Corrective Action Plans

Lack of Internal Control over Reporting and Noncompliance Name of Contact: W. Scott Pegau Corrective Action Plan: A new section on contracts was added to our accounting manual that describes the steps to be taken when a new contract is established. It identifies the need for the FFATA reporting. A second procedure outlines how to complete the required reporting. All existing subcontracts over $30,000 were reported as required. Proposed completion date: December 15, 2023.

Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.

Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,030. The Hospital reported lost revenues amounting to $999,172 on distributions totaling $1,177,041. The Hospital had excess lost revenues from previous periods available to be used through June 30, 2023 amounting to $5,406,884. The Hospital also reported expenses of $907,051. Corrective Action Plan Corrective Action Planned: The Hospital will undertake a review of its internal control policies and procedures surrounding the reporting on federal grant activities and add additional layers of review where necessary to ensure future reporting is accurate. Name of Contact Person Responsible for Corrective Action: Kelli Kane, Chief Financial Officer Anticipated Completion Date: April 15, 2024

Assistance Listings number and program name: 21.027 COVID-19 Corona Virus State and Local Fiscal Recovery Fund Contact: Maryn Belling Anticipated completion date: June 30, 2024 Corrective Action Plan: The County will develop, implement, and maintain procedures requiring both the performance & documentation of independent review and approval of all federal program reports prior to submitting them to the federal agency to ensure the reports are accurate, agree to County records, and contain only allowable expenditures. Program expenditures will be reconciled to the County’s accounting records. The County’s previous corrective action plan stated “Errors identified will be reported to the federal agency in adjusted or resubmitted reports” however the Federal Reporting interface lacks capacity for resubmitted reports. The adjusted reports resulted in the understatement and overstatement amounts noted in Federal Award Finding 2023-101. Departmental training will be provided for staff responsible for preparing and reviewing reports for both data management, compliance with Uniform Guidance, 2 Code of Federal Regulations (CFR) §200.510, and adherence to County’s policies and procedures.

Condition: We identified one instance where a student’s program enrollment effective date did not match the institution’s records. Recommendation: We recommend that the College enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The College will review enrollment reporting procedures to determine where additional review of data and monitoring of third-party servicer data can be implemented to ensure accurate reporting. Name(s) of the contract person(s) responsible for corrective action: Chris Peterson – Director of Student Financial Aid, Stacy Sharp – Director of Registration and Records, and Laura Beyers – Director of Registration and Records Planned completion date for corrective action plan: June 30, 2024

Ballad Health will utilize technology efficiencies within upgraded accounting system to supplement reporting. Additionally, a resource will be added directly responsible for grant accounting. The SEFA will also be reviewed frequently to ensure accuracy.

Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Mortgage Insurance Rental Housing Federal Financial Assistance Listing: #14.134 Finding Summary: There was one vendor with expenditures in excess of $25,000 and the Project did not verify the vendor against the central contractor registry prior to entering into the transaction or on a periodic basis to ensure that the vendor was not suspended or debarred. Prior to adoption of a procurement policy, management entered into a transaction over the micropurchase threshold with a vendor and documentation was unable to be provided to support procurement compliance for the vendor. Responsible Individuals: Sue Lund, Administrator Corrective Action Plan: During May 2023, the Project adopted a written procurement policy which conforms to the Uniform Guidance and the policy has been followed during the year informally and formally upon adoption. The Project reviewed the vendor against the central contractor registry during 2024 and noted the vendor was not suspended or disbarred. Sunnycrest Village individuals leading procurements will be given instructions on procurement policy. Bidding form used will incorporate a reminder that for expenditures in excess of $25,000, it requires to verify the vendor against the central registry prior to entering into the transaction. Anticipated Completion Date: May 31, 2024

Finding 2023-003 –Special Education Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Nathaniel Day and Robin LeClaire Contact Phone Number: 317-462-4434 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will complete semi-annual certifications. We will also document more fully formal secondary review of vouchers Anticipated Completion Date: Already completed for the 2023-24 audit year

Program: COVID-19 Aging Cluster Assistance Listing No.: 93.041, 93.042, 93.043, 93.044, 93.045, 93.052, 93.053 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Aging Award No. and Year: Various Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance and Instance of Non- Compliance Department’s Management Response: The Area Agency on Aging (AAA) management agrees that all required award information needs to be communicated to subrecipients at the time of the subaward and a subrecipient’s risk assessment needs to be completed and documented in accordance with 2 CFR section 200. View of Responsible Officials and Corrective Action: Beginning July 1, 2023, AAA merged with Human Services Agency (HSA). Administrative and fiscal functions have been integrated into HSA's administrative and fiscal management. The fiscal team has been working with AAA management to identify and address internal control and non-compliance issues, implementing procedures and policies to improve operational efficiency and internal controls. Risk assessment of subrecipients was performed in December 2023 to determine the level of monitoring needed. Federal award identification number (FAIN) will be provided to subrecipients, and the unique entity identifier (UEI) will be obtained from subrecipients by March 31, 2024. Once monitoring is complete, a monitoring report will be issued, any findings with be communicated with subrecipients. In the future, the FAIN and subrecipient’s UEI will be included in contract agreements. Name of Responsible Persons: Bernadette Heredia, Accounting Manager II Helina Wu, Chief Financial Officer, Human Services Agency Implementation Date: December 1, 2023, related to documenting risk assessments March 31, 2024, related to providing require award information to the subrecipient

These initial Pell overpayments were incurred in the “early” Pell disbursements that occurred a week before the semester started and the first two weeks of the semester. The enrollment was reported correctly, but part of the issue was the current FA system (SAM) was not programmed to adjust the amount disbursed based on the student’s current enrollment at the time of disbursement. For the Spring 2024 semester, testing will be done on SAM to disburse aid based on current enrollment for the early disbursements. If successful, this change will reduce the amount in overpayments if students drop below ½ time for the semester, or withdraw completely. In addition, the Financial Aid Office is transitioning from the SAM to the Colleague Financial Aid System (starting in 2024-25). Colleague is already programmed to disburse aid based on current enrollment status, so this will not be a recurring issue in the future. Early Disbursement and Overpayment Notes: • The 1st early Pell disbursement is based on 25% of a student’s semester award based on full-time enrollment. If a student is currently enrolled ½-time or higher when this disbursement is processed, they will receive the 25% award amount. If a student is enrolled in less than ½-time status (.5 units to 5.5 units), they will receive a $500 Pell disbursement to account for the lower semester Pell grant award for less than ½-time students. • We understand students add/drop courses through the first two weeks of the semester. The final Pell grant award for the semester is adjusted to the student’s enrollment status on Census day. Students who are ½-time or higher at Census will not be a Pell overpayment for the semester since their Pell grant award will be at 50% or higher. • For students who were enrolled at ½-time or higher at the time the early disbursement was processed, but then dropped to less than ½-time or withdrew completely by Census day, they will be considered a Pell overpayment. o These types of overpayments are unavoidable. However, we will work on minimizing the dollar amount of these types of overpayments with the actions stated above. We will test the current FA system (SAM) to disburse the early disbursements based on current enrollment status before Census and monitor closely. o Example: Currently, if a student is scheduled a $500 disbursement for the early 25% disbursement, and is enrolled ½ time, they will receive $500. With the change to actual enrollment (1/2 time for this case), the student will receive $250 instead of $500. If the student drops below ½-time or withdraws completely by census, the highest overpayment amount will be $250 instead of $500.

When the Transportation and Public Works Department (TPWD) receives certified payroll from the contractor, the project manager writes the contract number and sends this to the Department of Finance (Finance). The problem with this method is the project manager never receives confirmation from Finance about receiving these documents and storage of these documents are unknown. To correct this problem, TPWD plans to have the project manager send an email to the receiver in Finance indicating that TPWD has sent it and then have the receiver send an email back once they receive the certified payroll documents. Responsible Party: Gregory Mariscal Supervising Engineer Transportation and Public Works Department Anticipated Implementation Date: April 1, 2024

The City has studied its existing procedures and Information Technology (IT) resources in relation to the three noted exceptions. We have identified how the City’s procedures for inspectors lead to the exceptions and the conditions that allowed for the documentation and evidence of resolved inspection failures to be insufficient: • Since 2017, the City has served as a demonstration agency for what is now HUD’s final National Standards for the Physical Inspection of Real Estate (NSPIRE). The purpose of the demonstration was to conduct Housing Quality Standards (HQS) inspections and inspections under the test protocol simultaneously, with some inspectors using HQS and some inspectors using the test standards. The test standards were conducted using electronic devices so the inspection results could be communicated to HUD, and the HQS inspections continued to be documented using HUD Form 52580. • Utilizing two methodologies for inspection documentation over a time span of greater than five years lead to inconsistent training of new staff, and inconsistent methods and expectations for documenting failed inspection results and follow up. • This condition was exacerbated in Calendar Year 2021 and 2022 when the City began the “catch-up” inspections required by HUD after the COVID-19 inspection waivers. To resolve these issues and correct the conditions going forward, the City will: • Design and implement an inspection application (app) to be used on the inspectors’ mobile devices. The app will be based on HUD’s new NSPIRE Inspection Tool and Checklist. This document has not been assigned a HUD Form number, but is available for review on HUD’s NSPIRE website. The app will be functional on mobile devices even when there is no cellular signal or WiFi connectivity by storing the data, which will be downloaded by the inspector. • The app will include the following features to ensure that documentation is completed properly and timely: - An electronic signature will be required for all inspections, regardless of whether the inspection passed or failed. - An auto-generated summary report of the day’s failed inspections will be emailed to the Supervisors and to the inspector who completed the failed inspection. The report will include the family and owner name, the unit address, identification of the failed items, to whom the responsibility for resolving the failed item is assigned (either family or owner), and the deadline by which the failed items must be resolved. - An auto-generated letter to the family and owner will be mailed and/or emailed within 2 business days of the completed inspection. The letter will include the family and owner name, the unit address, identification of the failed items, to whom the responsibility for resolving the failed item is assigned (either family or owner), the deadline by which the failed items must be resolved, and the potential date of termination if the failed inspection is not resolved. This letter will replace the Failed Inspection Memo which is currently being used by the City to communicate inspection failures. - The app will send email notifications to the Supervisors and inspector beginning 10 days in advance of the repair deadline reminding them that the inspection has not been resolved. - The inspector will use the app to document the resolution of the inspection by indicating what evidence the inspector used to demonstrate the repaired/resolved item. - The inspector will use the app to assign an extension of the deadline when necessary and appropriate. - If a failed inspection has not passed by the deadline or extension, the app will alert the inspector and Supervisor to either document the resolved inspection items or begin the termination process. The City believes that automating these aspects of the failed inspection procedures will prevent the conditions noted in the audit findings by streamlining documentation for the inspectors, alerting supervisors of failed inspections, and providing a consolidated report across all inspectors that can be reviewed regularly. The City has already started the inspection app design process with the IT department, capitalizing and expanding on an existing app that inspectors use for scheduling inspections. When the inspection app is ready to test, the lead inspector, Sylvia Coombs, will begin using it immediately and communicate any feedback to Elizabeth Durham, Rebecca Lane and the IT department. The City anticipates the app will be ready for testing by March 31, 2024. When the app has been tested and refined, Sylvia Coombs and Elizabeth Durham will train the staff in its use and communicate the requirement and expectation that the app is replacing the paper HUD Form 52580 and the Failed Inspection Memo. This change will be implemented by April 30, 2024. Elizabeth Durham and Rebecca Lane will be responsible for monitoring the results of these changes. Responsible Party: Elizabeth Durham Acting Manager Housing and Community Services Department Rebecca Lane Program Specialist Housing and Community Services Department Anticipated Implementation Date: April 30, 2024

Finding 2023-003: Lack of Review Procedures of Cash Management for Grants Finding: NCBHS management stated that cash reimbursement requests were reviewed prior to submission to the grantor, but there was no verifiable evidence that the reviews took place. Corrective Actions Taken or Planned: The issue related to the monthly reimbursement requests for the DMH grants not being reviewed and approved by the CEO before they are sent to the State of Illinois. All reimbursement requests for both the State of Illinois and federal grants will be reviewed and approved by the CEO before they are sent to the appropriate parties for payment. Name of person responsible for corrective action: Diane Garland, CFO/VP of Finance Anticipated completion date: March 1, 2024

Management Response and Planned Corrective Action On occasion, given holidays, vacations, meeting schedules, etc., and the tight payroll submission timeline, it can happen that a timecard may be verbally approved but not signed and scanned when submitted for payroll processing and recording in the GL. Given the growth of the agency and the capacity of our administrative and accounting teams, we are in the process of transitioning to an online timecard process with a more robust payroll processing company. This should eliminate all timecard manual signature approval issues. This will be implemented by June 30, 2024. Views of Responsible Officials and Corrective Actions Management of NBCC agrees with the finding noted above, and will implement proper internal controls to correct the issue noted. Contact Information for Responsible Officials Kristine Schwarz, Executive Director, 805-963-7777

Finding 2023-002: Special Tests and Provisions: Enrollment Reporting Context/Condition: Of the 40 students selected for enrollment reporting testing, six (6) students within the sample were reported to NSLDS outside the maximum 60-day window and two (2) students within the sample were not reported to NSLDS. Recommendation: The auditor recommended that the College review and update internal controls to ensure student enrollment status in the National Student Loan Data System (NSLDS) is updated in a timely manner to ensure compliance with Federal requirements. Persons Responsible for Corrective Action: Registrar Janet Rodning Planned Corrective Action: Monthly the Registrar will audit a sample of students reported to the NSC to ensure that reporting happens within the 60-day window and will audit students’ conferrals to ensure that correct reporting is made to NSC and NSLDS. Additionally, internal control procedures will be updated to ensure timely updating of student enrollment status. Anticipated Completion Date: June 30, 2024.

First, although all purchasers are required to complete training on purchasing and payment policies prior to obtaining system access, a refresher policy training will be provided to the 13 departments in which exceptions were discovered along with a reminder communication to all the approximately 4,300 department purchasers. This will be completed by June 30, 2024. Second, for certain types of purchases such as those involving intellectual property rights, suppliers may complete work in good faith and request payment in the absence of a purchase order or contract. A new procedure has been instituted requiring the department/supplier to execute a contract prior to payment in order to minimize legal risks to the University and its funding agencies. This new procedure is complete. Finally, we are analyzing legitimate uses of the OPRS form and evaluating whether placing a maximum dollar limit, such as $5,000, for the use of the form will further strengthen internal controls. The evaluation will be completed by June 30, 2024. Implementing maximum dollar limits on the OPRS form will require IT changes, and therefore implementation will not occur until December 31, 2024. Anticipated completion date: Various completion dates noted above in the corrective action plan. Names of contact person(s) responsible for corrective action: Stephanie Ford-Jones, Director of Payment Processing and Compliance

Finding Number: 2023-007 Condition: Northeastern Illinois University (University) did not have adequate procedures in place to ensure the Education Stabilization Fund - Higher Education Emergency Relief Fund (HEERF) reports were accurate and timely submitted to the U.S. Department of Education and posted to NEIU’s website. Planned Corrective Action: The Grants and Contracts Office will frequently review funding agency websites to ensure reports are up to date with changes in reporting requirements. The published reports will be revised to meet the requirements of the funding agency. The Grants and Contracts Office will also ensure that reports will be submitted and published as required by the funding agency in a timely manner. Contact person responsible for corrective action: Jannica Rae Quintana, Director of Controller’s Office and Ruthann Griffith, Grants and Contracts Manager Anticipated Completion Date: 06/30/2024

Finding 2023-400: Education Stabilization Fund—ESSER Fund Reporting Planned Corrective Action: The Wisconsin Department of Public Instruction (DPI) will use data reporting procedures established after FY21 data to address the FY20 data reporting discrepancies found during the audit. These procedures include data quality testing to ensure data accuracy and will address the discrepancies between the information reported in the federal portal and the data collected in DPI’s grant management system. DPI will have the corrected data available for the Re-Open Data Collection Reporting Period by June 30, 2024. Additionally, DPI will utilize the federal Re-Open Data Collection Reporting period for FY22 to address the discrepancies identified in expenditure data previously reported and use our quality assurance procedures to ensure FY22 data is reflective of the accurate grants management data within WISEgrants and the ESF ESSER report. The federal Re-Open Data Collection Reporting period for FY22 data is between July 29, 2024, and August 15, 2024. The United States Department of Education will not re-open the portal sooner. Anticipated Completion Date: June 30, 2024 Person responsible for corrective action: Shelly Babler, Director Title I and School Support Team Division for Student and School Success Department of Public Instruction shelly.babler@dpi.wi.gov. Kyle Peaden, Assistant Director Title I and School Support Team Division for Student and School Success Department of Public Instruction kyle.peaden@dpi.wi.gov

I am writing to you in response to the finding 2023-500: Coronavirus State and Local Fiscal Recovery Funds. I agree with the finding and recommendation that was identified during the audit. Please see our below action plan that was conducted as soon as we were made aware of the issue: Corrective Action Plan Finding 2023-500: Coronavirus State and Local Fiscal Recovery Funds—Unallowable Costs Planned Corrective Action: Communication was sent out on October 2nd, 2023, to the Division of State Patrol on what classifications were deemed allowable for reimbursement to prevent future unallowable costs. On October 9th, 2023, a journal was completed for $2,173.12 to remove the unallowable costs from the grant. Lastly, on October 10th, the process of reviewing and approving the expenditures being submitted for reimbursement are now completed in three different organizational areas in the Department to ensure compliance with the MOA. Anticipated Completion Date: Completed on October 10th, 2023 Person responsible for corrective action: Cody Castillo, WisDOT Controller Division of Business Management, Bureau of Financial Management Cody.Castillo@dot.wi.gov

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-309: Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs. This is the department’s Corrective Action Plan.  Recommendation (2023-309): Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs We recommend the Wisconsin Department of Health Services ensure it retains documentation to support the costs charged to the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program, and work with the Department of Administration and the U.S. Department of the Treasury to resolve the questioned costs we identified. Wisconsin Department of Health Services Planned Corrective Action: As CSLFRF programs have matured, DHS has continued to review and revise our processes. DHS will take this opportunity to ensure that procedures surrounding approving of invoices, storing of documentation, and comprehension of the period of performance are updated and understood by our grant administrators. DHS will work with DOA and US Treasury to resolve the questioned costs. Anticipated Completion Date: June 30, 2024 Person responsible for corrective action: Natalie Easterday, Director Office of Preparedness and Emergency Health Care, Division of Public Health natalie.easterday@dhs.wisconsin.gov

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-307: Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs. This is the department’s response.  Recommendation (2023-307): Coronavirus State and Local Fiscal Recovery Funds – Unallowable Costs We recommend the Wisconsin Department of Health Services: • Review its current procedures for approving invoices related to the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program to ensure the steps required for approving invoices are appropriate and documented, and that documentation is maintained either in STAR or in a central location accessible in the event of employee turnover; • Take additional steps to ensure that expenditures charged to the CSLFRF program are within the period of performance; • Provide training to staff responsible for approving invoices to ensure staff understand what documentation is required to support approvals and the required period of performance for the CSLFRF; and • Work with the Wisconsin Department of Administration and the U.S. Department of the Treasury to resolve the questioned costs related to the CSLFRF program. Wisconsin Department of Health Services Planned Corrective Action: As CSLFRF programs have matured, DHS has continually reviewed and revised our processes. We will take this opportunity to ensure that procedures surrounding approving of invoices, storing of documentation, and comprehension of the period of performance are updated and understood by our grant administrators, including providing training as necessary. DHS will work with DOA and US Treasury to resolve the questioned costs. Anticipated Completion Date: September 30, 2024 Person responsible for corrective action: Christina Isenring, Director Bureau of Operations, Division of Public Health christinam.isenring@dhs.wisconsin.gov

Finding 2023-105: Coronavirus State and Local Fiscal Recovery Funds—Unallowable Costs Auditor Recommendation: We recommend the Wisconsin Department of Administration ensure only allowable costs are charged to federal grant programs, and work with the U.S. Department of the Treasury to resolve the questioned costs we identified related to the Coronavirus State and Local Fiscal Recovery Funds program. Planned Corrective Action: The Wisconsin Department of Administration (Department) resolved the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) costs questioned by the auditors by recouping from the school district the amount of the overpayment and obtaining from the local law enforcement agencies documentation of additional eligible expenses in amounts not less than the overpayments. The Department will continue to ensure only allowable costs are charged to federal grant programs. Anticipated Completion Date: December 18, 2023 Person responsible for corrective action: Colleen Holtan, Director Bureau of Financial Management Division of Enterprise Operations colleen.holtan@wisconsin.gov

Finding 2023-101: Homeowner Assistance Fund – Service Organization Controls Auditor Recommendation: Obtain the service organization audit report for the computer system used to administer the Homeowner Assistance Fund. Planned Corrective Action: The Wisconsin Department of Administration (Department) has requested and will obtain the service organization audit report for the computer system used to administer the Homeowner Assistance Fund. Anticipated Completion Date: Immediately following the issuance of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Auditor Recommendation: Complete a review of the service organization audit report, assess the effectiveness of the internal controls on the computer system maintained by the service organization, and document its review. Planned Corrective Action: The Department will develop the means to inform and document its review of the service organization audit report and its assessment of the effectiveness of the internal controls on the computer system maintained by the service organization. The Department will utilize those means to evidence reviews and assessments it completed but did not document as reported to and by the auditors, and for future received service organization audit reports, including the report that will be obtained for the period ended May 31, 2024. Anticipated Completion Date: June 30, 2024, as related to the development and use of the means to evidence prior completed but undocumented reviews and assessments, and within thirty days of receipt of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Auditor Recommendation: Complete a review of the complementary user entity controls at the Department of Administration that are required to be in place for it to rely on the service organization audit report, document its review, and implement user entity controls, if needed. Planned Corrective Action: The Department will develop the means to inform and document its review of the complementary user entity controls at the Department that are required to be in place for it to rely on the service organization audit report, and will implement user entity controls, if needed. The Department will utilize those means to evidence the review of complementary user entity controls it completed but did not document as reported to and by the auditors, and for complementary user entity controls contained in future service organization audit reports, including the report that will be obtained for the period ended May 31, 2024. Anticipated Completion Date: June 30, 2024, as related to the development and use of the means to document the prior completed but undocumented review, and within thirty days of receipt of the service organization audit report for the period ended May 31, 2024, which is anticipated to be received not later than September 30, 2024. Persons responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

Finding 2023-001 Condition The Corporation lacks proper segregation of duties with respect to the calculation of lost revenue. Proper segregation of duties is necessary to prevent a situation where one individual handles a transaction from beginning to end in order to reduce the potential for noncompliance due to error or fraud. During the audit of the lost revenue calculation, six months out of fifty-six were input incorrectly into the calculation from the source documents in error. Using the correct revenue amounts for those six months results in a higher total of lost revenue for the period. As a result of the lack of proper segregation of duties, noncompliance due to error or fraud could occur without being detected and corrected, timely. Corrective Action Plan Corrective Action Planned: The Corporation will have more than one person complete a full review of the lost revenue calculation for each report submission. After the information is gathered and reported by the Chief Financial Officer (CFO) but before the information is submitted, the Controller will be asked to review the data. After review and documentation that there has been a review, the reporting will be submitted. Name(s) of Contact Person(s) Responsible for Corrective Action: Brent Foster, Chief Financial Officer Anticipated Completion Date: Review process will be implemented immediately.

ection IV – Corrective Action Plan Finding 2023-001 Programs: LIFF Grant Significant Deficiency over Financial Reporting Repeat Finding: No Auditee’s Corrective Action Plan: In the future, when payroll data is imported from ADP, we will include LiFF grant code to track costs on the accounting system. This is implemented for non-payroll related costs. Contact Person: Berhane Ayichew