Corrective Action Plans

The University has revised processes to ensure that grant reporting requirement are adhered to. 1) Review and enhance processes to ensure accurate and timely reporting.

The University will revise processes to ensure that notifications are received as required by the Code of federal regulations. 1) Perform a review of (implement enhancements to) current processes to ensure appropriate notification to students.

The University will review processes to ensure that adequate internal control exists to mitigate risks related to collection of required verification documents are collected. 1) Ensure that staff are trained on the required verification documents to be collected. 2) Perform periodic review of student files to verify completeness of records.

The University will perform a risk assessment that is inclusive of the requirements outlined in the GLBA.

FINDING 2022-001 Contact Person Responsible for Corrective Action: Teresa Hester ? Clerk/Treasurer Contact Phone Number: 765-738-6381 Views of Responsible Official: We concur with finding: As stated in the Finding 2022-001 this finding is also a finding in the 2021-002. All of the transactions were already complete when the 2021 finding was noted. Difficult to change what already was. Internal controls were in place overall with the Grant Writer, Engineering Firm and Clerk/Treasurer, but the town was not provided with direct access to copies of the semi-annual reports. These reports were not accessible because OCRA does not give all unit?s rights to view. (Not being able to have access is where Government Officials should take into consideration when requiring units to be compliant.) Screen shots of the activity were provided to auditor. Description of Corrective Action Plan: The semiannual and other reporting was the responsibility/authority of our grant management. (Town officials have no log-in rights for the records) For future endeavors moving forward we will be implementing a more efficient internal controls. Collaborating with the grant management in knowing when the reports are being filed and that the Clerk/Treasurer is sent a copy of the reports for review. Anticipated Completion Date: This particular project has been finalized, therefore there is no an anticipated completion date. For future endeavors we will implement a more detailed and diversified internal controls process.

2022-002 Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that that County establish an internal control process for reviewing and approving indirect costs allocated in accordance with Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Regarding the review of indirect costs, management acknowledges that our internal control documentation fell short of the necessary standards. While the County?s documents effectively track the indirect costs associated with State and Local Fiscal Recovery Funds (SLFRS), management recognize that we were not utilizing the de minimis rate rule calculations as prescribed by federal regulations. Going forward, the County will ensure that the indirect costs are in full compliance with the de minimis rate rule. The County have established robust controls over indirect costs for SLFRS to mitigate any potential discrepancies and ensure that we are in alignment with federal guidelines by tracking the de minimis indirect cost rates using various spreadsheets and review by multiple approvers. Name(s) of the contact person(s) responsible for corrective action: Jian Ou-Yang Planned completion date for corrective action plan: December 31, 2023

Finding Number: 2022-001 Condition: In order to comply with program rules, nonfederal entities must establish and maintain effective internal controls over the federal award, as prescribed by 2 CFR 200.303(a). For Provider Relief Funds, the terms and conditions of the grant, according to U.S. Department of Health and Human Services (HHS), require that the System report certain information accurately into the HHS PRF Reporting Portal in order to attest to the utilization of the funding received. Specifically, the HHS June 11, 2021, post-payment reporting notice provides specific guidance on the calculation of lost revenue and amounts to be reported in the portal. Planned Corrective Action: Chief Financial Officer will insure that all guidance available for PRF reporting (FAQ's etc.) is reviewed prior to making any further submissions to the portal and that the Chief Financial Officer will review the filings with the preparer prior to submissions. Contact person responsible for corrective action: Chief Financial Officer Anticipated Completion Date: August 1, 2023

Finding: 2022-004 Contact Person Responsible for Corrective Action: Heather N Perry, Greene County Auditor Contact Phone Number: 812-384-8658 Views of Responsible Official: We concur with the finding. Description of Correction Action Plan: The Greene County Auditor?s office will establish and maintain effective internal controls over the Federal awards in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Lori Dawn Dickinson will review the P&E Report to verify that all entries are accurate and true, and I (Heather Perry) will submit the report. Heather Perry Greene County Auditor Anticipated Completion Date: April 30, 2024

FINDING 2022-003 Contact Person Responsible for Corrective Action: Heather N Perry, Greene County Auditor Contact Phone Number: 812-384-8658 Secondary Contact: County Attorney, currently Marvin Abshire Secondary Contact Phone Number: 812-384-0081 Views of Responsible Official: We concur with the finding. Description of Correction Action Plan: Corrective action will need to be taken to review the Sam.gov verification website in the future. We will be verifying that current and future Greene County vendors are not barred or suspended on the Sam.gov verification website before using their services. As county attorney is responsible for virtually all contract drafting or approval, county attorney has added to the public works contract checklist the determination whether or not federal funds are used in fulfillment of the contract and if so, that the contract will contain a suspension and debarment paragraph applicable to contractor and subcontractors. Further, should the county submit a request for qualifications for a design-build public works project, attorney will endeavor to assure that the request for qualifications requires information concerning debarment, disqualification, or removal of the design-builder or a team member from a federal, state, or local government public works project. Attorney will perform the sam.gov verification for qualifying contracts or matters implicating suspension and debarment; will date and initial or sign the verification; and will ask his assistant to review the verification and initial or sign and date same. Either a paper copy or a PDF of the confirmed verification will be maintained in the contract file. Heather N. Perry Greene County Auditor Anticipated Completion Date: 09/01/2023

Identifying Number: 2022-001 Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management reviews the reported grant expenditures. Management believes this review process to be adequate.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Wabash County Auditor, Marcie Shepherd Contact Phone Number: 260-563-0661 We concur with the finding. Description of Corrective Action Plan: We were unaware that once you elected to receive the funding as the standard revenue loss allowance that you would still need to verify for the suspension and debarment compliance requirement. Moving forward when a request for funding is being presented to the County Commissioners/Council, Commissioners/Council will require the office that is requesting funding to provide the Auditor?s office with a Suspension and Debarment form which is signed and dated from SAM.gov. The form will be kept in the ARPA binder. Anticipated Completion Date: August 8, 2023

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Angela C. Birchmeier, County Auditor Contact Phone Number: (574) 935-8555 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County and Auditor?s office were unaware of the requirement that a contract over $25,000 needed verification that the contractor had not been suspended or disbarred. Now that we are aware, each contract will be verified by either checking the EPLS (Excluded Parties List System) or that the clause for disbarment or suspension is included in the contract. The Department requesting the contract will verify if the clause is in the contract. The Claims Deputy will also verify during the claims process for payment and the 1st Deputy will also verify. Anticipated Completion Date: We have already implemented this procedure effective April 2023.

Management has been making updates to its policies and procedures throughout 2022 to be in full compliance with the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.

Finding 2022-06 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Medical Center tracked eligible expenses internally within a spreadsheet. The spreadsheet included errors in the calculation of allowable expenditures, which were included on the Period 1 report to the Health Resources and Services Administration (HRSA). Responsible Individuals: Tim Hall, HORNE Corrective Action Plan: Ensure that all of the spreadsheets used to track expenses are free of errors. Anticipated Completion Date: 3/31/2023

Finding 2022-05 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Medical Center tracked eligible patient care revenues internally within a spreadsheet. The revenues included in the spreadsheet and on the Period 1 report to HRSA, which were utilized to calculate lost revenues, contained an error. Responsible Individuals: Tim Hall, HORNE Corrective Action Plan: Ensure that all of the spreadsheets used to track revenue are free of errors. Anticipated Completion Date: 3/31/2023

FINDING 2022-001 Contact Person Responsible for Corrective Action: Colby Shank Contact Phone Number: 317-921-4765 Views of Responsible Official: Ivy Tech Community College disputes this audit finding. The College has an effective internal control system to ensure compliance with requirements related to the Special Tests and Provisions ? Return of Title IV Funds compliance requirement. The College previously determined that the Return of Title IV Funds (R2T4) is high-risk due to the large number of transactions, the College?s modular term-based system, and the manual nature of R2T4 calculations. Therefore, a robust quality control review process was implemented. College personnel regularly monitor the error rates and nature of errors discovered through the quality control review to identify, correct, and eliminate calculation errors. The claimed errors outlined in Finding 2022-001 relate to the interpretation of how a correction recalculation is determined. In correction calculations, aid previously returned as a result of the initial calculation in the 2021-2022 academic year was considered no longer disbursed and was included in the correction calculation as ?aid that could have been disbursed.? In certain scenarios, this can result in different return amounts than if the aid had been included in the calculation as ?aid disbursed.? In the absence of explicit guidance on how to handle these scenarios within the Federal Student Aid Handbook, College interpretation and precedent has been to treat aid previously returned under the original calculation as aid that could have been disbursed. Volume 5, Chapter 2 of the 2021-2022 Federal Student Aid Handbook states that ?any undisbursed Title IV aid for the period that the school uses as the basis for the R2T4 calculation is counted as aid that could have been disbursed.? Ivy Tech confirmed this interpretation as valid via a third-party financial aid expert who facilitated a discussion with a representative of the USDOE. This USDOE representative confirmed the accuracy of the calculation and the alignment with the Federal Student Aid Policy Implementation and Oversight Directorate. During this discussion, the representative stated that the results of the original calculation could not be ignored, and that including aid that is no longer disbursed as ?aid that could have been disbursed? is the proper way to perform a correction calculation. The auditors state the College should have performed the following actions: ?The College should have considered the original amount of aid to be returned that had already been posted to each student?s account. The College should have posted the additional amount of aid to be returned to the students? accounts based upon the net difference between the original calculation and the corrective calculation performed for each student.? This methodology would have produced inaccurate return amounts under the interpretation of guidance from Federal Student Aid from which the College was operating during the review period. Only posting the ?net difference? between the original calculation and the correction calculation would have resulted in too few funds being returned to Federal Student Aid for many calculations during the review period. Specifically, a difference in return amounts occurred when the amount of unearned charges (institutional charges for the period multiplied by the percentage of unearned Title IV aid) was less than the calculated amount of Title IV aid to be returned. Under the R2T4 calculation formula, the amount of unearned charges can effectively create a ?cap? on the amount of Title IV aid to be returned by the school. At Ivy Tech Community College, this cap is most often reached when students receive disbursements of federal student loans prior to withdrawing. Because a relatively small percentage of Ivy Tech students receive federal student loans, most correction calculations performed during the review period by Ivy Tech under our interpretation of the guidance resulted in accurate return amounts. This issue only impacted a subset of students who received a correction calculation during the review period. Description of Corrective Action Plan: Upon receiving new guidance from the Chicago/Denver regional office of Federal Student Aid, Ivy Tech has modified the way in which it performs R2T4 correction calculations. Aid returned as a result of the original calculation will remain in the correction calculation as ?aid disbursed? instead of ?aid that could have been disbursed.? The College is no longer following prior guidance received by an expert consultant, a representative of Federal Student Aid that advised the College to include aid that has already been returned as ?aid that could have been disbursed.? The calculation change will be monitored for correctness through the College?s previously established internal controls and quality assurance process for the R2T4 process. Financial aid staff have been trained on the calculation change. Ivy Tech will review all students during the review period who received a correction calculation and will cover with institutional aid any federal grant aid that otherwise would not have been returned under the new guidance from Federal Student Aid. Anticipated Completion Date: 3/31/2023

Corrective Action Plan for the Year Ended June 30, 2022 Finding 2022-006: Significant Deficiency ? Control Environment Condition/Context: It was noted during the audit, that there were gaps in the internal control structure of the College, that was no longer adequate to ensure compliance with federal regulations and compliance requirements. Action Taken: The staffing changes in the Business Office and the Financial Aid office resulted in learning curves for the new employees. Both offices have started projects to document procedures so that when turnover occurs, there is a blueprint in place to assist the new employees. SMC will also review the internal controls in place for federal reporting to determine how they can be strengthened. Name(s) of Contact Person Responsible for Corrective Action: Nicole Yu, AVP/Controller and Joseph Gilchrist, Interim Financial Aid Director Anticipated Completion dates: Documenting procedures is on ongoing project. Revised internal controls for federal reporting will be in place by June 30, 2023.

2022-002 United States Department of Agriculture CFDA 10.766 Community Facilities Loans and Grants Cluster Special Tests and Provisions Significant Deficiency in Internal Controls Over Compliance Finding Summary: There was no evidence retained that the Hospital?s recalculates debt covenants as required or performs any review of one of the two financial debt covenant calculations. Responsible Individuals: Brittany Johnson, CFO Corrective Action Plan: Management will implement a control process which includes periodic calulation and review of all financial debt covenants. Anticipated Completion Date: Action taken and completed on 5/31/23

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 1 and Period 2 reporting required an organization to illustrate how PRF funds received were used. An organization was allowed to include lost revenue attributable to coronavirus from January 1, 2020 through December 31, 2021 depending on the period reporting. Condition: During the process of identifying lost revenues attributable to coronavirus, management reported all lost revenue as Medicaid. However, support provided by management indicated that lost revenue was also identified for self-pay revenue and other payers. Planned Corrective Action: Management agrees with the noted finding. Management will continue to refine its processes to more diligently review the lost revenue reporting key line items to ensure such amounts are in accordance with the terms and conditions of the federal award. Planned Completion Date: June 30, 2023 Person Responsible: Scott Hoffman, CFO

Significant Deficiency: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 1 and Period 2 reporting required an organization to illustrate how PRF funds received were used. An organization was allowed to include eligible expenditures from January 1, 2020 through December 31, 2021 depending on the period reporting. Condition: During the process of identifying expenses that were incurred to prevent, prepare for, or respond to the coronavirus pandemic, management included expenses incurred which were not supported by management in relation to prepare, prevent, or respond to coronavirus. Planned Corrective Action: Management agrees with the noted finding. However, Mosaic also incurred and reported unreimbursed expenses attributable to coronavirus of $3,530,376 which could be used to replace the identified costs unrelated to coronavirus. Management will continue to refine its processes to more diligently review expenditures to ensure only those eligible costs incurred are included in future reporting. Planned Completion Date: June 30, 2023 Person Responsible: Scott Hoffman, CFO

As requested, the New Mexico Coalition to End Homelessness has completed its corrective action plan for the audit findings in the 2022 fiscal year annual audit report. We have reviewed the findings and have made a corrective action plan to address each of the findings with completion dates. 2022-002?PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Federal Agency: All presented in the Schedule of Expenditures of Federal Awards. Program Name: All presented in the Schedule of Expenditures of Federal Awards. Assistance Listing Nos. and Program Expenditures: All presented in Schedule of Expenditures of Federal Awards. Award Number and Program Award Year: All presented in Schedule of Expenditures of Federal Awards. Compliance Requirement: Other ? Schedule of Expenditures of Federal Awards preparation Type of Finding: E Questioned Costs: None Statement of Condition While conducting the audit, the following was reviewed; the Coalition?s Federal grants report for the fiscal year and identified the federal grants, Assistance Listing # (AL#) and the amounts of the federal expenditures and all of the other items required to properly present the Schedule of Expenditures of Federal Awards (SEFA). The finance staff of the Coalition confirm the correctness of the SEFA. Despite the confirmation of accuracy, additional federal expenditures and grouping of grant expenditures were identified after several reviews of the SEFA. Criteria 2 CFR 200.510 indicates that the auditee must prepare a schedule of expenditures of Federal awards (SEFA) for the period covered by the auditee?s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502 Basis for Determining Federal Awards Expended. Per 2 CFR 200.502 the determination of when a Federal award is expended should be based on when the activity related to the Federal award occurs. Generally, the activity pertains to events that require the non-Federal entity to comply with Federal statutes, regulations, and the terms and conditions of Federal awards, such as expenditure/expense transactions associated with awards. In addition, 2 CFR Part 200.303 requires the program establish and maintain effective internal controls over Federal awards that provides reasonable assurance of compliance with Federal statutes, regulations, and the terms and conditions of Federal awards. Effect Without an established process governed by effective internal controls, the Coalition may not prevent or detect material misstatements on its SEFA in a timely manner. In addition, the errors could result in improper selections of major program(s) for the single audit and a substandard single audit. Cause Historically, the Coalition has requested the auditor assist in identifying accruals related to federal grant expenditures as the organization has maintained these records on a cash basis. As the organization has taken more responsibility on maintaining its federal grant expenditures on an accrual basis, an incomplete SEFA has been provided. Recommendation It is recommended the Coalition prepare the Schedule of Expenditures of Federal Awards and submit this to the auditor for testing. The SEFA should include the name of the grant, name of grantor, the AL #, the pass-through number if applicable and a reconciliation of the federal revenues and expenditures to the Coalition?s general ledger. The Coalition staff should perform more detailed reviews of the reports to ensure they properly reflect grant receipts and expenditures. This review should be performed by someone other than the preparer and should include documented evidence of agreeing the reported data to the accounting records. We further recommend training for those individuals involved in the preparation and review of the reports to ensure they are fully aware of the requirements. View of Responsible Officials and Corrective Action Plan: The corrective Action Plan will be carried out in the 2023 Fiscal Year and information will be given to the auditors when requested for the 2023 Audit. The Coalition will ensure that all information needed for the SEFA is kept and entered accurately. When the fiscal year closes out, the Coalition will provide the auditors with a test SEFA to confirm that the information we are collecting throughout the year and are asserting are the correct numbers for our federal grants, is indeed the correct information. Corrective Action Plan Timeline: Completed by October 31, 2023 (Final copy of the SEFA will not be given to the auditors until requested for the 2023 Audit) Designation Of Employee Position Responsible For Meeting Deadline: Executive Director, Monet Silva will oversee this project and work closely with the auditors to make sure that the information saved and shared is correct. Thank you, Monet Silva Executive Director

FINDING 2022-003 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective internal control system in place to ensure compliance with the Reporting requirement in the COVID-19 ESSER grants. Description of Corrective Action Plan: The school corporation will implement an internal control of dual signatures on all reporting related to the ESSER and GEER grants. This will provide an extra layer of oversight to ensure complete accuracy with reporting. Anticipated Completion Date: 4/30/23

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective control system in place to ensure the correct information entered in the Eligible Schools Summary section in the Title I application for Nonpublic schools was accurate. Description of Corrective Action Plan: The school corporation will work with the non-public schools within our district to implement a set of procedures to ensure the accuracy in reporting poverty counts in the Title I application. Anticipated Completion Date: 4/30/23

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective internal control system in place to ensure compliance with the Matching, Level of Effort, and Earmarking requirements in the Special Education grant. Description of Corrective Action Plan: The school corporation will continue to hold regular meetings with the nonpublic schools in our district to ensure they spend their allocations appropriately and timely. If the non-public schools do not spend their allocations within the grant period, Clark-Pleasant will request a waiver from the DOE to repurpose those funds in the grant. Anticipated Completion Date: 4/30/23

Finding 2022-003 Internal Control Over Compliance Description of Finding The School Department does not have policies and procedures designed to ensure that appropriate written documentation is maintained for all students who withdraw from the district. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Public entities throughout the Country were impacted the hardest during the Global Pandemic, PPSD was not an exception, the District realized a high number of student withdrawals, employee turnover, and are still dealing with staff shortages due to labor market conditions. As a result, new staff members were not fully trained on some of the practices and procedures that needed to be followed. As a corrective next step, the District will ensure employees will be trained on the procedures that need to be followed regarding Students transfer and withdrawal practices. Name of Contact Person John Welch Projected Completion Date 6/30/2023