Corrective Action Plans

Finding 2022-006: Federal Financial Reporting Requirements (Significant Deficiency) Information on the Federal Program: U.S. Department of State ALN 19.040 Criteria or Specific Requirement: Code of Federal Regulations (CFR) Section 200.303(b) requires non-federal entities to establish and maintain effective internal control over federal awards that provide reasonable assurance that the non-federal entity is managing federal awards in compliance with federal statutes, regulations, and terms and conditions of the federal award. CFR Section 200.502(a) states that the determination of when a federal award is expended should be based on when the activity related to the federal award occurs. CFR Section 200.510 states that the auditee must prepare a schedule of expenditures of federal awards for the period covered by the auditee's financial statements which must include the total federal awards expended as determined in accordance with CFR Section 200.502. Condition: The schedule of expenditures of federal awards for the year ended December 31, 2022, did not originally include indirect costs totaling $43,632. Cause: FCE's management prepared the schedule of expenditures of federal awards using only direct costs. However, FCE had applied the 10-percent de minimis indirect cost rate when submitting its financial reports. Effect or Potential Effect: The exclusion of indirect costs caused inaccurate amounts to be reported in the SEFA at the start of the audit. This could have caused an inaccurate major program determination. Recommendation: FCE should implement a process for preparing the SEFA that includes comparing amounts reported in the SEFA to amounts included in financial reports of expenditures that are submitted to federal agencies. Action Taken: FCE acknowledges the importance of proper Federal Financial Reporting. FCE will develop and implement formal accounting policies and procedures to ensure that Federal Financial Requirements are met. These will include the steps to follow for preparation of the SEFA, including comparing amounts reported in the SEFA to amounts included in financial reports of expenditures that are submitted to Federal agencies.

Individuals Responsible for Corrective Action Plan: Jason Penegar, BGCA Vice President ? Controller Shelby Mahoney, Accounting Manager - State Alliances Corrective Action: Management will review grant agreements to confirm whether expenditures from pass-through entities are related to federal or state grants, and appropriately include applicable federal grants in the SEFA. Anticipated Completion Date: December 31, 2023

Corrective Action Plan: The Agency has recognized the need to improve our SEFA compilation process and has begun using a quarterly reconciliation process with all agencies and departments. We are currently reconciling data from VISION to the data submitted to the U.S. Treasury for ARPA-SLFRF Quarterly Reporting. We are using this new quarterly reconciliation process as a starting point to check Subrecipient expenditures against total expenditures, as well as reviewing Grant Accounts and reviewing Class Codes. We are checking all of our programs and looking at Beneficiaries vs. Subrecipients to ensure we are categorizing correctly at the macro level. There will be an enhanced collaboration internal to the Agency between the Department of Finance & Management and the Financial Services Division that will occur after agencies and departments submit their ACFR-9s used in the SEFA consolidation process to provide greater review and oversight. Scheduled Completion Date of Corrective Action Plan: Completed: February, 2023: Quarterly Reconciliation Process (VISION to Treasury) Expected: June, 2023: Subrecipient vs. Beneficiary classification review Expected: September, 2023: Collaboration between DFM and FSD for SEFA preparation

Audit Period: Fiscal year ended June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule of findings and questioned costs. Findings - Financial Statement Audit MATERIAL WEAKNESS None Reported SIGNIFICANT DEFICIENCY None Reported Findings - Federal Award Programs Audit MATERIAL WEAKNESS None Reported SIGNIFICANT DEFICIENCY None Reported Water and Waste Systems -ALN: 10.760 Finding: Schedule of Expenditures of Federal Awards Preparation Recommendation: Procedures should be implemented to ensure completion of an entry to the Schedule of Federal Expenditures of Federal Awards to achieve a reliable reporting of total expenditures for an audit period. Action Taken: We acknowledge our responsibility to present the Schedule of Expenditures of Federal Awards and related notes in accordance with Uniform Guidance requirements. To ensure future implementation of this requirement, the City of Cave Spring will record all expenditures on the schedule of federal expenditures.

CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2022 Finding No. 2022-002: Incomplete Schedule of Expenditures of Federal Awards- Material Weakness and Material Noncompliance Finding: During our audit, we identified a grant that is required to comply with the applicable requirements of 2 CFR Part 200 and thus should have been included in the Schedule of Expenditures of Federal Awards. Once this grant was properly included, the Organization exceeded $750,000 in qualifying federal expenditures thus meeting the requirement for a Uniform Guidance audit to be conducted. Corrective Actions Taken or Planned: Management has hired a Director of Grants Financial Management who is heading a team to ensure effective management and compliance with all awards in the agency. In addition, management has acquired an award management system and implemented new processes to identify Federal awards. These processes consist of (1) clearly identifying Federal awards on the new Grant Code Form, (2) conducting new award kick-off meetings within the Awards Management, Budget, and Compliance team, and (3) tracking all awards on an award and contracts matrix, as well as in the new awards management software system. For each new award, a Grant Code Form is created. The form allows the Awards Management, Budget, and Compliance team to direct the Accounting team to create a grant code for tracking purposes in the accounting financial system. When the Awards Management and Budget team complete the form, the grant will be clearly identified as a federal grant. In addition, when KIND receives a new award, the Awards Management, Budget, and Compliance team conduct kick-off meetings within the team to discuss award financial, programmatic and compliance requirements. During this meeting the team completes an awards summary template that clearly identifies an award as a Federal award and any related compliance and other requirements. In addition to the processes mentioned, the Awards Management, Budget and Compliance team has created a new contracts and awards tracking matrix. The awards tracking matrix identifies Federal grants, along with any related award requirements and other identifying information. This matrix is maintained and updated by the Awards Management, Contracts and Compliance Officer and reviewed by the Director, Grants Financial Management on a regular basis. The review includes existing procedures related to awards management and monitoring of processes. This is on-going and already in progress. In addition to the above-mentioned processes KIND will do the following: continuously review existing processes around clearly identifying Federal awards and make adjustments to strengthen internal controls as needed; review and discuss with the awards management software vendor, additional improvements that can be made to the system to better identify and report Federal awards and review the current awards matrix and make additional improvements that will better identify and track Federal awards. Name and Person Responsible: Rochelle Quillman, Director of Grants Financial Management Expected Completion Date: October 31, 2023

Corrective Action Plan Finding 2022-001 In response to the reported deficiency of internal controls over compliance with the preparation of the Schedule of Expenditures of Federal Awards (SEFA), Riverside is implementing the following Corrective Action Plan: 1. Upon notification from the Contracts Department of new awards or modifications, the Program Controller will review the Project Setup with an emphasis on ensuring the Project Type is correctly assigned. 2. Prior to approving the Project Setup in Cost Point by the Contracts Department, the Contracts Manager will ensure the Project Setup is accurate. 3. Riverside will perform a rigorous review of the SEFA in advance of submitting the document to our external auditors. This will include reviewing the Project Type of each project identified as required to be reported in the SEFA. Individual(s) Responsible for the Corrective Action Plan: Vivian Arthur, Controller, (703) 908-2135, Gary Van Gorder, (937) 427-7009. Anticipated Completion Date: December 2023

Community Development Block Grants ? Assistance Listing No. 14.228 Recommendation: We recommend that the Council record federal expenditures on the SEFA under the program in the year upon which the loan disbursement occurs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Council has revised their procedures so that loan disbursements will be recorded on the SEFA in the year in which they are disbursed. Name(s) of the contact person(s) responsible for corrective action: Anita Cameron, NLF Director, and Becky Walter, Fiscal Manager Planned completion date for corrective action plan: December 31, 2023

Name of Responsible Individual(s): Jason Penegar, BGCA Vice President ? Controller Shelby Mahoney, Accounting Manager - State Alliances Corrective Action: Management will review grant agreements to confirm whether funding received from private entities are federal funds that should be reported on the SEFA. Anticipated Completion Date: December 31, 2023

Individuals Responsible for Corrective Action Plan Jeff Scaccia, CPA (Vice President for Finance and Administration) Libby Shull, CPA (Controller) April Baur, (Director of Student Financial Aid) The SEFA as prepared by management did not originally include one federal grant with federal expenditures to be reported with the 2022 SEFA. Corrective Action Plan: The grant included in the finding was received from a local government entity which did not communicate any reporting requirements associated with the grant. The College will be more vigilant in future years in assessing any grants received for inclusion on the SEFA. Anticipated Completion Date: March 1, 2023.

Federal Grantor: U.S. Department of Health and Human Services, Family Violence Prevention and Services/State Domestic Violence Coalitions, State Coalition Technical Assistance and Training Program, Director Program, Federal Assistance List Number 93.591 Condition: Expenditures reported on the Schedule of Expenditures of Federal Awards (SEFA) were revised during the single audit. Auditor Recommendation: The Partnership should work with its external accounting firm to ensure the SEFA is complete and accurate and expenses agree to federal revenues reported and ensure revenues and expenses for each federal grant are included in the appropriate grouping code for the grant so revenues and expenses claimed are accounted for separately in the general ledger. Partnership Contact Person Responsible for the Corrective Action: Aleese Moore-Orbih, Executive Director Management Response and Corrective Action Plan: The Partnership concurs with the finding and recommendation. We have begun the process of increasing the capacity of our finance department to include an Associate Director, who, like the Senior Director, will be familiar with Uniform Guidance and nonprofit grants management and accounting. They will work in collaboration with our accounting consultants to ensure the SEFA is complete and accurate and agrees to recorded revenue. The target date for hiring is September 1, 2023.

Finding 2022-002 ? Significant Deficiency Award No.: 97.083, Staffing for Adequate Fire and Emergency Response Federal Grantor: U.S. Department of Homeland Security, Federal Emergency Management Agency Compliance Requirement: Other compliance requirements. Condition: The schedule of Expenditures of Federal Awards (SEFA) was not complete, and expenditures reported on the SEFA were revised during the single audit. Recommendation: We recommend additional review procedures be implemented to ensure the SEFA is complete and accurate when the single audit begins. Management Response and Corrective Action Plan: The Finance division will work with other departments to ensure that data provided in the SEFA are complete and accounted for on an accrual basis. We will also implement efficiencies in our accounting systems to ensure expenditures are captured correctly to prevent errors and omissions. Additional review will be completed by the Finance Director for completeness.

Finding Number: 2022-005 Condition: The schedule of expenditures of federal awards (SEFA) for the year ended June 30, 2022 includes expenditures incurred during the prior fiscal year. Planned Corrective Action: The Organization acknowledges this finding. Going forward the Organization will implement a review process of the Schedule of Expenditures of Federal Awards. Contact person responsible for corrective action: Bregeita Jefferson, President of FEED International Anticipated Completion Date: January 31, 2023

Condition: During the audit, significant adjustments were identified and proprosed (which were approved and posted by management) to adjust the College's general ledger to the appropriate balances. Planned Corrective Action: A detailed business procedure will be written and implemented that expressly lists how to handle year-end audit as it relates to both the Annual Financial Audit and teh Single Audit. The procedure will include processes for quarterly balancing and review, at a minimum. The procedure will include the creation of the annual SEFA document to be used by auditors in determining what programs the College has been awarded and what expenditures have been made. It will also include who is to handle all pieces of the audit and preparation in the absence of the Director of Financial Services. Contact person responsible for corrective actions: Dana Blair, Director of Financial Services Anticipated Completion Date: January 15, 2023

2022-008 ? Completeness and accuracy of certain COVID-19 programs on the Prior Year Schedule of Expenditures of Federal Awards (SEFA) - (Significant Deficiency) Cluster: Not applicable Sponsoring Agency: Department of Health and Human Services (HHS) - Health Resources and Services Administration (HRSA) and Department of Education Award Names: COVID-19 Provider Relief Fund (PRF) and COVID-19 Higher Education Emergency Relief Fund (HEERF) Institutional Portion Award Numbers: Not applicable and P425F202269 Assistance Listing Titles: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution and COVID-19 HEERF Institutional Portion Assistance Listing Number: 93.498 and 84.425F Award Year: 2020-2021 and 2020-2022 Pass-through entity: Not applicable Management agrees that additional controls should be implemented to ensure the accuracy and completeness of the SEFA. As a result of the prior year omissions discovered during the current year SEFA preparation and Single Audit, the University performed a reconciliation (prior to issuance of the audit report) of the PRF payments reflected in the HRSA reporting portal systemwide. The reconciliation did not identify any misstatements other than those described in the finding. The University of California Office of the President (UCOP) will work with campuses to fully reconcile PRF for the fiscal year 2023. Also beginning in 2023, campuses and medical centers will be assigned responsibility for reviewing and signing off on their respective final SEFAs, inclusive of HEERF, PRF, and any other atypical federal programs that are not captured in the campuses? financial system (e.g., those for which there is not expense recognition in a federal fund). The Systemwide Controller will also be included in the review process and signoff on the final SEFA reports. Beginning in FY 2024, the University will implement more comprehensive financial reporting controls as follows: ? Interim SEFA reports, inclusive of atypical programs, will be prepared centrally and distributed to campuses for review and alignment with campus records. Campus management will be tasked with the responsibility for overall review and signoff for both interim and final SEFA reports. ? The Systemwide Controller will also be included in the review process by performing an overall review and signoff for the final SEFA report. For inquiries regarding this finding, please contact Barbara Cevallos at (510) 987-0013 who is responsible for the corrective action.

When CSC provided the 2022 SEFA to the Auditor, it contained errors, which resulted in this finding. The errors resulted from us not fully understanding the fields on the SEFA. We completed the SEFA thinking that it was only meant for 2022 transactions only. We shall continue to increase our familiarity with this one-page report, required only for single audits.

Department: Education Administrative and Financial Services Title: Internal control over the submission of CNC Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will report expenditures for the School Breakfast Program and Special Milk Program under the individual ALNs rather than including those expenditures in the broader ALN 10.555. The Department will report noncash assistance at the amount actually used rather than the amount authorized for use. The Department will add a note to the SEFA report indicating any COVID-19 expenditures that cannot be isolated due to waivers. Completion Date: June 30, 2023 Agency Contact: Nicole Denis, Director of Finance, DOE, 207-530-2161

We agree with the finding, This was due to the modification of assistance listing number for two awards. We will strengthen our controls for review of all grant documents before issuing the SEFA report.

Identifying Number: 2022-002: Improper Preparation of Schedule of Expenditures of Federal Awards Finding: The SEFA initially drafted and provided for formal audit documentation by the University contained all expenditures but was considered incomplete as the definition was expanded to include lost revenues which were not included in the first draft of the report. As a result, this finding is categorized as not complete as it did not include all ESF Institutional funds that should have been reportable for the year ended June 30, 2022. Corrective Actions Taken or Planned: Management has reread the applicable FAQ documents incorporated in the Uniform Guidance regulations related to HEERF III lost revenue documentation and how such funds should be reported on the SEFA, or not reported, as applicable. Person(s) Responsible for Correction Actions: William E. Davies, Vice President for Finance and Business, Anne Miller, Controller Anticipated Completion Date: Completed March 22, 2023

Volunteers of America Colorado Branch June 30, 2022 Corrective Action Plan Finding Number: 2022-001 Condition: The Organization excluded certain amounts from prior years' schedule of expenditures of federal awards. The amounts excluded for the prior two years are as follows: Assistance listing number 10.558 - Child and Adult Care Food Program - CCAP Classroom: See Corrective Action Plan for chart/table. Assistance listing number 14.267 - Transitional Living Program: See Corrective Action Plan for chart/table. Planned Corrective Action: During the year, the Organization created and hired for a new position, Director of Financial Analysis and Internal Controls/Contracts to provide additional oversight over the Schedule of Expenditures of Federal Awards. Contact person responsible for corrective action: Jonathan Resnick, Senior Director and Controller, Accounting and Finance Anticipated Completion Date: Fully corrected as of September 30, 2022

The Organization has implemented a full review of the contracts at year end to make sure all expenses are assigned to a funder code in the accounting system. In additional, as a final control procedure, Accounting will run a final report for all contracts that have been identified as federal vs actual invoiced expenditures and further compared to what has been expensed per the financial statements and provide to the Chief Program Officer to compare and reconcile to the SEFA. 39

Finding 2022-006 Programs: All Material Weakness over Schedule of Expenditures of Federal Awards (SEFA) Reporting Repeat Finding: Yes Auditee?s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. Although Workday is ?live? as of August 2022, the City is currently working to refine the software and fully utilize functionality. The Workday grants modules requires the grant funding source be defined prior to grant approval and fields are available for the AL titles and numbers and sub-recipients? information. The implementation of the Workday grants modules centralizes much of the grant management function by requiring the agencies to upload the grant documents into Workday. The City has: ? Held weekly meetings for two years with agency grant representatives to design and configure the Workday grant module. ? Uploaded the grant award, sponsor information and grant budget data into a Workday. ? Implemented a ?new grant? request which uses a Workday business process. ? In the process of reviewing and correcting recoverable costs per grant award so it is properly reported. Contact Person: Michael Moiseyev, Chief Financial Officer, Baltimore City. Completion Date: June 2024

2022-049a ? Finance and the Office of Highway Safety will work together to create policies and procedures for the completion and submission of the Highway Safety Plan. 2022-049b ? Finance and the Office of Highway Safety will work together to create policies and procedures for the completion and submission of the Federal reimbursement voucher. 2022-049c ? DOT is working with DOA Accounts and Control to develop and implement policies to ensure Federal expenditures are not duplicated in the State system and on the SEFA. Anticipated Completion Date: September 30, 2023 Contact Person: Loren Doyle, Acting Chief Operating Officer / Chief Financial Officer Department of Transportation loren.doyle@dot.ri.gov

View of Responsible Official Management agrees with the auditor?s recommendation and will strengthen procedures on the preparation and review of ROE and the SEFA to ensure the correct amount of expenditures allowable for reimbursement are reported. Management will confirm agreement between the quarterly ROE and the general ledger at that time prior to submitting for reimbursement. Further, management is correcting the reimbursement report for the quarter ending March 31, 2023, to account for the $409,485 of questioned costs.

2022-033 Veterans State Nursing Home Care - Assistance Listing No. 64.015 Recommendation: We recommend that The Department review and enhance procedures over accounting for and reporting federal program expenditure activity. The Department's enhancement to the procedures should strengthen internal controls over the preparation and review of the SEFA to ensure that all grant award information and related expenditures are complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Mississippi Veterans Affairs will submit all financial data for the GAAP reporting packets and ensure necessary adjustments and corrections are accurately reported. The preparation of reviewing and recording federal awards expenditures will be maintained and tracked accordingly. The Mississippi Veterans Affairs Internal Auditor will monitor the Finance Department internal processes and procedures to implement corrective actions for compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Demetrice Watts Planned completion date for corrective action plan: December 31, 2023

Finding 2022-001 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: Various Federal Agency: Department of Homeland Security Assistance Listing: 97.036 ? COVID-19 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Through Award Number: 4494-DR-MI Pass-Through Award Period: 1/20/2020-7/1/2022 Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Award Period: 1/1/2020-12/31/2022 (Periods 3 and 4) Summary of finding: The draft Schedule of Expenditures of Federal Awards (the Schedule) prepared by Corewell Health and Subsidiaries (the System) was misstated. Total federal expenses included on the Schedule were $102,235,937 for the year ended December 31, 2022. Total expenses included on the final Schedule were $101,562,371 for the year ended December 31, 2022. The federal expenditures were misstated as follows: See Corrective Action Plan for chart/table. Corrective Action Plan: The enhanced Schedule process and controls implemented by Corewell Health East in 2023 will be reviewed. The misstated amounts of the R&D Cluster occurred as a result of the timing of posted expenses during the first month of the merger of Spectrum Health and Beaumont Health in February 2022. This was a one-time occurrence and we do not anticipate that this will be an issue in future years. In addition, the successful implementation and transition to Workday, a new Corporate financial management system, has improved award setup functionality that enables improved differentiation of awards, identifying which need to be included on the annual Schedule of Expenditures of Federal Awards and those that should be excluded. The understatement related to FEMA was a one-time occurrence related to the clarification of guidelines on the inclusion of a new Category Z FEMA obligation in 2022 on the SEFA. This has been corrected in 2023. The overstatement related to PRF was due to an initial inclusion of Corewell Health East funding on the Schedule as well as an adjustment related to the submitted amount of Corewell Health West funding on the Schedule. On the 2023 SEFA, a management review and sign-off of the inputs prior to submission will be implemented. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East and Cindy Brink, Director, System Accounting and Reporting Timing of corrective action: July 1, 2023 and going forward.