Corrective Action Plans

Significant Deficiency ? Item No. 2022-003 Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the audited financial statements to be provided to the federal agency annually within 9 months of fiscal year-end, as well as quarterly internal financial statements. Condition: The Hospital did not submit the audited financial statements within the prescribed period or request an extension and did not submit any quarterly reports to the federal agency. The Hospital was not asked for the information after they failed to submit it. The audit financial statements are readily available to the federal agency through the federal clearinghouse website. Planned Corrective Action: Management agrees with the finding and are implementing procedures to ensure that the required financial reports are submitted in a timely manner in accordance with the terms and conditions of the federal award. Planned Completion Date: June 30, 2023 Person Responsible: Nate Thompson, Chief Executive Officer

Finding Number: 2022-002 Planned Corrective Action: The District is currently working with OSBA to update the policies and policy DJC states ?If feasible, all purchases over $20,000 and not otherwise subject to required federal or state bidding requirements will be based on price quotations submitted by at least three vendors.? The Treasurer and Business Manager will ensure that policy is followed when applicable. Anticipated Completion Date: October 31, 2023 Responsible Contact Person: Muata Niamke, Business Manager and Taylor Friedrich, Treasurer/CFO

FINDING 2022-001 Contact Person Responsible for Corrective Action: Dawn Mason and Dana Hedges Contact Phone Number: 260-868-2125 Views of Responsible Official: We agree with the finding. Description of Corrective Action Plan: The Food Service Director will obtain price or rate quotes for vendors exceeding $10,000 from three sources. These will be reviewed and initialed by the Business Manager. For vendors with total disbursements expected to be between $50,000 and $150,000, the Food Service Director will obtain contracts from the vendors and these contracts will be stored at our Central Office. DeKalb Eastern will confirm with the Education Service Center via email or letter that the Service Center is correctly certified with the state for procurement requirements. 1f the Education Service Center remains uncertified, the Food Service Director will obtain price or rate quotes for milk from three sources. These quotes will be reviewed and initialed by the Business Manager. The Food Service Director will request a certification from vendors with contracts over $25,000 to show they are not excluded from participation in federal award programs. In the event the vendor is unable to provide a certification, DeKalb Eastern will utilize the SAM website to view the exclusions list of vendors . Anticipated Completion Date: Ongoing - The Food Service Director will obtain the necessary price and rate quotes, as well as contracts and certifications and the Business Manager will review and initial the quotes.

COLEGIO LA MILAGROSA, INC. (A nonprofit organization) CORRECTIVE ACTION PLAN JUNE 30, 2022 FINDING NO. CORRECTIVE ACTION COMPLETION DATE CONTACT PERSON 2022-001: FINANCIAL STATEMENTS ? The Organization, Colegio La Milagrosa, hired a new employee. This employee is being trained to comply with the recommendations and apply them to the school year of 2021-2022. ? The Food Service area hired a new accounting company, LRR Services as of July 1, 2018 and implemented the recommendation provided by the company RRC CPA Group, PSC, and to comply with the financial processes required in the 2 CRF 200. ? Also, subsequent to June 30, 2022, an internal accountant was hired, who among other responsibilities, is coordinating and supervising the record keeping and compilation of interim and year end closing and reporting process. ? As part of our internal controls, the Food Service area has created an implemented an internal guide with procedures related for accounting processes (attached in this report). June 30th 2022 Liz M. Santiago/ Odette Y. Pacheco Torres / Lizzette Ruiz / Hector Rodriguez

CORRECTIVE ACTION PLAN October 19, 2022 Cognizant or Oversight Agency for Audit Boston Senior Home Care, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: AAFCPAs 50 Washington Street Westborough, MA 01581 Audit period: July 1, 2021 ? June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PASSED THROUGH CITY OF BOSTON COMMISSION ON AFFAIRS OF THE ELDERLY 2022-001 National Family Caregiver Support, Title III, Part E-AL No. 93.052. Recommendation: Boston Senior Home Care, Inc. should implement a formal, Board approved, procurement policy and procedures which encompass the requirements in Federal CFR Part 200.318 through 200.327 and the Boston Age Strong Commission contract manual requirements. These procedures should be applied to any purchases made with Federal funds. In addition, BSHC should review its vendor files to ensure that appropriate procurement documentation exists throughout. Action Taken: Subsequent to the Board review of the fiscal year 2022 audit package, Boston Senior Home Care?s procurement policy will be revised to align with Federal guidelines. The policy will go to the Audit Committee or full Board for approval. If the Boston Senior Home Care, Inc. has questions regarding this plan, please call Charlie J. Webb, C.P.A. at (508) 366-9100. Sincerely yours, Jon Stumpf, Chief Financial Officer

Lack of Purchase Order Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles We will make sure that we follow our SOP and that proper controls are in place to ensure the policies and procedures are being followed. We also have a new E.D. who checks and approves every purchase order. The proper controls are now in place.

Finding 2022-002: Procurement and Suspension and Debarment Audit Finding: During testing for the Fund?s controls on compliance over procurement and suspension and debarment, the Fund could not provide a procurement policy that is in compliance with prescribed standards in the Uniform Guidance. Additionally, suspension and debarment verifications were not performed prior to entering a covered transaction. Corrective Action Plan: While The Conservation Fund?s current practice includes procuring goods and services only from reputable vendors, the Fund agrees that its procurement procedures should be strengthened. By August 2023, an update of the procurement policy will be completed to reflect all aspects of the requirements of the Uniform Guidance, and the Fund will implement steps to screen vendors for suspension and debarment. Person(s) responsible for implementation of the corrective action plan: Monica A. Garrison, Senior Vice President Finance & Treasurer. Hillina Fetehawoke, Director of Accounting & Financial Reporting.

Bonner County Clerk Michael W. Rosedale Clerk of the District Court Ex-Officio Auditor & Recorder Clerk of the Board of County Commissioners Chief Elections Officer CORRECTIVE ACTION PLAN June 5,2023 Cognizant or Oversight Agency for Audit: Department of Treasury. Bonner County respectfully submits the following corrective action plan for the year ended September 30th,2022. Name and address of independent public accounting firm: Hayden Ross. PLLC 315 S Almon St. Moscow.ID 83843 Audit Period: Year ended September 30. 2022. The findings from the September 30, 2022, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF TREASURY 2022-001 2 CFR 200.318 General Procurement Standards Recommendation: The County should expedite the provisions subject to vetting and begin following the Federal Procurement Policy and Procedures document which was adopted August 9,2022. Planned Corrective Action: The internal control oversight committee, comprised of all nine elected officials, along with the Comptroller has narrowly construed federal award purchases to fully comply with 2 CFR 200.318. This corrective action has already been addressed and is being remediated beginning May l, 2023. If the Department of Treasury has questions regarding this plan, please call Nancy Twineham or Michael Rosedale at208.265.1437. (Comptroller and Elected Clerk) Respectfully, Michael W. Rosedale Bonner County Clerk

Finding 2022-101 - Improve the Timeliness and Accuracy of Financial and Programmatic Reports (Significant Deficiency) FAL Numbers: 17.258, 17.259, 17.278 Program Title: Workforce Investment Opportunities Act (WIOA) Cluster Condition and Context: Two of three monthly programmatic reports tested were submitted past the deadline for the WIOA Cluster. Specifically, the January 2022 and June 2022 reports were submitted 9 days late and 26 days late, respectively. Recommendation: The auditors recommend that Pinal County improve controls over grant reporting that includes a process for identifying reporting requirements and monitoring the timely grant reporting. The system of control should include evaluating and documenting the reporting requirements of each grant and, assignment of both the employees responsible for preparation of the grant reports and a secondary employee assignment for overall monitoring of the timeliness of all grant reports. Contact Name: Joel Millman, WIOA Program Manager Corrective Action Planned: Although there are no excuses for untimely filing of financial reports, the issue found regarding the 2022 finding has been addressed. During the audit period, the Accountant position was in a state of transition with the previous Accountant leaving the position in June 2022. Since this staff departure, a new Accountant has been hired and subsequently underwent significant training provided by the Pinal County Budget and Finance Department as well as the Arizona Department of Economic Security?s Division of Employment and Rehabilitation?s (DES/DERS) Financial and Business Operations Administration. In order to ensure timely submittal of financial reports, new procedures have been implemented, these include cross training of the Pinal County Economic and Workforce Development Departments Administrative Specialist in monitoring financial report submittal dates. Additionally, the Accountant and Pinal County Economic and Workforce Development Department?s Workforce Development Manager meet upon receipt of contractor invoices to review and approve payment to ensure timely submittal of associated reports to DES/DERS. Of note, a fiscal review of the Workforce Innovation and Opportunity Act (WIOA), Title 1B program was conducted November 8th-10th, 2022 by the DES/DERS Business and Operations Administration. The periods selected for their testing were the periods of January 1, 2022, through April 30, 2022. The purpose of this review was to determine compliance with WIOA Title IB regulations and procedures, Department of Labor (DOL) guidelines and State policies. The review covered the areas of internal controls, general operation procedures, cash receipts and disbursements, accrued expenditures, program income, cash management, and miscellaneous items as outlined in the Fiscal Monitoring Guide. Documents reviewed within these general categories included disbursements journals, payroll journals, paid expense invoices, receipts journals, and payroll time sheets. No findings were submitted. Anticipated Completion Date: June 30, 2023

Criteria: The Hospital must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a reserve fund at specified balance levels. Condition: During 2022, the accounts that represented the reserve fund had a balance below that required by the loan resolution agreements and required deposits were not being made to restore the balances to required levels. Planned Corrective Action: Management agrees with the finding and will deposit required amounts into the reserve fund. Planned Completion Date: Ongoing Person Responsible: Jeremy Bauer, CEO

FINDING 2022-001 Contact Person Responsible for Corrective Action: Amy Copeland Contact Phone Number: (812) 689-6311 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Ripley County Auditor, Amy Copeland, has already been in contact with the Auditors in the State of Indiana to help with a Procurement Policy they already have in place. This is so the Ripley County Attorney and I can work on getting Ripley County a Procurement Policy in place as soon as possible. Ripley County will also be writing a Suspension and Debarment Policy for any checks written over $25,000.00 to any subrecipient or contracts. The new polices will address procedures for procurement and suspension and debarment to ensure there is a review and approval process in place to ensure compliance. Anticipated Completion Date: 8/30/2023

CORRECTIVE ACTION PLAN (Concerning Finding 2022-001 & 2022-002) Contact Person Responsible for Corrective Action: Tracy Roy, Finance Director Corrective Action: The City of Lewiston will take the following actions to address finding 2022-001: The City of Lewiston has reviewed the contract and is adding the necessary sections to all contracts. Anticipated Completion Date: January 30, 2023 Corrective Action: The City of Lewiston will take the following actions to address finding 2022-002: The City of Lewiston started to require the SAM approval print out before contracts are signed with vendors beginning January 1, 2022. The Purchasing Agent or the designee will not complete the process until the SAM certification is received. The SAM document will be filed with the contract. This has been done but the employee in Economic Development gave the wrong SAM approval. Anticipated Completion Date: January 1, 2022

Finding 2022-001 Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Mortgage Insurance Rental Housing Federal Financial Assistance Listing #14.134 Procurement, Suspension, and Debarment Finding Summary: The Project does not have a written procurement policy which conforms to Uniform Guidance as outlined in 2CFR 200.317 through 200.327. During the year, management entered into transactions over the micropurchase threshold with eight vendors. Documentation was unable to be provided to support procurement compliance for seven vendors. In addition, 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. Responsible Individuals: Sue Lund, Administrator Corrective Action Plan: The Project is drafting a written procurement policy which conforms to Uniform Guidance as outlined above. In addition, for expenditures in excess of $25,000, the Project will 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. Anticipated Completion Date: July 2023

2022-001: Procurement Requirements Criteria: The Organization is required to establish a procurement policy in accordance with Uniform Guidance requirements, as specified in the compliance supplement. Condition: The Organization did not establish a procurement policy in accordance with Uniform Guidance 2 CFR 200.318 ? 200.327, as required for the major program. The Organization developed and implemented a policy during 2022 but it was not in effect for the whole organization for the entire year. Questioned costs: None Cause and Effect: By not having an updated procurement policy the Organization could expense funds that are not in accordance with the procurement policies established by Uniform Guidance. Corrective Plan: Midwest Food Bank NFP established a procurement policy in accordance with Uniform Guidance in 2022 to be fully implemented across the Organization with an effective date of January 1, 2023, led by Lisa Martin, CFO.

SEE ATTACHED

The City has identified federal grants subject to the Uniform Guidance and will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions.

FINDING 2022-005 Craig Wright (765)747-4828 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Correcting the audit findings is ongoing. The city has implemented monitoring procedures to review and prevent reoccurring errors. Anticipated Completion Date: The internal control monitoring and checks and balances will be implemented immediately and continue going forward.

U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation’s existing controls over federal award reporting did not identify and correct that reports submitted to the grantor were submitted with inaccurate information and that the supporting documentation used to prepare the reports were utilizing budgeted expensed amounts rather than actual. Furthermore, the budgeted expensed amounts from the supporting documentation that were the basis for the amounts to report, did not agree with the ultimate amount reported. Management’s Response and Corrective Action Plan: Televerde Foundation has experienced significant growth from inception in March 2020 to fiscal year ended December 31, 2022. We have grown from contributions and grants of $83 thousand and $50 thousand, respectively, in March 2020 to contributions and grants of $236 thousand and $978 thousand, respectively, as of December 31, 2022. During this same period, Televerde Foundation went from 3 employees to 21 employees and experienced significant turnover in finance staff including 2 CFO’s, 2 Controllers, and four staff accountants. The growth combined with lack of a consistent finance team is the primary cause of this deficiency. To address the deficiency, management will perform the actions below. Management will leverage our general ledger to retain documentation for approval and review of expenditures. We will utilize actual amounts for expenditures and in circumstances where budgeted amounts are needed, we will perform a true-up on a quarterly basis. Management will perform quarterly reviews over financial reporting. Responsible Individuals: Michelle Cirocco, Executive Director Anticipated Completion Date: July 2023

U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not retain documentation to support performance of a price analysis nor provide the opportunity for open competition. Additionally, the Foundation did not review for suspension or debarment and required contract provisions were not followed. Management’s Response and Corrective Action Plan: Televerde Foundation has experienced significant growth from inception in March 2020 to fiscal year ended December 31, 2022. We have grown from contributions and grants of $83 thousand and $50 thousand, respectively, in March 2020 to contributions and grants of $236 thousand and $978 thousand, respectively, as of December 31, 2022. During this same period, Televerde Foundation went from 3 employees to 21 employees and experienced significant turnover in finance staff including 2 CFO’s, 2 Controllers, and four staff accountants. The growth combined with lack of a consistent finance team is the primary cause of this deficiency. To address the deficiency, management will perform the actions below. Management will retain and catalog documentation related to price quotes for certain Foundation expenditures. We will update our procurement policy to be consistent with federal guidelines to assist in streamlining the procurement process. We have hired a Grant Administrator and Analyst who is responsible for reviewing contractors against the System for Award Management for suspension or debarment, including subrecipients. Responsible Individuals: Michelle Cirocco, Executive Director Anticipated Completion Date: January 2024

The County Council and County Executive will work through the Audit Committee and Policy Review Committee to review, update, and strengthen policies and internal controls related to County and Federal procurement policies. The County will provide sufficient training and resources for staff to make sure all County and Federal procurement policies are followed correctly. The County will also monitor these processes through internal audit procedures

FEDERAL AWARDS – CORRECTIVE ACTION PLAN REFERENCE # 2022-001 PROCUREMENT SUSPENSION AND DEBARMENT – MATERIAL WEAKNESS- NON-COMPLIANCE Program Name/ALN Emergency Solutions Grant Program (ALN # 14.231) Criteria: As per § 200.318 General procurement standards. (a) The Non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in §§ 200.317 through 200.327. (d) The Non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Condition/Context: Condition: Based on our review of the Procurement compliance requirements, we noted that the Division has written procurement policies and competitive policies as required by CFR § 200.318 General procurement standards. We selected five (5) vendors for procurement Suspension and Debarment compliance testing of total population of 5 vendors subject to procurement and we were not provided with Procurement comparative bids therefore, we were unable: • To verify that the procurement method used was appropriate based on the dollar amount and conditions specified in 2 CFR section 200.320. • To Verify that procurements provide full and open competition (2 CFR section 200.319 and 48 CFR section 52.244-5). Questioned Costs: Cannot be determined Recommendation: We recommend that the Division must: (1) Use documented procurement procedures, consistent with State, and local, laws and regulations and the standards, for the acquisition of property or services required under a federal award or subaward. (2) The Division must maintain records sufficient to detail the history of procurement. These records should include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Corrective Action Plan: The Division will work with Territorial Headquarters to document procedures as outlined in the Recommendations above. 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

Corrective Action Plan for the Calendar Year Ended December 31, 2022 In response to the finding from the Federal single audit for the fiscal year ended December 31, 2022. Major Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (Assistance Listing Number 21.027) (G2022-09) Finding: 2022-002 - Reporting and Procurement (Material Weakness and Material Non-Compliance) Management Response: Management will strengthen its processes and internal controls to ensure the report of expenditures is reviewed by Finance prior to submission and only includes expenditures incurred in the period. In addition, Management will amend its procurement policy to ensure the policy includes the required regulations as outlined in the Code of Federal Regulations in relation to Federal Awards. Christopher Caulfield, Executive Director of Financial Operations, will implement the corrective action plan, which is anticipated to be completed by December 31, 2023. caulfieldc@sihmc.org 973-754-2016

Corrective Action Plan: PREMA will establish and document formal procedures for the preparation, review, reconciliation, and timely submission of SF-425 Federal Financial Reports for EMPG grants by implementing a report reconciliation checklist requiring agreement of reported data to PRIFAS and SEFA records, ensuring each report includes federal and recipient share, drawdown activity, and unliquidated obligations, designating an official responsible for report review and approval prior to submission with evidence of filing retained, and providing staff training on federal reporting requirements under 2 CFR 200.327–200.329 to improve accuracy, completeness, and compliance in federal financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.

Preparation of written federal procurement procedures for compliance purposes

We agree with the finding and acknowledge that this issue has been previously identified in past audits. The repeat occurrence was primarily due to understaffing and turnover followed by additional staffing challenges during and post COVID 19 pandemic of 2020. In addition to the Corrective Action Planned related to Finding 2021-102, with respect to the Head Start grant reporting compliance for 90CI010041-01, the Finance Director has developed a grant tracking document to ensure timely completion and submission of all grant reports. The Grant Tracker has been reviewed by finance staff and is updated and referenced weekly. The Executive Director and Finance Director have regularly scheduled meetings each month and will coordinate improved reporting processes and monitoring systems with existing fiscal contractors to ensure the timeliness and training on the required filing and reporting requirements of all federal and state funds. The Executive Director has met with the Head Start and other ITCN Program Directors following review of the prior repeat audit findings. We have been implementing collaboration between program directors and fiscal staff to improve overall compliance for grant funds, including budgeting, reporting, policies and procedures and processes. Program directors are now required to collaborate and actively participate in all administrative and fiscal requirements of the grant funds, including attendance of administrative/fiscal training opportunity by funding agency, and review and understanding of grant compliance and internal controls. The Executive Director will continue to meet with the Finance Director on Corrective Action Planned, including oversight of and review of the monitoring list consistent with the timing of reporting filings. Anticipated Completion Date: On-going –The Final FY 2021 Financial Statements, including the Corrective Action Planned will be presented to the executive board and program directors for overview. The Executive Director will be responsible for ongoing communication and engagement to improve internal controls, and regularly scheduling meetings for status updates on the Corrective Action Planned and review quarterly reports.