads a journal entry to the general ledger to record these expenditures. The review and approvals for these postage transactions occur upfront at the agency level, not through a NH First approval workflow. DHHS and DAS will work together to document adequate evidence of this upfront review and approval.

Corrective Action Planned: The Bureau of Employment Supports has undergone significant programmatic changes over the past 3 years. As part of those changes, our Work Verification Plan was updated and submitted for approval on July 8, 2022. It was approved by the Administration of Children and Families on February 9, 2024, making the updates to the NH work verification plan in effect back to July 9, 2022. The audit period in question is from July 1, 2022 to June 30, 2023. Trainings, supports and guidance have taken place throughout that time to correct hour errors such as those identified through this audit. Uploading documents into the e-folder was found to be error prone, therefore, on March 1, 2023, NHEP leadership provided guidance and training on a specific process of indexing and scanning documents to ensure that moving forward the Career Counselors are checking their e-folder’s to ensure that documents are properly uploaded and visible. In addition, a statewide training took place on May 5, 2023, to look in depth at past audit findings, during which, strategies were identified to help alleviate these errors from re-occurring. An additional statewide training also took place on December 15, 2023, which involved discussion around the audit, which was about to begin, including what the general focus of the audit has historically been. As of April 2023, an additional Quality Assurance Specialist was hired to help monitor and support newly hired career counselors in their first year of employment. This additional Specialist has allowed for guidance to be available not only to newly hired staff, but also to seasoned staff throughout the state. The need for an extra layer of training throughout the year for newly hired Career Counselors was identified in the summer of 2023 and the NHEP Leadership Team developed a weekly Quality Assurance meeting. These weekly meetings started August 30, 2023. These meetings provide real time training to review best practices and further career counselors understanding of federal and state policies. The meetings have been successful and are now bi-weekly. As of February 28, 2024, the meetings have been opened to all career counselors throughout the state, not just those under 9 months of employment. The meetings ensure that there is consistent messaging across the state and also provide an opportunity for statewide collaboration between career counselors. Through cursory investigations, we believe that these new supports and processes, have already shown to be effective in improving the accuracy of supporting and recording hours. The last audit yielded 15% discrepancies in hour errors. This audit period had a decrease of 12%, indicating 3% discrepancies in hour errors. NHEP leadership has also been working with the NEW HEIGHTS system to streamline the process of uploading documents to further decrease the potential for errors. A change request form was submitted approximately two years ago. In order to address the audit findings, within the next 90 days, NHEP leadership is holding a statewide mandatory staff training to review the audit process and findings that were identified. During the meeting, in regards to the over reporting hours error, the Leadership Team will reiterate and discuss the importance of uploading documents prior to inputting hours. In regards to the under reporting hours error, the meeting will also include further training about the importance of justification for any differences in hours than what is reported on the activity tracker. Further, that any differences need to be documented in either a sticky note or a RID note. In addition, the Quality Assurance meetings will continue to be held bi-weekly to address issues or trends in the moment. Our continuous transparency will further ensure buy-in from the staff to put systems in place for themselves as well as to increase self-monitoring practices and in turn, decrease errors in the future.

This function (FFATA reporting) has now been designated to our Federal Reporting Group, which will allow for redundancy in personnel. A new policy and procedure, which will include internal controls, will be developed and implemented.

NHED concurs with the finding identified with the expenditures of $3605. The NHED will have the LEA’s submitting for indirect costs after September 30th upload an invoice and back up documentation into GMS. The NHED concurs with the findings identified with expenditures of $5,172. There were in fact some items that were charged outside the period of performance. This happened prior to us receiving the FY22 audit finding and putting in place new controls to prevent. We have since put into place DOE-OBM-33 to ensure payments are being reviewed closely to the period of performance at multiple times. We have also corrected any items charged to the wrong CAN. The NHED concurs with the findings identified with expenditures of $816. We will look into the district returning these funds or other enforcement actions. In addition to the DOE-OBM-033 process, the Division of Learner Support has created and implemented a transfer of funds procedure.

The Office of ESEA Title programs and Covid-19 education programs have established an internal process to sample and test reports compiled to ensure operations are executed as intended. These internal controls include a monthly reporting sign off Excel sheet, certification on each FFATA submission and a secondary certification for accuracy verification, and a division wide process for FFATA filing and verification. Division wide training occurred on October 26, 2023. Due to grant award notification (GAN) changes and development within our grants management system (GMS), the FFATA process has also been developing and shifting; therefore the FFATA process will be revisited annually and updated as needed. A revised procedure for FFATA reporting will be completed prior to additional training being offered. To ensure that processes are being followed, newly hired staff is trained appropriately, and updates to the GAN process are considered within the FFATA process we will hold another training this spring, March 14th, 2024, prior to new subawards being issued.

Corrective Action Planned: The Office of ESEA Title Programs’ accountant identified when the miscalculation first took place in 2021-2022 and made changes to the workbook formula to correctly calculate the LEA allocations. The office administrator and the bureau administrator both thoroughly reviewed the Title I, Part A allocation workbooks and relayed questions, comments and concerns to the accountant, to ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. This three-step review ensures that formulas are executed as required under Title I, Part A legislation. As a part of the corrective action plan, the Office intends to establish internal controls that ensure the three-step review will take place annually prior to awarding allocations to LEAs. Each level of review will be passed forward via email documenting that the allocation review has taken place and allocations are approved, in order of; 1. Accountant, 2. Office Administrator, 3. Bureau Administrator. Once all three reviews are completed and approved via the same email chain, the email will be saved on the department’s common drive for auditing purposes.

BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance exists, and that all documentation used to support the amounts reported on the federal report are properly maintained. Condition A has been completed. In January 2024, BEA evaluated internal controls related to the review and approval of expenditures. The following additional reconciliation step was added to the processes of preparation of expenditure draws and reporting preparation: • Broadband program Accountant II performs a data extract from NHFirst and reconciles the drawdown calculation totals as well as “dashboard” reporting totals to the NHFirst data extract to confirm accuracy of all data points. This second data validation step has been added to ensure all expenditures recorded in NHFirst are evaluated against program guidelines, submitted for reimbursement and included on required reports. Condition B & C to be completed no later than 12/31/2024.

Corrective Action Planned (Condition A): The DAS analyzed the six items erroneously reported as subawards and noted the errors were isolated to two specific agencies, the Department of Health and Human Services and the Department of Environmental Services. In response to the prior year finding 2022-002, the DAS had strengthened internal controls related to the review and validation of amounts reported by individual state agencies as pass through expenditures. This included an additional control specifically verifying SLFRF pass through expenditures reported by each agency. The DAS will offer additional training relative to identification and reporting of subaward expenditures in its annual statewide Single Audit training and re-evaluate the precision of execution of controls over the validation of pass through reporting in assembling the SEFA for fiscal year 2024. Corrective Action Planned (Conditions B through E): The State largely concurs with the findings and recommendations and has implemented procedures to address the identified conditions already or will do so. With regards to condition B, The State will work with the individual agencies to ensure that individual agencies entering into such agreements clearly indicate the terms required by Uniform Guidance, including permitted indirect cost rates and whether the award is for R&D. The State has already begun this corrective action plan with the agencies. With regards to condition C, for a. and b. for payments by agencies, there are standard procedures for review and authorization of invoices and payments and those payments are documented. For c. The State has already implemented an agency wide framework for subrecipient monitoring. The State will provide re-training for those agencies that had not properly documented monitoring as outlined by the subrecipient risk assessments and ensure monitoring reports are documented. With regards to condition D, The State has already implemented an agency wide framework to help ensure policies and procedures are in place concerning Uniform Guidance Reports. We will work those agencies that had not documented the date received and the review of the Uniform Guidance Reports to ensure written documentation occurs. Where findings have been reported in the Uniform Guidance Report, ensure timely Management Letters are documented and provided with the summary review of Uniform Guidance Report.

Corrective Action Planned (Condition A): The DAS would note the definition of a subaward per 2 CFR 200.1 specifies a subaward may be provided through any form of legal agreement, including an agreement that the pass-through entity considers a contract. State procurement policies require contracts, including contracts deemed subawards, greater than $10,000 are subject to legislative and executive branch approval prior to final execution. The resulting contracts are managed within the State’s financial system using purchase orders which in turn encumber funds. To support the testing of procurements, the State provided a detailed listing of purchase orders initiated during the audit period and in doing so clearly expressed the resulting population would include contracts considered subawards. Accordingly, the State deems the portion of selections identified as subawards to be reasonable and appropriate given the population sampled. However, the DAS will re-evaluate the precision of execution of controls over the validation of the subrecipient population in fiscal year 2024. Corrective Action Planned (Condition B): The State concurs with the findings and recommendations and has implemented procedures to address the identified conditions already or will do so. With regards to condition B, The State will work with the individual agencies to ensure that individual agencies maintain and document the search of SAM.gov for suspension and debarment.

In order to meet the segregation of duties, the Department will explore the need to create a position to ensure requisite segregation of duties requirements. With regard to the segregation of duties, the SF-270 is required form that DMAVS submits to the National Guard Appendix Program Manager for reimbursement with all back up documentation. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense on behalf of DMAVS to request the cash draw. Prior to the submission of reimbursement of any funds, each billing and invoice is reviewed, entered into a ledger and reconciled by three members of the accounting team. Once reconciled, the SF-270 is prepared and signed by the Financial Administrator. The SF-270 is then submitted to the appendix program manager for concurrence and then to the federal fiscal agent (USPFO) for approval. No funds are drawn down until approved by the USPFO. If this is not a satisfactory level of review, the department will request a new position to ensure that there the business function has the proper level of staffing to meet the requirements for segregation of duties.

For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all transactions that reconciles every month to NH First Detail Transaction Register (DTR), Federal Fund tracking sheet, and Federal reimbursement tracking sheet with backup documents. The tracking sheet for the federal register is not intended to account for the state share of billing. The state share is accurately accounted for in the DTR, the cumulative accounting in the SF-270 and associated back up documentation. Supporting documentation to substantiate the accuracy of lines a, c, e, and f is in the DTR, the cumulative accounting of each SF-270, the supporting documentation sent with the billing to the Federal Government, and Year-end Agency Report for Federal Awards. This includes reconciliation and analysis of SADB expenditures and revenues to the Statement of Appropriations by each Program Accounting Unit. The SF-270 form is continuous cumulative data that starts Oct 1st and runs through the end of that Federal Fiscal Year. The SF-270 is the required federal form DMAVS submits to the Federal National Guard Appendix Program Manager for reimbursement. Back up documentation is submitted with the SF-270. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense to affect the cash draw. DMAVS does not unilaterally make cash draws to the federal government. The USPFO, who is substantially involved provides an independent review and reconciles any discrepancies prior to approving any requests for reimbursement. One possible explanation for the finding is that the selected test works were not continuous.

2023-006 – Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Finding Summary: Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control over Compliance Corrective Action Plan: The City’s Purchasing Department has taken two steps to address this finding. First, the Purchasing Manager is currently checking for debarment and suspension prior to contract issuance. Second, the city’s standard contract is being revised to include language that requires contractors to affirm that they are not debarred or suspended. Responsible Individual(s): Lincoln Bogard, Administrative Services Director; A’ja Wallace, Deputy Finance Director; and Barbara Mason, Purchasing Manager Anticipated Completion Date: December 2024

Finding 2023-002 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: BHD, LLC calculated their indirect cost rate based on the total grant budget and took an equal amount of that per month instead of calculating the indirect cost rate percentage of direct expenditures for each month. Responsible Individuals: Kim Ashby, Vice President of Finance Corrective Action Plan: Indirect costs for some grants were allocated based on a percentage of the grant budget. Management has changed the policy for allocation of indirect costs for all grants to require allocation based on a percentage of actual grant expenditures. Anticipated Completion Date: August 1, 2024

Finding 2023-001 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Pass-Through Grantor: Not applicable Pass-Through Award Number: Not applicable Pass-Through Award Period: 1/1/2020-12/31/2023 (Periods 5 and 6) Summary of Finding: The “Total Lost Revenues for the Period of Availability (January 1, 2020 to June 30, 2023)” line in the HRSA PRF portal for Spectrum Health System (the Parent), TIN 383382353, General Distribution HRSA PRF report in Reporting Period 5 was $108,697,843. The correct amount of lost revenue reported for Period 5 should have been $107,045,743. The difference represents a $1.6M error in adjusting for targeted funds to determine the Parent lost revenue for period 5. Corrective Action Plan: No further lost revenue reporting is required on the HRSA PRF Portal. Management will implement more robust internal controls in preparation for similar future filings. Individuals responsible for corrective action: Cindy Brink, Director, System Accounting and Reporting Timing of corrective action: July 1, 2024 and going forward.

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Rhonda Casey, Business Manager Corrective Action: The Millinocket School Department will take the following actions to address finding2023-001: The School Department will ensure that each employee’s classification is identified in his/her Letter of Contract and that each contract appropriately outlines job duties and responsibilities as they pertain to each funding source. Additionally, the School Department will revise times sheets to reflect hours worked under each funding source. Anticipated Completion Date: July 1, 2024

In regards to COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) - Assistance Listing No. 21.027; Grant period - Year ended December 31, 2023 the District will put measures in place to ensure that only costs compliant with the proper period of performance are charged to the grant. The anticipated completion date of these actions is April 18th, 2024 with Jeff Peeples the responsbile person for implementation

In regards to COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) - Assistance Listing No. 21.027; Grant period - Year ended December 31, 2023 the District will put measures in place to ensure that applicable vendors are checked for suspension or debarment. The anticipated completion date of these actions is April 8th, 2024 with Clint Harbison the responsible persion for implementation.