Corrective Action Plans

Grant expenditures that specify a period of coverage and/or performance will be amortized based on the service contract terms. Amortization costs that go beyond a grant?s expiration date will not be recorded against the expired grant.

2022-006: Internal Control Over Compliance and Compliance with Period of Performance Management is emphasizing prompt period closing to ensure that know Items are recorded in the wrong period. New layers of internal control have been added to ensure detailed review of accounting transactions. The ERM department is in the process of hiring an international compliance director, whose team will work as the second set of eyes (internal audit function) to ensure compliance. Individual(s) Responsible for Corrective Action Plans: Simon Peter Kabogoza, Controller, Heartland Alliance International skabogoza@heartlandalliance.org Anticipated Completion Date: 12/2023 Anticipated Completion Date:

Finding 2022-005: Internal Control Over Compliance and Compliance with Period of Performance Management through the local offices has already developed a policy to ensure that the period of performance is adhered too. Management is in the process of hiring another international compliance officer in both US and Iraq to particularly focus on grants performance requirements and sub-recipient grants management. Management through its Enterprise risk management is planning to schedule trainings for various departments concerning period of performance. Individual(s) Responsible for Corrective Action Plans: Simon Peter Kabogoza, Controller, Heartland Alliance International skabogoza@heartlandalliance.org Anticipated Completion Date: 12/2023

Contracts charged for expenses outside of the period of performance have been credited for ineligible expenses. Share's Director of Finance, Christopher Brox will provide training to accounting staff responsible for expense entry, expense review and approval, and invoicing by June 30, 2023 that include the following topics: - Allowability of expenses based on both contract criteria and the period of performance. - key identifiers that could flag an exception in allowability based on period of performance, and how to catch this in the review of expenses. - General ledger transactions that require further review for period of performance allowability during monthly review of expenses prior to preparing invoices. This training will highlight this being a specific area of focus for review during periods when a contract terms and a new contract starts. This training will happen with all new accounting staff responsible for expense entry and review and will be incorporated as refresher trainings if contract and grant administrator expense reviews identify this as being a continued issue by staff performing expense data entry.

FINDING 2022-003 Finding Subject: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: Noncompliance regarding the above compliance requirements Contact Person Responsible for Corrective Action: Koren Gray Contact Phone Number: 765-436-2205 Views of Responsible Official: No corrective action is required. The Town?s use of funds was appropriate under the law effective at the time of their actions. While the FAQs and fact sheets seem fairly clear that ARPA funds cannot be used to pay for any debt, including, specifically, BANs and tax anticipation warrants, the language in the actual Interim Final Rule seems to allow ARPA funds to be used for new debt. The Interim Final Rule, issued in May 2021, states: ?Contributions to rainy day funds and similar financial reserves would not address these needs or respond to the COVID?19 public health emergency but would rather constitute savings for future spending needs. Similarly, this eligible use category would not include payment of interest or principal INDIANA STATE BOARD OF ACCOUNTS 27 Per Uniform Guidance: 2 CFR ? 200.511(a) ? ?The auditee is responsible for follow-up and corrective action on all audit findings. . .The auditee must also prepare a corrective action plan for current year audit findings. . . The corrective action plan and summary schedule of prior audit findings must include findings relating to the financial statements which are required to be reported in accordance with GAGAS. ? 2 CFR ? 200.511(c) ? ?At the completion of the audit, the auditee must prepare, in a document separate from the auditor's findings described in ? 200.516, a corrective action plan to address each audit finding included in the current year auditor's reports. The corrective action plan must provide the name(s) of the contact person(s) responsible for corrective action, the corrective action planned, and the anticipated completion date. If the auditee does not agree with the audit findings or believes corrective action is not required, then the corrective action plan must include an explanation and specific reasons.? on outstanding debt instruments, including, for example, short-term revenue or tax anticipation notes, or other debt service costs. As discussed below, payments from the Fiscal Recovery Funds are intended to be used prospectively and the interim final rule precludes use of these funds to cover the costs of debt incurred prior to March 3, 2021. Fees or issuance costs associated with the issuance of new debt would also not be covered using payments from the Fiscal Recovery Funds because such costs would not themselves have been incurred to address the needs of pandemic response or its negative economic impacts.? The Final Rule, issued in 2022, summarizes the Interim Final Rule, including that the Interim Final Rule did not allow for ?payment of interest or principal on outstanding debt instruments; ? [or] fees or issuance costs associated with the issuance of new debt?? The issue date of these bond anticipation notes is the same as the actual date of delivery, which is after March 3, 2021. Under all federal laws, debt does not exist until it is actually issued ? that is to say, debt does not exist at the time of approval of the PER, the time of adoption of the authorizing documents, or at any point before it is actually issued. The Thorntown BANs were issued after March 3, 2021, making them ?new debt,? not ?outstanding debt? for the purposes of the Rules. The Interim Rule does not allow for debt service payments on outstanding debt as it is not a prospective use of the funds. It does, however, seem to allow for debt service payments on ?new debt,? just not for issuance costs, which were covered by the SRF. The Final Rule also includes this statement: ?Specifically, use of funds for debt service, to replenish financial reserves, or to satisfy an obligation arising from a judicial settlement or judgment were ineligible uses of funds under the eligible use categories for public health and negative economic impacts and revenue loss. These restrictions apply to all recipients. Recipients should note that restrictions on use of funds for debt service, to replenish financial reserves, or to satisfy an obligation arising from a judicial settlement or judgment apply to all eligible use categories, not just the eligible use categories in which they were discussed in the interim final rule.? The Final Rule clarifies several times that all debt service, including short term debt issued after the beginning of the pandemic in response to the lack of revenue, was intended to be an ineligible use. However, because the Final Rule seems to make it clear that the Interim Final Rule was unclear on this point, the Town can make a strong argument based on the points above that this BAN was an eligible use under their interpretation of the Interim Final Rule and should be allowed under the Treasury?s Statement Regarding Compliance with the Coronavirus State and Local Fiscal Recovery Funds Interim Final Rule and Final Rule. Description of Corrective Action Plan: Not Applicable. However, as final guidance and the final rule are now available, the Town would not use ARPA funds to pay for any new debts moving forward. INDIANA STATE BOARD OF ACCOUNTS 28 Per Uniform Guidance: 2 CFR ? 200.511(a) ? ?The auditee is responsible for follow-up and corrective action on all audit findings. . .The auditee must also prepare a corrective action plan for current year audit findings. . . The corrective action plan and summary schedule of prior audit findings must include findings relating to the financial statements which are required to be reported in accordance with GAGAS. ? 2 CFR ? 200.511(c) ? ?At the completion of the audit, the auditee must prepare, in a document separate from the auditor's findings described in ? 200.516, a corrective action plan to address each audit finding included in the current year auditor's reports. The corrective action plan must provide the name(s) of the contact person(s) responsible for corrective action, the corrective action planned, and the anticipated completion date. If the auditee does not agree with the audit findings or believes corrective action is not required, then the corrective action plan must include an explanation and specific reasons.? Anticipated Completion Date: Not Applicable.

Finding 2022-005 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of finding: Management does not track expenses by budget period for Corewell East federal Research and Development (R&D) grants and is therefore unable to support that expenses are recorded in the appropriate period of performance. Corrective action plan: The hierarchy and functionality of the prior Corporate financial management system (prior to July 1, 2023) did not support separate budget periods during a single award project period. This was managed manually by the CHE Sponsored Programs Administration via a customized internal report. Effective July 1, 2023, the institution transitioned Corewell Health East onto Workday, the common financial management system already used by Corewell Health West. The Workday financial management system includes a separate grant module that has the capability to establish defined budget periods under a single award. CHE successfully transitioned to Workday beginning July 1, 2023. With the functionality now enabled by Workday, we do not anticipate any barriers to maintaining defined budget periods within an award funding cycle to assure that expenses are recorded in the appropriate period of performance. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: July 1, 2023 and going forward.

Identifying Number: 2022-002 Finding: The following discrepancies and inconsistencies were identified: administrative procedures and requirements of the grantor were not followed; there were no proper review or approval of required reporting prior to submission. Contact person responsible for corrective action: Kevyn Harmon, Senior Director of Finance & Administration Corrective Action: All personnel involved with the Title programs undergo training on the all the processes and requirements to administer the programs, and management will perform proper review of all claims for reimbursement. In additional, an annual update on the procedures and the requirements to ensure propriety and accuracy. Proposed Completion Date: EPIC Academy will complete implementation of the above procedures by November 30, 2022.

U.S. Department of Education 2022-004 Special Education Cluster ? Assistance Listing No. 84.027 and 84.173 Recommendation: The Board should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Fiscal Services will improve internal controls over the procedures that ensure expenditures to a program are incurred within an award?s allowable period of performance. During the year-end close out process, the Lead Restricted Funds Accountant will review the close out of all restricted funds against the grant periods. If expenditures are inadvertently incurred outside of the grant period, the expenditures will be reclassified to an existing like grant if allowable or to the operating budget. If the Lead Restricted Funds Accountant is unavailable or has closed out grants themselves, this review will be done by the Budget Manager. The school district will implement a new financial system in July 2023. The implementation of this new system will allow for more automated internal controls. Name(s) of the contact person(s) responsible for corrective action: Rosa Aquino and/or Sherri Fisher-Davis Planned completion date for corrective action plan: December 31, 2022

Corrective Action: Management will review all cost allocations and implement documented policies and procedures to ensure sufficient support of any allocations of costs is maintained as required by 2 CFR §200.403. In addition, Management has developed a cost allocation worksheet and framework and is in the process of implementing a new procedure to ensure it is reviewed by accounting and grant managers to ensure accurate reporting. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: March 2024

Corrective Action: Management will review all cost allocations and implement documented policies and procedures to ensure sufficient support of any allocations of costs is maintained as required by 2 CFR §200.403. In addition, Management has developed a cost allocation worksheet and framework and is in the process of implementing a new procedure to ensure it is reviewed by accounting and grant managers to ensure accurate reporting. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: March 2024

Finding No. 2022-007 -Activities Allowed or Unallowed, Eligible Uses - FEMA Condition During the closeout procedures, the Cenh·al Office of Recovery, Reconstruction and Resiliency (COR3) office performed a 100% validation on Rental Equipment, supporting documents including conh"act smmnary record, invoices, and proofs of payment. As a result of the validation, the total validated amount is $979,259 from an original amount of $1,260,775 submitted by the Corporation for reimbursement. Corporation response The Corporation agrees with the finding. Corrective Action Plan Upon receiving the audit findings, we initiated an immediate review of our FEMA-funded projects and expenditures. We are implementing immediate corrective actions to address the identified deficiencies and ensure strict compliance with FEMA guidelines regarding eligible uses. • Policies and Procedures Review - Simultaneously, the Corporation is reviewing our existing policies and procedures related to FEMA funds, with a specific focus on eligible activities. Any necessary revisions will be made to strengthen our policies and ensure rigorous adherence to FEMA guidelines and regulations. • Enhance Internal Controls - We are enhancing our internal controls related to FEMA fund utilization. This includes implementing additional checks and balances to improve the accuracy and reliability of our project management processes, ensuring they align with FEMA guidelines. ■ Communication Protocols Enhancements - We understand the importance of transparent communication regarding the use of FEMA funds. To address this, we are enhancing our communication protocols to ensure that all relevant stakeholders are informed of FEMA guidelines, project eligibility requirements, and any changes to procedures. • Return of Funds - Initiate the communication process with the Central Office of Recovery, Reconstruction, and Resiliency to obtain instructions for returning the funds to FEMA. Follow FEMA's specific guidelines on the return of funds, including the appropriate documentation, timelines, and c01mnunication procedures. ■ Finance Team - The Corporation has made changes to its management staff structure in the finance and budget department, with the mission of improving the monitoring process and compliance with federal and local regulations and the support of independent consultants. A new Finance and Budget Director and the Associate Director of Finance and Budget have been appointed. Names of the contact persons responsible for corrective action plan Jesus A. Rodrfguez Aviles - Financial Planning and Analysis Associate Director Cecilia Robles Kakiuchi - Financial Planning and Analysis Director Anticipated Completion Date Fiscal Year 2024

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

• Condition: During our testing of reimbursement requests, we identified an invoice that included expenses outside the period of performance for a grant in the federal program. • Response MHA relies on our accounting representative to ensure that the invoices submitted to the accountant each week are added to the appropriate GL account to ensure the account is being invoiced for the correct expenses during the proper timeframe • Planned Corrective Action: During the newly established monthly meetings that will take place, MHA and Accounting Rep will review the expenses being submitted for reimbursement together to ensure no invoices are submitted outside the grant period.

The County plan has been implemented.

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management concurs with audit recommendation. Correction Action to be Taken: Management has established policies and procedures that define how personnel are to record involvement in project activities. These records are used to document time and labor for specific projects and in combination with time‐ keeping documentation will reflect this data in payroll documentation. DoD has reviewed the matters covered in the audit report thoroughly, and the grant was closed out without any repayment of funds to DoD. Upon subsequent review and reconciliation, amounts were not overcharged.

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.

Name of the Contact Person Responsible for the Corrective Action Plan: Gia Scruggs, City Manager Corrective Action Plan: The private contractor engaged in 2017 to provide government management and operations services staffed the engagement with less than 40 staff including 5 consultants. The City, since the termination of the services contract effective December 31, 2021, has 79 staff involved in City management and operations roles including 5 elected officials. The additional staff, including an additional 5 in accounting/finance, affords the City the capacity to effectively account for and report on restricted funds received in connection with state and federal grant programs. The City Manager staff has grown by an additional 3 staff persons from the contractor level that was assigned in 2021 to monitor grants providing sufficient City staff for current grant programs to be monitored and grant conditions complied with. As the City continues to be eligible for additional state and federal grants, a Grants Administrator position has been added to staff organization and the plan is to organize a grants management team devoted to reporting and compliance assurance as well as seeking to apply for state and federal grant and program funds. Anticipated Completion Date: City Finance Department staff, together with the City Manager, are presently monitoring compliance and reporting relating to state and federal grants and program support. Third-party contractors will no longer be used for these tasks, and as more restricted funds are received by the City, the grants management team will be organized. Presently, the City has only one federal grant program and one state program. The corrective actions have been implemented and are presently operative and in place

Invoices that are received will be scanned to “invoices”. This will direct them to our electronic software, Docuware. The item will then be forwarded to the appropriate Program Director for approval, and they will indicate the appropriate cost centers / allocations. Bookers will then review the approved coding and entered fiscal software. If there is a question or concern about approved coding by the bookkeeper they will speak with Director of Finance, Ethan Terrio. Once invoices are entered into fiscal software, checks will be printed. The check stub and invoice will be attached to each other and filed in the fiscal department.Paper documents will continue to be maintained in fiscal until we go 100% paperless, then all documents will be stored in Docuware.

Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. We mplemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding No Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and fall within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system • Conduct regular review of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure the ongoing compliance with the grant’s period of performance

Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding No Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and fall within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system • Conduct regular review of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure the ongoing compliance with the grant’s period of performance

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022