Corrective Action Plans

Finding 2022-006: Reporting Federal Agency Name: Department of Health and Human Services CFDA #93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: Through testing of one programmatic report, the number of adults and children served during the reporting period included six individuals twice. As a result of a software change during the grant year, management combined the listing of adults and children served from two electronic health record systems and did not identify these six individuals were duplicates in the listings. Responsible Individuals: Project Directors (Missy Martini, Rebecca McCrackin) and CEO (Dan Ries) Corrective Action Plan: CEO will review reports prior to submission and will do random testing of numbers included in the report to ensure numbers reported have supporting documentation. Documentation used to complete the required reports will be retained by the Center. Anticipated Completion Date: This process was implemented beginning January 2023.

Finding 2022-004: Reporting Federal Agency Name: Department of Health and Human Services CFDA #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: Through testing of one programmatic report, amounts reported did not agree to supporting documentation. Programmatic information included within the report were included in the wrong category for services provided to adults and children and amounts were included in two categories for services in which no adults or children were provided services. The preparer of the report improperly input the case sizes within the incorrect column within the report and entered incorrect information in two instances. The report included programmatic information in the wrong categories for services provided and services not provided to adults and children. Responsible Individuals: Project Directors (Christina Eggink-Postma, Sarah Heinrichs) and CEO (Dan Ries) Corrective Action Plan: CEO will review reports prior to submission and will do random testing of numbers included in the report to ensure numbers reported have supporting documentation. Documentation used to complete the required reports will be retained by the Center. Anticipated Completion Date: This process was implemented beginning January 2023.

Recommendation: We recommend that the University post and maintain the Student Aid Quarterly reports on the University?s website, as required. In addition, in order to prevent similar instances in the future, we recommend the University ensure interpretation of guidance is accurate through use of trainings, consultations and direct correspondence with the regulatory agency, when necessary, to ensure full understanding of reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The university agrees. OSU reported the HEERF student aid portion quarterly on our reporting webpage. We initially interpreted the guidance to mean that at each quarter we should update the report the total student portion on the webpage to be cumulative and the previous quarter report was removed from the website. OUS will go back and report each quarter separately instead of as one aggregate total. We will post this data on the current reporting page by February 10, 2023. Name of the contact person responsible for corrective action: Keith Raab, Director of Financial Aid Planned completion date for corrective action plan: February 10, 2023

December 9, 2022 Aldrich CPAs + Advisors LLP 7676 Hazard Center Drive, Suite 1300 San Diego, CA 92108 RE: Corrective Action Plan Dear Aldrich, The following are responses to the finding identified in Union of Pan Asian Communities (UPAC) audit for the year ended June 30, 2022: 1) Finding 2022-001 a. Program Information: 93.778 Medicaid Cluster ? Medical Assistance Program, Pass-Through Awards #560005 and #555861 b. Criteria: In accordance with 2 CFR 200.329, non-Federal entities must submit performance reports at the interval required by the Federal awarding agency or pass-through entity no later than the specified due date. If a justified request is submitted by a non-Federal entity, the Federal agency may extend the due date for any performance report. c. Condition: During our audit, we identified two quarterly status reports that were submitted to the Contracting Officer?s Representative (COR) after the stated due date. Response: UPAC has put in place to email those staff who are responsible for submitting the performances reports to the Contracting Officer?s Representative a few days before the stated due date. Contact persons responsible for corrective action: 1) Annette Phan, Chief Financial Officer 2) Manuel Mercado, Staff Accountant Completion date: Additional internal control procedure noted above will be effective immediately. Sincerely, Margaret Iwanaga Penrose Chief Executive Officer Union of Pan Asian Communities

2022-002 Internal Control over Compliance and Compliance with Reporting (Preparation of Schedule of Expenditures of Federal Awards) Auditor Recommendation: We recommend management attend Federal award trainings and information to ensure the documented policies and procedures can be performed as described. This will ensure the Federal funds are reported accurately on the SEFA and that programs are reported under the correct assistance listing number. Corrective Action: The year ended August 31, 2022 was the first year in which the Center expended federal awards in excess of the limit that requires a Single Audit. Since receiving the EIDL loan, the Center maintained detailed tracking and documentation of all disbursements associated with the loan and understood such expenditures exceeded the $750,000 threshold for a Singe Audit during the fiscal year ended August 31, 2022. With the clarification of the specific rules surrounding the disclosure of EIDL loans on the SEFA, management will continue to review Federal Award guidance and requirements to ensure compliance with current and future federal awards. Name of Responsible Contacts: Larry Goodpaster, Director of Finance & Operations, and Kelly Martin, Accounting Manager Projected Implementation Date: May 1, 2023 and ongoing

Finding Number: 2022-001 Untimely and Inaccurate Reporting - Planned Corrective Action: Management met with assigned Department of Education grant representative via telephone and received instructions for submitting revised quarterly HEERF reports. The Controller will revise all applicable quarterly reports for review and approval by the Chief Financial Officer. Management will re-submit the reports to the Department and post on the College's website as required. Person Responsible for Corrective Action Plan: Quintress Hollis (Controller). Anticipated Date of Completion: April 30, 2023.

FINDING 2022-005: CAFETERIA NUTRITION CLUSTER REPORTING The Deputy Treasurer prints, verifies, initials the Employee Trial Balance Report (Payroll Report) every pay period. The Treasurer reviews these reports, but has not initialed them. Corrective Action Plan: The Treasurer will begin reviewing and initialing these reports for FY 2023. The Cafeteria Director will submit the child reimbursement form to Central Office for review and verification prior to submission for payment to the Indiana School Lunch Program for FY 2023.

FINDING 2022-008 Contact Person Responsible for Corrective Action: Dan Durrwachter Contact Phone Number: 765-473-3081 Views of Responsible Official: We agree with these findings. Description of Corrective Action Plan: The financial specialist will prepare a report the data for the reports and will be approved by the treasure to ensure accurate FTE is reported before submitting the reports. Anticipated Completion Date: : 6/01/2023

FINDING 2022-009 Contact Person Responsible for Corrective Action: Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Documentation to support reporting data will be prepared by the business office. Full-time equivalent positions will be reviewed by the Human Resources department to ensure that the FTE positions reported are accurate. This will be signed by the preparer, Human Resources, and the program administrator. All ledger expenditures will be included in any report requirement. The prepared report and supporting documentation will be reviewed and approved by Assistant Superintendent, Tracey Noe. Anticipated Completion Date: May 2023

The Controller and Compliance Officers are working together to correct the previously filed reports to update the estimated total number of students at the institution that are eligible to receive Emergency Financial Aid Grants to Students under the CARES (a)(1) subprogram and the CRRSAA and ARP (a)(1) subprograms. Completion Date: April 2023 Contact Person: Tom Corley, Controller and Director of Fiscal Operations and Carrie Stevens, Associate Vice President of Compliance

County Judge/Executive?s Response: The fiscal court would like to point out that ARPA funds were properly distributed. During this time there was little guidance on how to manage the reporting. All reporting has been corrected.

The university website has been updated to include estimated total number of students at the institution that were eligible to receive Emergency Financial Aid Grants to Students under the ARP (a)(1) subprogram.

ARPA Business Support Program ? Assistance Listing No. 21.027 Recommendation: CLA recommends that the Chamber submits Performance Progress Reports in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Chamber is not expecting to receive federal funds exceeding the $750,000 single audit threshold in the future, but the Chamber is committed to ensuring all reports are filed for any funds received in the future. Name of the contact person responsible for corrective action: Colin Hastings, Executive Director Planned completion date for corrective action plan: May 2023

Corrective action plan: TWC has already reviewed all ACF-196R and ACF-204 Report queries and made the appropriate criteria modifications to appropriately reflect and report Agency activities. The query review and modifications were completed in October 2022, and subsequent Federal Financial Reports, for active TWC grants, were modified to reflect accurate cumulative activities. Implementation date(s): October 31, 2022 Responsible persons: Teri Goodwin, Financial Reporting Manager

FINDING 2022-002 Contact Person Responsible for Corrective Action: Shannon Fritz, Corporation Treasurer Cathy Rowe, Superintendent Contact Phone Number: 219-567-9161 Views of Responsible Official: We concur with the audit findings. We have initiated corrective action as referenced below and will strive to ensure a proper system of internal controls. Description of Corrective Action Plan: The treasurer and superintendent will both review and sign all federal financial reports prior to submission. Anticipated Completion Date: January 1, 2023 Cathy Rowe, Superintendent Shannon Fritz, Corporation Treasurer Date: 2-27-23 Date: 2-27-23

Finding 2022-004 Condition Based on the controls in place as described by staff of the organization, there were multiple instances of invoices and timesheets that did not contain evidence of approvals. Corrective Action Plan We understand the auditor?s comments and the following action will be taken to resolve the situation. We will further develop policies and procedures, in addition to following those already in existence, for reviews and approvals. This process will be implemented and adhered to immediately.

2022-003 Performance Reporting Microloan Program ? Assistance Listing No. 59.046 Recommendation: We recommend management develop procedures to ensure the required reporting is completed within the timeline allowed by the granting agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New staff has been trained and the reporting calendar updated. CFO/COO to monitor and submit in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Nasibu Sareva (CEO) and Felicia Ravelomanantsoa (CFO/COO) Planned completion date for corrective action plan: 12/31/2023

Finding 2022-002: Significant deficiency in internal control over reporting. Summary: Although total award expenditures for the year agreed to the amount reported, quarterly reporting and annual reporting submitted for grant tracking did not match quarterly information as per accounting records. Corrective Action Planned: Written policies and procedures over the review and approval of Federal Award reporting will be updated to ensure complete and accurate reporting of award expenditures. Anticipated Completion Date: By Sept 30, 2023. Name of Contact Person Responsible for Corrective Action: Tammy Rash, Administrative Services Director

FINDING 2022-005 Finding: Internal controls were not in place/effective in relation to the Title I Annual Expenditure Reports filed during the audit period. Subsequently, the 20-21 Title I Annual Expenditure Report did not agree with School Corporation?s ledgers. $578,452 of expenditures were reported the Annual Expenditure Report and $677,514 from Fund 4121 on the ledgers. Contact Person Responsible for Corrective Action: Carrie McGuire Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: When required annual federal grant reports are completed for submission, they will be reviewed by the treasurer for accuracy. Both the treasurer and the grants coordinator will sign off on the reports. In order to address the issue related to earmarking and set-asides within Title I not be completed, Concord Community Schools created a Grants and Assessment Coordinator position in May 2022. A person was hired to fill this position starting on July 1, 2022. One of the essential functions of this position is maintaining current and accurate records related to federal and state grants. Starting in January 2023, in addition to the Grants and Assessment Coordinator, a member of the business department will be a second reviewer and sign the semi-annual certifications. Anticipated Completion Date: December 31, 2023

UDC OCFO agrees with the conditions and recommendations of this finding. No action is required since UDC has already implemented corrective action to maintain evidence of submission of quarterly reports to the UDC webmaster. UDC also developed a sign-off coversheet to document evidence of review by the preparer, the reviewer and approver of the quarterly and annual reports. See Corrective Action Plan for chart/table

FINDING 2022-006 Contact Person Responsible for Corrective Action: Tyler C. Osenbaugh Contact Phone Number: 260-336-0217 Views of Responsible Official: Agree with the finding Description of Corrective Action Plan: Meal counts differed from the Meal Magic generated Z report and the Chartwells Profit and Loss statement. These meal counts are reconciled by dividing the a la carte purchases by $2.70 to equate to a meal served. Future Z reports will have the a la carte meal equivalents indicated. These figures will be reviewed and validated during the monthly meeting between School Food Authority and Food Service Director (Chartwells? Director of Dining Services). Anticipated Completion Date: April 2023

Views of Responsible Officials and Planned Corrective Action The HPU Office of Sponsored Projects (OSP) and Office of Financial Aid work to follow all federal reporting regulations and guidance mandated for the Federal grant & contract programs. For future programs, the Institutional Research, the Office of Sponsored Projects and the Financial Aid Office will generate the reports and will implement layers of review procedure to ensure that the reports are accurate, complete, submitted timely, and if needed, posted in HPU website. For the Institution portion, the Manager for Grants and Contracts will prepare the grant report and this report will be reviewed by the Assistant VP for OSP. For the student portion the periodic reports will be prepared by the staff of the Office of Financial Aid and will be reviewed by the Director of the Financial Aid office. The Business Office will perform a high-level independent review for completeness and accuracy. Finally, moving forward, all the files and documents that support the grant report will be retained. Person Responsible: Manager, for Office of Sponsored Projects & Assistant VP for Office of Sponsored Projects, Director of Financial Aid Targeted Correction Date: June 30, 2023.

FINDING 2022-003 Subject: COVID-19 ? Education Stabilization Fund - Reporting Person Responsible for Corrective Action: Tammy Whisenant ? 219-962-1159 Views of Responsible Official: We concur with the finding. I have viewed and acknowledge the discrepancies listed. However, as I am new to my position, I am unable to determine the cause of the discrepancies. Personnel responsible for these areas assumed responsibilities just prior to and/or after this audit period commenced. Description of Corrective Action Plan: The corrective action will include: 1) Assess current assignments and identify opportunities to implement multiple level of review and verification. 2) Continue improved training, education and professional development of personnel responsible for financial transactions and reporting relating to federal programs. 3) Improved use of technology-based financial systems to ensure effectiveness and accuracy of financial transactions and reporting for federal programs. Anticipated Completion Date: An assessment of actions, needs and a plan will be completed by April 30, 2023; with an implementation to occurring by June 30, 2023. ________________________________ Tammy Whisenant, Director of Finance/Treasurer Lake Station Community Schools February 28, 2023

Responsible Official ? Kyle Dombrowski, Director of Tax and Financial Reporting During bi-weekly meetings with the grant office, we will ensure that we are aware of deadlines and that we will files reports in a complete, accurate, and timely manner. Anticipated Completion Date: 3/30/2023

United States Department of Health and Human Services Infinity Health respectfully submits the following corrective action plan for the year ended November 30, 2022. Audit period: December 1, 2021 ? November 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT None FINDINGS?FEDERAL AWARD PROGRAMS AUDITS United States Department of Health and Human Services 2022-001 Reporting ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend that multiple members of management be involved in the preparation and review process of the UDS report, and that supporting documentation, which agrees to the amounts in the report, be saved in a manner which allows for easy access and recovery if needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We believe the inability to provide sufficient supporting documentation for the 2021 UDS report to be an anomaly due to the extenuating circumstance of a flood that closed Infinity Health?s main administrative building during the preparation of the 2021 UDS report. The preparation of the 2022 UDS report was completed by the CEO, CFO, COO and Director of Quality and Efficiency. All supporting documentation has been reviewed and saved on a network drive that allows for easy access, recovery and back up retrieval if necessary. Name(s) of the contact person(s) responsible for corrective action: Samantha Cannon, CEO, and Michelle Leonard, CFO. Planned completion date for corrective action plan: 4/26/2023