Corrective Action Plans

Finding 2022-001 Program: Shuttered Venue Operations Program Assisting Lister Number: 59.075 Federal Grantor: U.S. Small Business Administration Passed-through: N/A Award No. and Year: SBAHQ21SV002930.2 and 2022 Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Material Weakness in Internal Control and Instance of Non-Compliance Management?s Response or Department?s Response Management agrees with the recommendation. Views of Responsible Officials and Corrective Action Management has designed controls for the supervisors to show evidence of the approval of the timecards and ensure the costs are allowable costs and activities allowed. Anticipated Completion Date September 2023. Contact Information of Responsible Official Name: Jim Shaw Title: Director Phone: 661-665-1450

FINDINGS - FEDERAL AWARD PROGRAM AUDITS U.S. DEPARTMENT OF EDUCATION Finding: 2022-001: IDEA - Part B, Section 611 (84.027) & IDEA - Part B, Section 619 (84.173) Recommendation; We recommend that the District have proper internal controls in place to ensure that the employees working in the grants are certifying their actual percent of time and effort that is being spent working in the federal award program. Monthly certifications should be completed if less than 100% of time is being worked in the federal award program or semiannually if 100% of time is being spent. Corrective Action Plan: The District will implement a system of internal controls to ensure that all certifications are completed in accordance with the percentage of time worked (ie. Monthly or semiannually) and that they are completed timely. Additionally, the District will ensure that time being charged to the grant agrees to actual time spent working in the grant for each employee. Anticipate,/ Completion Date: Currently in process with a final expected date of October 31,2022.

Finding 2022-002 The Center?s use of spreadsheets for labor allocations did not provide a documented system of internal control that could be used to test changes to allocation made during the year. Corrective Actions Taken or Planned: Management concurs with this finding. On March 1, 2023, Carole Robertson Center for Learning transitioned tracking of labor costs to our human resource information system, Paycor. This has been a work-in-progress which began in the fall of 2021. The result has been accomplished with diligence, attention to detail, efficiency and accuracy during a period a significant growth. Each pay period, Paycor produces a Job Costing Report that supports the reimbursement process for labor costs. Further, the content of the Job Costing Report seamlessly exports these costs to the general ledger for each pay period. A formal approval process will be established to connect the flow of documentation from budgeting, to actual costs incurred, to the reimbursement from funders so that verification of each element (grant budget development, payroll, cost allocations, general ledger entries, and reimbursement requests) will match/reconcile without requiring recalculation. The contact person is Peg Heslinga, Chief Financial Officer. SAGE Intacct accounting software will be implemented with a planned go-live date of July 1, 2023. The contact person is Peg Heslinga, Chief Financial Officer. Our Accounting Policies and Procedures will be reviewed by November 1, 2023, and revised to reflect accounting policies that have been modified since the previous version was approved in September 2022. Going forward, these policies will be reviewed annually for needed revisions. The contact person is Peg Heslinga, Chief Financial Officer. The Controller, the Director of Accounting, the Director of Contracts Management, and the Contracts Manager will attend Uniform Guidance training, and all positions within the Finance Department will be reviewed to determine additional training and education needs. Implementation is planned for completion by September 30, 2023. The contact person is Peg Heslinga, Chief Financial Officer.

Respectfully, the school corporation does not agree with several of the findings in regards to segregation of duties and purchases. First, the SBOA auditors' told the school corporation during the 2019 audit that operating the school lunch program through the extracurricular account was not legal. The school corporation was informed that this account must be transferred to Central Office and a Corrective Action Plan must be in place. This directive was incorrect and pointed out in the official response from November 5, 2019 under IC 20-26-5-4(a)(l l). Second, segregation of duties, oversight, and approval of functions existed in 2019 and are presently occurring daily, weekly, and monthly within the cafeteria program under the corporation accounts and supervision of Central Office. Cafeteria workers record and submit timesheets of duties performed during each payroll period. The Cafeteria Director verifies and signs timesheets to be submitted to the Treasurer and Deputy Treasurer for review and payment from the Cafeteria account. A payroll docket report is sent to the Superintendent prior to payment from the bank. Prior to the 2019 audit, the High School Treasurer spent approximately two hours per day counting cash received each day from school lunches purchased. She also receipted those funds it into the software system, made deposits to the bank, paid invoices for food expenses, and processed part of payroll. Tasks conducted by the High School Treasurer were segregated by a timesheet and supervised by the High School Principal. All those tasks were shifted to Central Office in 2020 and are now segregated to the Treasurer and Deputy Treasurer. The Treasurer documents hours spent on Cafeteria accounts on a timesheet for review and signature by the Superintendent. Financial reports of expenditures and revenues are provided for review and oversight to the Superintendent and School Board at monthly board meetings. Third, RSSC has a small Central Office consisting of a Superintendent, Treasurer, Deputy Treasurer, and Secretary. It has no Assistant Superintendents, Human Resources Director, or Business Manager. Each person in Central Office wears multiple hats and performs multiple duties each day. It was noted in the Audit Report filed from July 1, 2008 to June 30, 2010 that " ...Randolph Southern School Corporation is unable, due to financial limitations, to employ additional personnel to segregate duties in our receipts and cash and investment balances. This statement would apply to all of our internal controls. " The circumstances for RSSC have not changed in the audit periods from July 1, 2010 through June 30, 2022. Corrective Action Plan: The School Board had chosen not to add additional staffing due to costs. RSSC is still unable to segregate duties for financial transactions and reporting. Fourth, the Cafeteria Program only has one full-time staff member, the Cafeteria Director. Eight part-time cafeteria workers prepare and feed up to 300 students each day. This food service program is one of the best run programs in the State oflndiana. It has not had one food preparation or sanitation violation from IDOE or Department of Health in the last 12 years. Fifth, the Cafeteria Program is economically efficient and fiscally responsible. The account carries at least a 3-month cash balance at all times. This success is a direct result of oversight by the combination of the Superintendent, Treasurer, and Cafeteria Director. RSSC adopted board policy 6114 Cost Principles-Spending Federal Funds on May 9, 2016. RSSC has had an Indirect Cost Rate in place since 2013. The adopted policy allows the school corporation to apply Indirect Costs to all federal funds including the Cafeteria account. On December 5, 2019, email communications between the Dr. Donnie Bowsman, Superintendent and Tina Herzog, IDOE Assistant Director of Operations and Food Distributions clearly state the school corporation can apply the Indirect Cost Rate to the Cafeteria account. The email communication clearly states that the high cash balance was a result of not applying the Indirect Cost Rate to the Cafeteria account (See Exhibit 1 Emails). The Indirect Rate was approved by the IDOE Office of School Finance and existed prior to the audit years being referenced in the finding. Technically, the prospective portion (going forward for the next school year) as referenced on pages 24-25 of USDA Indirect Cost Guidance Manual pertains to the 2013 Fiscal Year. Moreover, the fact was reiterated by the IDOE School Nutrition Office with email communications on December 5, 2019, not 2021 or 2022 as referenced in the finding. RSSC has not charged or recouped the Cafeteria Account the Indirect Cost rate for many years and has subsidized this account which should be independent and self-sufficient. The School Corporation did not apply the Indirect Cost Rate in 2020 or 2021 because we were not sure how many students would be eating and how fiscally sound the account would be due to students not attending school because of COVID. Corrective Action Plan: The Indirect Cost Rate will be applied and collected in the future prior to June 30 of each current fiscal year. It should also be noted that in 2021, RSSC purchased a new cafeteria dishwasher utilizing ESSER II funds. This unit was 20+ years old and needed to be replaced in order to continue feeding children and to run the food service program. This expense could have been and should have been a direct cost of $58,189 to the Cafeteria account. However, due to the unknown circumstances of COVID, the RSSC could not take a chance. The ESSER II grant is still open and we are now questioning whether this expense could be charged directly to the Cafeteria account. Those ESSER II fund could be utilized for staffing to support student learning loss and remediation. Sixth, COVID caused this financial account to increase exponentially from 2020 to 2021. ESSER funds were provided by the federal government to provide free lunches to every child which paid the food operations expenses for two school years. Student participation of eating school lunches increased during these time periods. Additionally, staff members were receiving hazard pay incentives on top of their regular hourly rate. Further, the School Corporation and Cafeteria Program took on the enormous task of feeding children over the summers of 2020 and 2021 when COVID cases were at its peak. The cafeteria personnel fed 5286 and 5740 students respectfully during those summers. The number of meals served during the summer almost equaled the total amount of meals served during the entire school year for each respective academic year. These additional meals created additional unexpected revenues for the fiscal year. The school corporation did not charge mileage for satellite lunches being delivered or indirect costs.

To address the identified issue and enhance our internal control system for charges to Federal awards, Nourish Colorado will implement the following corrective actions: Enhancement of Timesheet Tracking: As July 2023 we initiated a comprehensive review and upgrade of our timesheet tracking system to ensure it accurately captures and allocates employee time spent on various funding sources or cost objectives. Employees will be provided with clear guidance on the importance of accurately tracking their time and correctly allocating it to specific projects or grants. Regular training sessions will be conducted to educate staff on the proper utilization of the improved timesheet tracking system. Supervisors and project managers will be responsible for monitoring timesheet compliance and addressing any discrepancies promptly.

Finding 2022-005 Condition One of the thirty-seven payroll transactions tested was more than actual costs incurred due to incorrect payroll information being used to calculate the payroll expense. Our sample was not statistically valid. Corrective Action Plan Corrective Action Planned: The reimbursement reports prepared by the Clerk of Courts will be reviewed by a person other than the preparer to ensure accuracy. The review will be completed before the reimbursement request is submitted to Child Support. Name(s) of Contact Person(s) Responsible for Corrective Action: Shelly Maas, Deputy Clerk of Courts Anticipated Completion Date: August 2023

FINDING 2022-002 ALLOWABLE COSTS AND ALLOWABLE ACTIVATES ? ABSENCE OF RECORDS IN SUPPORT OF PERSONAL COSTS CHARGED TO FEDERAL PROGRAMS (MATERIAL WEAKNESS) 1) Michael Greenberg, Chief Financial Officer Telephone: 212-949-5002 Email: mgreenberg@childrensaidnyc.org 2) Drema Brown, Head of School Telephone: 646-459-8415 Email: dbrown@childrensaidcollegeprep.org View of Responsible Officials and Corrective Action Plan: Plan: Charter School management has subsequently put in place policies and procedures to appropriately document costs allocated to federal and other awards. Steps include review and signoffs of timesheets, aggregated summaries and reconciliations to justify amounts charged to federal and all other funding sources. Interim processes include manual oversight, signoffs and paper-based processes followed later by best-practice time and effort electronic reporting systems and digital tracking. Extenuating Circumstances Relating To Finding: During the time period audited (July 1, 2021 to June 30, 2022) the Charter School did not have employee-signed timesheets. All federally funded supplemental payments to employees for after-school and summer tutoring were entered by the supervisors (i.e. school Principals) in Google trackers which were reviewed and approved by the Principals and Head of School on a bi-weekly basis. The Charter School?s timekeeping and payroll system during this same time period only tracked the regular 80-hour workweek. Approvals for supplemental payments were done via the Google trackers and emails confirming approval by the Principals and the Head of School. Prior to COVID, all compensable time (including supplemental payments) were tracked and monitored via the school?s timekeeping system which utilized biometric clocks for punching in and out. Supervisors could approve all of their employee?s time within that system. The New York State Education Department put a ban on biometric devices (including timeclocks) when the COVID crisis began (Summer 2020) and they have not reinstated their use. Bi-weekly hours for the regular work-week were entered manually since biometric clocks were not permitted. This also left a gap in our procedures for tracking additional or supplemental paid time which led us to create a system that relied on the use of the Google trackers and email approvals described above. Corrective Action: Management has updated its policies and procedures related to timekeeping and approval of timesheets to reflect staff?s hours worked and the sign-off on their own time for each day worked, including a Supervisory bi-weekly review and manual sign-off on these timesheets and final review and submission of timesheets to Payroll by the Sr. Manager of Operations and/or Head of School. Further, beginning in September 2023, all time will be tracked in a new digital timekeeping system that was implemented and training provided during the Summer of 2023 which is compliant with federal time and effort tracking best practices.

FINDING 2022-003 Contact Person Responsible for Corrective Action: Christopher Dixon, Director of Nutrition Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation will document the review/oversight of disbursements from program funds prior to payment. Claims will be prepared and reviewed by Christopher Dixon, Director of Nutrition, or designee, and submitted to the Accounts Payable Specialist for payment. Claims will be initialed or signed demonstrating approval of disbursements. Accounts Payable Specialist enters claims into the financial software and pays claims after approval by the Chief Financial Officer and School Board. Documentation for claims will be kept in the business office. GCS will obtain prior written approval from IDOE and approval documents will be maintained by the Director of Nutrition. Assistant Superintendent, Dr. Barry Younhans, retired from GCS in July 2022. This corrected the finding. To ensure compliance, the payroll distribution report is reviewed and signed by the Treasurer and applicable program administrators prior to the completion of payroll by the payroll specialist. The report is reviewed to verify that employees are paid out of the correct accounting line. This process was implemented in December 2022. Anticipated Completion Date: April 2023 INDIANA STATE

2022-001 Community Services Block Grant? CFDA No. 93.569 Noncompliance: Audit procedures revealed that there was a lack of clear documentation to support the actual hours that were allocated or expensed to each agreement. In practice, the Association records payroll expenses by award based on an estimate with a set number of hours allocated per week to each award. Actual payroll hours expensed to the grant were not tracked. Recommendation: We recommend that Management strengthen their processes, controls, and review over payroll recording and documentation to ensure compliance with Uniform Administrative Requirements, as well as their own time entry policies Responsible Person for Corrective Action: Megan Hannan, Executive Director Corrective Action to be Taken: Management and Administration will have new processes to document and track payroll hours and associated expenses to awards with quarterly review to adjust or validate expenses charged. There will be the additional involvement of a new fiscal agent as of January 2023 with significant skills, knowledge and experience working with Federal grants and compliance. The anticipated completion date for this corrective action is 9.30.23

As required the District is writing a corrective action plan to address Audit Finding 2022-001. This finding is in regards to the District not having all of the required time and effort logs for employees paid with federal funds, specifically, Title 6B. Our correct action is simple. We will insure that all employees paid for with federal funds account for 100% of their time spent charged to a federal grant. For hourly employees this is currently done with the certification of their hourly timesheets and was found to be in order. For our salaried staff, we did not have all of the correct documentation available for the Audit Team to review. We will use the forms supplied by the Wyoming Department of Education's Federal Grants Unit and maintain the original certifications in each of their personnel files. This should be adequate evidence that the employees' time is properly charged to the federal Title 6B grant. In addition, the District, will for the first time in its history, begin to use the indirect cost option available on some grants to fund a position to assist the grant managers in compliance and reporting on federal grants. This position has become more critical than we realized in response to the volume and variety of individual grant requirements. thank you for helping us correct this oversight and we look forward to your next review and a deficiency free audit of our federal funds. Sincerely, Jeremy W. Smith Business Manager

Finding 2022-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Through testing of operational expenditures of the College, it was determined; o Payroll expenditures charged to the award were not for costs newly associated with the coronavirus, a requirement communicated within the supplemental guidance in the Higher Education Emergency Relief Fund III Frequently Asked Questions published May 11, 2021 and updated May 24, 2021. Through testing of disbursements to students, it was determined; o No support could not be provided to substantiate a secondary level of review was completed prior to disbursement of funds. o 26 instances identified in which the College directly controlled how student?s use their emergency financial aid grant. o 8 instances identified in which college discharged outstanding balance on student account for costs incurred prior to March 13, 2020. o 2 instances identified in which the College charged coronavirus vaccine incentive payments under the student portion of HEERF award. Responsible Individuals: Dr. Lane Azure, President Corrective Action Plan: o In response to the payroll finding, this was funded through MSI (no Student or Institutional funds were used for payroll). SWC president attended weekly meetings with American Indian Higher Education Consortium (AIHEC) who assisted and advocated for these HEERF monies for all Tribal Colleges and Universities (TCU). Handouts (attached) of slides were given to each institution and Payroll was an allowable cost with the exception of the President. The college president believed in order to allow the college to stay open and not lose students and staff, subsidies had to be included in payroll. There were no predictions on how long this world-wide pandemic was going to last or how much funds the government was going to give to IHE. SWC is a small tribal college where hiring and maintaining qualified personnel has been difficult long before the pandemic and now even more so. SWC could not afford to hire new staff even if it was feasible to find someone to fill new positions. Therefore, SWC used HEERF to make payroll on many employees whose job duties changed so they could assist the college in staying open and transition to a completely different method of delivering education to SWC students. SWC president was told by the Department of Education and AIHEC that these funds had to be exhausted in a limited amount of time. In addition, there was a limited number of items that the funds could be spent on, but it was changing every day to be more liberal. In March 2020, SWC had to begin offering courses via distance delivery which was a completely new method for this college. In summer 2020, the college did not offer classes and in fall 2020 SWC had to begin offering a hybrid method of delivery. Every single employee of this college had to do their day to day duties differently in order to support the new delivery method for education ranging from contact tracing, hyflex delivery, social distancing, hygiene, masking up, staff meetings, parking, teaching, and etc. The range of employees went from admissions, student services, academic staff, faculty, and the business office. All employees were coming in at different shifts, and/or working remotely, while social distancing. o The College will ensure documented secondary level of review and approval is retained. o For grant payments funded by institutional portion, Grant payments were applied to student accounts and if no outstanding balance, a check was given to the student. For grants funded by MSI, a formula was used to distribute $125 per credit and an allowance for books and fees. The COARS was a financial aid grant to the student who applied for the relief. o Any debt relief provided for students was for those students who could not attend the current academic year because of a prior balance. In order to attend college during the pandemic, MSI funds were used to discharge the student?s balance at the discretion of the student. o The checks for these instances were given directly to the student to defray costs of going to get the vaccine, for transportation, for cost of the office visit, or whatever it may have been they needed in order to get the vaccine. It was emergency aid to the student. Anticipated Completion Date: July 1, 2022

FY22 Audit Corrective Action Plan: 2022-001 - Allowable Cost/Cost Principal Condition: During audit procedures, it was identified that the Unit did not complete the semi-annual time certifications/periodic time certifications for six employees. Cause: The CSD does not have the necessary internal controls over compliance. Effect: Expenses may not be properly allocated to the grant; this could result in unallowable expenses being charged and subsequently improperly reimbursed by federal funds Recommendation: It is recommended that the Unit implement internal control processes and procedures to ensure that time and effort records for employees working are properly documented in accordance with the grant requirements. FY22 Process: The Five Town CSD had regularly had each employee paid with federal money sign a semi-annual certification and that certification is maintained in the employee?s personnel file under Contracts. The CSD believes that these certifications had been pulled from the files by the prior business manager in an effort to compile compliance paperwork to the Maine DOE for reimbursement purposes. New Process: In addition to our practice of requiring compliance from the employee or supervisor with direct knowledge of the employee?s time and effort, we are preserving a digital copy in our federal funds cash management folders as well at attaching the document to the employee?s digital record so they are preserved and available for federal grant and audit compliance. Time and Effort records will be reconciled semi-annually with the general ledger documentation of grant funded salary expenditures. Responsibility: The Business Manager, Peter Orne, and Human Resources Director, Monica Gallagher, are responsible for the execution of the plan and subsequent reconciliation. Completion Date: This is an ongoing process and semi-annual certification for July 2022 to December 2022 has been reconciled.

Finding Number 2022-001 Planned Corrective Action - Significant Deficiency ? Internal Controls Over Payroll (Documentation of review of timesheets by an appropriate level of supervisor was not consistent) This finding was originally communicated to AIM after last year?s audit. AIM has included a policy in both its Financial Policies and Procedures and its Employee Manual that requires that timesheets be submitted to and approved by the employee?s supervisor. Compliance has been consistent since mid-October 2021. Anticipated Completion Date - October 15, 2021, Responsible Contact Person - Virginia Moss, CPA, Chief Financial Officer

Response to Finding #2022-002: The Business Office, in coordination with the Human Resources Department, is developing a process to ensure timely reviews and approvals of employee time and effort charged to federal programs is documented on a periodic basis. The corrective action is expected to be implemented by June 30, 2023.

FY 2022 Corrective Action Plan Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2021 ? 06/30/2022 Contract Number: FCSAK05984 Award Year: 2021 ? 2022 Comments on Findings and Recommendations: Finding 2022-001?Budget Based Salary Allocation (Compliance and Control Finding)? The Jewish Federation of Metropolitan Chicago (the Federation) allocated staff salaries to the federal program based on budget estimates, which alone does not qualify as support for charges to federal awards. The Federation allocated one employees? salary to the program based on a budgeted rate. All other employees have 100% of their salaries allocated to the program. 2 CFR 200.430(i) Standards for Documentation of Personnel Expenses (1) Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that the non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustment must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Action Taken?As the Federation does not have processes and controls in place for federal program time tracking, the Federation will only allocate staff to the program that spend 100% of their time on the program starting July 1, 2022. The required corrective action for Finding 2022-001 for the period 07/01/2021 ? 06/30/2022 was completed on July 1, 2022. The person responsible for completion of the corrective action plan was James Pinkston, Vice President, Accounting. James Pinkston Date Vice President, Accounting Jewish Federation of Metropolitan Chicago 30 South Wells Street, Chicago, IL 60606 Email: jamespinkston@juf.org

SAU 58 had a big transition our office with the replacement of all three of our accounting positions; Business Manager, Payroll/HR and Accounts Payable & Grants. The Accounts Payable position was then vacated for a second time and we found a new replacement in Jan 2022. During this transition period the Time and Effort for two positions that were grant funded, was overlooked. We did provide documentation of payroll from Payroll/HR but did not get the signature of the teacher or other staff member on the Certification form. Typically, we would have been able to rectify the omission but the employees had both left our district at the end of the school year. The Business manager is ultimately responsible for the implementing of the process and internal controls and will follow up with the Accounts Payable clerk to be sure each month all documentation is on file. Since the new AP person came on, she has implemented a spreadsheet to track each employee paid by Federal Funding. This way we know who has submitted their certification, and at what point we are at during the year. We will be looking at electronic documents in the future for easier tracking and getting signatures on certification documents but as of now the spreadsheet has made this process much easier to track and be sure we do not miss documents. If a big transition happens again the Accounts Payable Clerk will be responsible for all grant compliance paper work. The Business Manager will oversee this process. The above processes and procedures have already been implemented and the Business Manager will follow up monthly with the Accounts Payable clerk. Name of Contact Person and Completion Date: Name 1 Heather McMann Name 2 Tiffany Griffin Anticipated Completion Date ? Already implemented.

Finding 2022-007 Personnel Responsible for Corrective Action: Assistant Comptroller ? Brian Huggins Anticipated Completion Date: June 2023 Corrective Action Plan: The University's current process is to collect and retain procurement documents for no less than five years. The institution will work to strengthen the current process in place relevant to securing adequate documentation. Supporting documentation was provided for data selection relating to the upgrades to the HVAC, ventilation, and the spacing of the academic facilities which were all completed in accordance with Covid guidelines. The University is working with our third-party payroll provider to automate time and effort reporting.. We are currently using paper forms for reporting until we can implement Time & Effort through ADP. The Director of Title III & Finance Compliance officer to further discuss time and effort.

Finding 2022-003 Personnel Responsible for Corrective Action: Director of Title III and Compliance ? Dr. Neidra Butler Anticipated Completion Date: July 2022 Corrective Action Plan: The University is working with our third-party payroll provider to automate time and effort reporting.. We are currently using paper forms for reporting until we can implement Time & Effort through ADP. The Director of Title III & Finance Compliance officer to further discuss time and effort.

Finding 2022-003 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425E P425E200919- 20B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Eide Bailly LLP found that the University over-awarded Higher Education Emergency Relief Fund (HEERF) funding to one student based on its determination over eligibility of the student portion of HEERF funding, which is awarded based on (1) expected family contribution and (2) enrollment status. The student was awarded based on fulltime enrollment; however, the student's enrollment status was part-time. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance; Elizabeth Porteous, Accountant; Karrie Morgan, Director of Financial Aid; Anna Heckenliable, Registrar Corrective Action Plan: Responsible Individuals above will review credit hour reports pulled from the system for accuracy to ensure no hours are duplicated. Anticipated Completion Date: Management expects this finding to be resolved by January 31, 2023.

2022-002 Activities Allowed or Unallowed, Allowable Costs/Cost Principles Medical Assistance Program ? CFDA No. 93.778 ? Award Period: July 1, 2021 through June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance Response: Adult Care Management, Inc. (ACMI) agrees with the finding of Taylor Roth & Company, PLLC, in the fiscal year 2022 Single Audit (SEFA) that the established internal controls over payroll cost allocation did not operate as intended to ensure appropriate allocation of payroll costs across all programs in the five (5) of the twenty-four sampled payroll periods for one (1) individual. Action: Effective March 10, 2023, the internal control practices of ACMI will be strengthened to support a review system able to prevent and/or detect and correct errors in a timely manner to ensure payroll costs are accurate, allowable, and properly allocated. Specifically, management?s monthly review of all cost allocations will include a review of the data entry hours from payroll timesheets into the payroll allocation spreadsheet of no less than 10% of total reporting employees, with a priority focus on employees reporting time to more than one program / cost center.

2022-001 ? Employee Time and Effort Documentation (Significant Deficiency) Federal Program Information: Funding Agency: U.S. Department of Education Title: Teacher & School Leader Incentive Program Assistance Listing: 84.374 A Passthrough: N/A Award Year: 2022 Condition: The Foundation does not have a system of internal control to accurately track personnel costs when the individual works on more than one program. The Foundation makes a good-faith effort to budget an individual?s time based on their best estimate of the distribution of the employee?s time over the various programs. However, the Foundation?s employees were not required to track their time on a daily basis and identify which program was worked on during that day. The Foundation did not require those employees who are assigned to multiple cost programs to track and certify their time. The Foundation did not ?true-up? actual time versus budgeted time for the various programs during the year. Auditor?s Recommendation: The Foundation should implement internal control policies and procedures which require employees who work under two or more programs to track their time in a method that allows for proper allocation of expenses between those programs. Additionally, the Foundation should implement a process for employees to certify that their time is properly tracked and allocated. Finally, the Foundation should implement a time-frame to adjust budgeted salaries to actual salaries based upon the tracking performed by employees. Responsible official?s view: Specific corrective action plan for finding: Dr. Linda Coy in conjunction with James Coy, CFO and Patty Eaton, Business Manager have developed a revised process of collecting T & E data from employees affected by this action. Each affected employee will collectdaily activities tied to the percentage of time allocated to their respective positions and submit on a monthly basis to the business office. The business office will calculate the time spent on each project and provide that information back to the employee for adjustment during the following month. The documentation, for each employee that is part of this process will be available to the auditors during the next audit cycle. The HR department will maintain these files for inspection. Timeline for completion of corrective action plan: After consultation with the auditor, it was decided that the effective date for implementation is September 1, 2023. Employee position(s) responsible for meeting the timeline: Dr. Linda Coy, Three Rivers Education Foundation Director & James L. Coy CFO

2022-003 ? Allowable Costs/Activities Allowed or Unallowed: Fringe Benefits and Shared Costs Name of Responsible Individual(s): Pamela Aguilera, Chief Financial Officer Corrective Action: During the initial year of receiving our first direct federal grant, Safe & Sound calculated fringe benefits based on a percentage of the salaries allocated to the grant. Salaries were calculated based on time and effort. Safe & Sound has reviewed the current practices related to allocating fringe benefits and shared costs. Safe & Sound?s Finance team reviewed and verified that we have the adequate fringe benefit and shared costs to meet the costs allocated to this grant. To ensure we have the proper supporting documentation to meet the Uniform Guidance requirements in 2 CFR Sections 200.303 and 200.403, we will implement time and effort documentation for benefit and shared cost allocations on a monthly basis and will review for any necessary budget to actual adjustments. Date Completed: 8/31/2023

2022-004 Federal Agency: U.S. Department of Education Pass Thru Entity: Oklahoma State Department of Education Program: COVID-19 Education Stabilization Fund Assistance Listing: COVID-19- 84.425D & 84.425U Grant Period: Year ending June 30, 2022 Recommendation: The Auditor recommended that The District needs to have time and effort documentation maintained. The District needs to develop procedures to maintain documentation supporting work performed. Action Taken: District was unaware of the time and effort requirement for this program. New Federal Program director is monitoring this time and effort. FY23 the time and effort documentation has been kept for this program. Anticipated Completion Date: May 2023 Responsible Official: Superintendent

Please allow this correspondence to serve as Cook County Health (CCH) and Cook County Department of Public Health (CCDPH) response to the audit findings. During the FY2022 Single Audit, six audit findings were identified by Washington, Pittman & McKeever, LLC. CCH and CCDPH will address the recommendations of the auditors by taking the following Corrective Action Plans (CAP) outlined below: Finding 2022-004: regarding not maintaining adequate controls over allowable costs as required by Federal regulations. Cause: The cause of this finding resulted from Program Leads and the Accounts Payable unit not following the established requirements for properly supporting invoices for services provided. The invoices that were attached in EBS Oracle were insufficient as required by the established County Policy. Correction Action: The CCH Director of Grants Accounting will be responsible for training the Program Leads and Account Payable (AP) unit to ensure proper supporting documents are attached to each invoice as required by the established County Policy. In the event the AP unit determines more supporting documentation is needed, then the Program Director/Lead will assist in obtaining proper supporting documents from partnered subrecipients and/or vendors. Supporting documents may include additional timesheets, payroll registers, T&E justification, etc. Issues will be flagged (based on assessed risk) by applying requirements identified in the CCH Subrecipient Monitoring Policy. Anticipated completion of the corrective action will be December 31, 2023.

Finding #2022-007: regarding not maintaining adequate controls over allowable costs as required by Federal regulations. Cause: The cause of this finding resulted from the Program Leads and Accounts Payable unit not following the established requirements for properly supporting invoices for services provided. The invoices that were attached in EBS Oracle were insufficient as required by County Policy. Correction Action: The CCH Director of Grant Accounting will be responsible for training the Program Leads and Account Payable (AP) staff to ensure proper supporting documents are attached to each invoice as required by County Policy. In the event the AP unit determines more supporting documentation is needed, then the Program Director/Lead will assist in obtaining proper supporting documents from partnered subrecipients and/or vendors. Supporting documents may include additional timesheets, payroll registers, T&E justification, etc. Issues will be flagged (based on assessed risk) by applying requirements identified in the CCH Subrecipient Monitoring Policy. Anticipated completion of the corrective action will be December 31, 2023.