Corrective Action Plans

This is repeat Finding from 2022. Key personnel have since been replaced at the RPC and those in in the new positions understand the importance of proper and timely reporting and accurate financial records. The Auditor’s Office will meet with the new executive director, the current (new) finance director, and board members to emphasize the importance of deadlines and financial accountability when working with Grants. Additional Controls will be emphasized to assist with timely filing, as well as Invoice Entry to ensure duplicate payments are not made.

The position of Grants Coordinator has been created and filled to handle grants management functions which will ensure proper quarter end dates and expenditures appropriate for the period are reported. Under the new process, the Grant Coordinator collaborates with the Construction Financial Administrator to complete forms which are then reviewed with the Director of Grants and CFO prior to submission.

FINDING 2023-007 Finding Subject: COVID-19 – Education Stabilization Fund – Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance for the reporting requirement. Not all EESER reports submitted by the School Corporation during the audit period were not supported by the School Corporation's records. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are implementing a proper system of internal controls and developing policies and procedures to ensure all reports are submitted accurately. Description of Corrective Action Plan: We are implementing a proper system of internal controls and developing policies and procedures to ensure all reports are submitted accurately. Moving forward we will ensure all ledgers are attached to the reports that have been submitted. Anticipated Completion Date: The anticipated date of correction for this finding is January 1, 2025.

FINDING 2023-004 Finding Subject: Twenty-First Century Community Learning Centers – Cash Management, Program Income and Reporting. Summary of Finding: The School Corporation had not established an effective system of internal controls related to the grant agreement and the Cash Management, Program Income and Reporting compliance requirements. Cash Management The school submitted reimbursement requests without taking into considering the program income or reducing the request by the program income earned due to the lack of adequate program income. Program Income Controls had not been designed or implemented adequately to ensure that the proper fees were assessed and that the cash collections remitted were accurate. Additionally, the school-maintained program income in a separate fund and comingled with other non-grant funded program revenues. The unit did not deduct program income from allowable costs prior to claiming reimbursement. Reporting The total requested reimbursements for the audit period were understated by $32,605 when compared to the ledger. Of the two End of Year reports selected for testing neither properly included program income that was received during the year due to inadequate tracking of program income. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are implementing a system of internal controls to strengthen our policies and procedures and ensure the proper tracking of Program Income is reported and submitted accurately for Twenty First Century Learning center grant funds. Description of Corrective Action Plan: We have reached out to our liaison at the Department of Education to determine if program income should be reported monthly or annually. Management will be working with the Safe Harbor Director to implement a system to ensure separation of the Twenty first Century grants and other funds that are under the Safe Harbor program. Anticipated Completion Date: The anticipated date of correction for this is January 1, 2025.

Finding: The County’s reported expenditures incurred in fiscal year 2022 were incorrectly reported. Cause: Internal controls and review processes were not in place to ensure the accuracy of expenditures reported on the annual SEFA. Recommendation: Management should implement procedures to help ensure that controls are in place that will allow for the accurate preparation of the SEFA. We recommend that the County perform a detailed analysis of expenditures for all significant awards on an annual basis. Corrective Action Plan: Effective immediately, the County will put in additional controls and verify all grants are monitored under additional scrutiny and are reported accurately in quarterly reports and the County’s Annual Comprehensive Financial Report (ACFR). Staff Responsible for Implementation: Matt Davis, County Auditor; Mike Sloan, Senior Associate; Jordan Wilson, Grant Associate Implementation Date: December 31, 2024 Status: In progress

FINDING 2023-006 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include proper segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were complied, prepared and submitted by one employee without documentation to support an oversight or review process in place to prevent, or detect and correct, errors. In addition, because the unit was unable to provide supporting documentation for the information contained in the six reports submitted during the audit period, three of these reports contained errors. Contact Person Responsible for Corrective Action: Kelly McPike Contact Phone Number:765-689-9131 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: An effective internal control will be developed to ensure supporting documentation is used and retained for all required reports submitted on behalf of the Education Stabilization Program Funds. The reports will be compiled, prepared, and submitted by more than one employee to support any possible oversight or errors. Anticipated Completion Date: April 2024

The audit testing in question related to transactions that occurred from October 1, 2020, to December 31, 2021. At this time, due to COVID and the use of Charity CFO, an outside accounting organization, to record and manage our transactions, 9/11 Day chose to track federal expenditures independently and internally through accounting spreadsheets. Although these transactions were included in 9/11 Day Quickbooks software as well, Charity CFO did not separate them under categories that identified them as federal grant expenses. At the request of the Auditor, 9/11 Day reviewed and reconciled these federal transactions in Quickbooks, without discrepancies. Beginning in 2023, we began tracking federal grant expenses and revenue in Quickbooks. In response to Auditor recommendations, we are reviewing and will update our written procedures for tracking, reviewing, approving and retaining documentation of federal expenses consistent with Federal Financial Reports submitted to the Agency.

2023-001 Name of Contact Person: Matthew Roy Corrective Action: After the September 2023 staffing changes, the Finance Director and the Accounting Manager reviewed the FFR reports prior to filing. The Finance Director provided verbal approval to file. For all reports going forward, Greenheart will document approval of filing via email exchanges from the Accounting Manager to the Director of Finance. Proposed Completion Date: Management considers this finding resolved as of August 2024.

Reporting was corrected through the ODOD

1. A critical aspect of Cleveland UMADAOP’s updating of financial policies and procedures will be training on the proper and timely completion of federal forms 2. Weekly meetings will be held with Program Directors with a standard agenda item of upcoming due dates within the subsequent four weeks. 3. During these meetings, Directors will be required to provide status updates and draft submissions when applicable. 4. Once a quarter, a federal compliance requirement will be selected to have a deep dive review. 5. An HQ Administrative Assistant will be hired to monitor compliance as well as adherence to deadlines and will prepare a monthly report for the Executive Director’s review.

COMMONWEALTH OF PUERTO RICO CORRECTIVE ACTION PLAN MUNICIPALITY OF NARANJITO FOR THE FISCAL YEAR ENDED JUNE 30, 2023 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and 2 CFR 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Audit Period: July 1, 2022 – June 30, 2023 Fiscal Year: 2022-2023 Principal Executive: Hon. Orlando Ortíz Chevres - Mayor Contact Person: Mrs. Belinda Álvarez, Finance Director Phone: (787) 869 – 2200 Original Finding Number: 2023-005 Statement of Concurrence or Nonconcurrence: We concur with the finding. Corrective Action : Quarterly Progress Reports for large projects will be prospectively adjusted to reflect expenditures incurred over the reporting period. Implementation Date: March 31, 2025 Responsible Person: Mrs. Belinda Álvarez - Finance Department Director

Finding 2023-002: Reportable Finding Considered a Significant Deficiency – Reporting Assistance Listing Number: 10.181 Agency: U.S. Department of Agriculture Program: Pandemic Relief Activities: Farm and Food Worker Relief Program (FFWR) Award Number: AM22FFWDC0002-02 Grant Years: 2023 Views of Responsible Officials – We acknowledge the finding regarding the reconciliation of Form SF-425 for the period November 4, 2022, through April 3, 2023. The issue arose because the preparer did not properly reconcile financial records or obtain a secondary review prior to submission. We are committed to maintaining compliance with 2 CFR sections 200.328 and 200.329 and have already taken corrective steps. Corrective Actions – Root Cause Analysis: The deficiency was caused by the preparer’s failure to review and reconcile Form SF-425 with the financial records prior to submission. The preparer submitted the form without verifying the accuracy of the data. Revised Reporting and Review Process: • Action: We have implemented a formal review process where all Forms SF-425 are reconciled with the financial records before submission. This process includes: o The preparer reconciles the financial data with the underlying financial records. o A mandatory review by the Finance Director or another senior finance officer before submission. o Final approval is given by the Program Director and then the President. • Results: This process was successfully implemented for the April 4, 2023, through October 3, 2023, filing, significantly improving accuracy and compliance. • Responsible Person: The Finance Director is responsible for overseeing the reconciliation and review process. • Timeline: The new process is already in place and was followed for the second filing in 2023. Documentation of Review and Approval: • Action: All review and approval process steps are documented through email communications, ensuring that each step—from reconciliation to final approval—is tracked and recorded. • Responsible Person: The Finance Director ensures that email approvals are completed and stored as part of the official documentation. • Timeline: This documentation process is currently in place and was followed for the April 4, 2023, through October 3, 2023, submission. Conclusion: The corrective actions outlined above have been implemented and are already showing positive results, as demonstrated by the successful filing of the April 4, 2023, through October 3, 2023, From SF-425. By ensuring that every Form SF-425 is reconciled and reviewed before submission, we are confident that these measures will prevent future discrepancies. Completion Timeline: The revised review and approval process is fully implemented and has been successfully applied to the April 4, 2023, through October 3, 2023, filing.

Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Alliance Director Corrective Action: The Alliance will enhance its procedures and internal controls to ensure that records of report submission are appropriately retained. Anticipated Completion Date: December 31, 2024

Finding 2023-002 - Source Documentation (Significant Deficiency) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) CARES 5311 Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring accurate and timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper grant accounting, reporting, and reimbursement. Questioned Cost: No Context: Internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures created a potential for inaccurate, incomplete reporting. Repeat of a Prior-Year Finding: Yes, Findings and Questioned Costs 2022-003 Recommendation: The District should continue to improve grant accounting efforts, and establish a more simplified and effective process for the review and approval of grant accounting and reimbursement requests. Additional training of management should occur to ensure they fully understand all compliance regulations and have the skills to assist in designing and implementing effective controls. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. . Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District

Management of the Town will work to adopt a formal federal reporting policy and monitoring system that will ensure accurate and timely reporting of all grants. The Town will also assign a reporting leader to become familiar with all reporting requirements and monitor the timeline of the reporting requirements.

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Although the funds were transferred to utilities and not paid directly from ARPA Funds, the funds were used to make necessary investments in utility infrastructure during 2023. We have been fully informed of the guidelines for the use of the ARPA funds since this transfer occurred and will use the remaining funds according to the ARPA guidelines. The Clerk-Treasurer has contacted the Department of the Treasury to get guidance on what can be done to rectify our misuse of the funds. Anticipated Completion Date: Unknown- When a resolution is reached with the Federal Government.

Finding 2023-006 – Coronavirus State and Local Fiscal Recovery Funds - Reporting (Significant Deficiency) Criteria: "The financial management system of each non-Federal entity must provide for the following: (2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in §§ 200.328 Financial reporting . . . ." 34 CFR 76.722 states: "A State may require a subgrantee to submit reports in a manner and format that assists the State in complying with the requirements under 34 CFR 76.720 and in carrying out other responsibilities under the program." Context: There was no documented review by someone other than the preparer of the annual report to ensure the information submitted was complete and accurate. Per discussion with management, verbal review occurred but there is no documentation to support that review occurred. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that review of the annual report is documented. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect in 2024.

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purpose of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. The Health Issues and Challenges grant is a reimbursable grant, whereby the County received reimbursement on a percase basis at a stated rate for Case Management and Environmental Investigation activities performed. The Department of Health received federal receipts related to the grant in the amount of $130,479 during 2023. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. Receipts of the program were adequately identified through the use of an account number within the County Health Fund (285) in the Allen County's ledger (ledger) which was unique to the Health Issues and Challenges grant receipts. However, the ledger did not adequately identify the expenditures of the grant program within the County Health Fund. Through inquiry with the Department of Health employees and review of unitprepared support of grant expenditures, we determined expenditures were made with grant funds during the audit period, however, we were unable to distinguish between the expenditures of the Health Issues and Challenges grant and all other activities of the Department of Health in the County Health Fund. Due to the lack of separate identification of expenditures in the financial records, we were not able to establish a population from which to audit the Health Issues and Challenges grant for compliance with the following compliance requirements of the program: 􀁸 Activities Allowed or Unallowed 􀁸 Allowable Costs/Cost Principles 􀁸 Period of Performance 􀁸 Procurement and Suspension and Debarment As such, the full award amount of $130,479, as reported on the Schedule of Expenditures of Federal Awards, was determined to be questioned costs. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Recommendation: We recommend that management of the Health Department establish a system of internal controls to ensure that grant award funds are adequately accounted for and tracked in such a manner as to determine the activity, receipts and disbursement, associated with the grant. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: When we were informed of the outcomes of the SBOA audit and the subsequent needs for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP. We feel this finding/issue could be easily remedied by following our normal procedure for grants, whereby we develop a new fund, craft a Fund Ordinance for approval by the Allen County Commissioners to establish said new fund, and then subsequently track all expenditures and reimbursements in the separate fund vs. utilizing a line item for deposits in the main Health Fund as was done with this grant (which lacked the ability to denote exact salary expenditures and such next to each payment as it was all done within the larger fund for all staff and expenses. We were not aware of this need. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a separate fund will be created through development and approval of a local fund ordinance. All expenditures allowed by said grant and all reimbursements received by the grant funder will be tracked solely and only within the separate grant fund that is tied to the signed contract from the funder. If there are staff payments for salaries or benefits being reimbursed by a grant, we will ensure that: (1) the hours/minutes per staff member per pay period for all work associated with these grant duties are tracked appropriately so as to ensure we are invoicing the grant funder for the exact and accurate work hours (regardless of whether or not the grant contract specifies this be tracked or reimbursed per minute/hour, as most do not require this); and (2) these amounts will be noted alongside the expenditures in the grant fund for clarity upon invoicing or auditing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024. This is the standard practice for most grants we have accepted, and therefore, we will not vary from this practice in the future even if given permission to do so.

Corrective Action Plan: Management is developing a process to include a periodic review of all compliance aspects related to the grants including financial and performance reporting. This will be completed by December 31, 2024. Individual responsible for corrective action plan: Steven Ramirez

FINDING 2023-002 Finding Subject: COVID- 19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For one of the three reports tested, the report was not supported by the unit’s records. The financial information provided did not agree with the data submitted in the Reports, therefore we could not determine their accuracy. Contact Person Responsible for Corrective Action: Matt Miles Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will work to ensure the ESSER report amounts tie to the accounting records and will improve record keeping of supporting documentation. If the amounts do not match, District will document support for all claims. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

Finding 2023-003 Reporting – Internal Control and Compliance over Reporting Information on the Federal Program: Assistance Listing Number: 21.027 Federal Program Name: Coronavirus State and Local Fiscal Recovery Fund Federal Agency: Department of Treasury Pass-Through Entity: N/A Federal Award Number and Award Year: N/A - FY22-23 Criteria: Title 2 - Grants and Agreements. Subtitle A - Office of Management and Budget Guidance for Grants and Agreements. Chapter II - Office of Management and Budget Guidance. Part 200 - Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. Subpart D - Post Federal Award Requirements. Performance and Financial Monitoring and Reporting. §200.328 – Financial Reporting (2 CFR 200.328): Unless otherwise approved by OMB, the Federal awarding agency must solicit only the OMB-approved governmentwide data elements for collection of financial information (at time of publication the Federal Financial Report or such future, OMB-approved, governmentwide data elements available from the OMB-designated standards lead. This information must be collected with the frequency required by the terms and conditions of the Federal award, but no less frequently than annually nor more frequently than quarterly except in unusual circumstances, for example where more frequent reporting is necessary for the effective monitoring of the Federal award or could significantly affect program outcomes, and preferably in coordination with performance reporting. The Federal awarding agency must use OMB-approved common information collections, as applicable, when providing financial and performance reporting information. Title 31 – Money and Finance: Treasury. Subtitle A – Office of the Secretary of the Treasury. Part 35 – Pandemic Relief Programs. Subpart A – Coronavirus State and Local Fiscal Recovery Funds. § 35.4 Reservation of authority, reporting. (c) Reporting and requests for other information. During the period of performance, recipients shall provide to the Secretary periodic reports providing detailed accounting of the uses of funds, modifications to a State or Territory’s tax revenue sources, and such other information as the Secretary may require for the administration of this section. In addition to regular reporting requirements, the Secretary may request other additional information as may be necessary or appropriate, including as may be necessary to prevent evasions of the requirements of this subpart. False statements or claims made to the Secretary may result in criminal, civil, or administrative sanctions, including fines, imprisonment, civil damages and penalties, debarment from participating in Federal awards or contracts, and/or any other remedy available by law. Condition: For the Coronavirus State and Local Fiscal Recovery Funds (SLFRF), the City did not submit the reports within the required deadline: Report Type Report Type Period Date Due Date Submitted Project and Expenditure Report Performance Report 1/1/23-3/31/23 4/30/2023 5/3/2023 Project and Expenditure Report Performance Report 4/1/23-6/30/23 7/31/2023 8/25/2023 Four (4) performance reports were tested and two (2) of the reports tested were not submitted by the required deadline. In addition, expenditure information reported on the Project and Expenditure Reports were not supported by the City’s accounting records and did not match expenditures reported on the SEFA. This was due to the City not reporting the Revenue Replacement project expenditures of $4,821,936. The City’s Corrective Action Plan: The City concurs with the auditors’ finding. The City will take steps to improve identification and monitoring of required grantor reporting deadlines. Contact person responsible for corrective action: Betsy Howze, Interim Finance Director Anticipated completion date: June 30, 2024

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs / Cost Principles, Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Any transfers that happen, will be reviewed, and will have better documentation of what claims made the transfer happen and make sure supporting documentation is attached to the claim to prove the use of the transferred funds. Anticipated Completion Date: Immediately

The Management of Franciscan Alliance, Inc. and Affiliates (“Franciscan”) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities, especially as they relate to the funds received from the Federal government. Management has continued to promote sound business practices and effective internal controls across the organization through communication, training, and consistent enforcement of the Franciscan’s policies. The following are the Views and Corrective Action Plans of Management regarding the Schedule of Findings and Questioned Costs for the year ended December 31, 2023 for Franciscan Alliance, Inc. and Affiliates. AUDIT FINDING 2023-001 – Compliance with Reporting Requirements MANAGEMENT’S RESPONSE: Management concurs that the Programmatic Report due December 28, 2023 was not submitted until July 25, 2024. CORRECTIVE ACTION PLAN: Franciscan submitted the report on July 25, 2024. Franciscan created an additional tracking system to document reporting requirements for all grants, provide reminders, and document the submitted date. The tracker is prepared and reviewed monthly, with appropriate segregation of duties, to ensure all reports are being submitted accurately and timely. Franciscan now verifies the appropriate individuals have access to reporting systems in advance of reporting due dates. RESPONSIBLE PERSONS: Gregory Pantale, Director Grant Administration, Franciscan Alliance, Inc. COMPLETION DATE: September 2024

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full – range of controls relating to reporting, including federal program reporting. MARR will take such steps as necessary to ensure that reports are timely and accurately prepared, reviewed, and approved prior to filing. All controls, including review and approval will be documented in such documentation to be maintained.

Re: Information missing SLFRF reporting for revenue replacement. As per my conversation with Eric Rochoe at Treasury on 8/27/24, when the reporting period opens in April 2025, I am to add the revenue replacement amount of $5,227,729.00 in the obligaiton line.