Corrective Action Plans

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

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

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 No. 2022-002 Material Weakness Personnel Responsible for Corrective Action: Archdiocesan Finance Office, Marilisa Heiderscheid (Controller) Anticipated Completion Date: March 31, 2023 Corrective Action Plan: Management will implement procedures to assure that all costs charged to the Provider Relief Fund are reviewed by a competent individual, and those reviews will be documented.

2022-004 Federal Agency: Department of Education Federal Programs: TRIO Student Support Services, TRIO Talent Search, TRIO Upward Bound, and TRIO McNair Post-Baccalaureate Achievement Assistance Listing Numbers: 84.042, 84.044, 84.047, and 84.217 Condition Purdue did not have adequate controls in place to ensure the SEFA was prepared to include appropriate ALN's for each federal program and federal programs were included in the appropriate cluster. Views of Responsible Officials and Planned Corrective Actions Contact Person Responsible for Corrective Action: Susan Corwin, Purdue West Lafayette Director of Post Award Contact Phone Number: 765-494-1052 ? A report has been created to identify all grants assigned a placeholder ALN. ? This ALN report will be reviewed monthly by the Senior Manager of the Award Set-Up Team in Post Award to ensure all placeholder ALNs are appropriately and timely corrected once the proper ALN is known. ? Annually, as the SEFA is prepared, a full review of all grants assigned a placeholder ALN will be conducted by the Assistant Director of Post Award and the Assistant Director of Research Quality Assurance and any mis-assigned ALNs will be appropriately corrected before the SEFA is created. Anticipated Completion Date: Monthly report review will start February 2023, Annual report review will start in May 2023 prior to the preliminary SEFA creation. Once the Corrective Action Plan is completed, Purdue Internal Audit will conduct a follow-up review to ensure the corrective action plan is fully implemented and being followed consistently.

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.

Management?s Views and Corrective Action Plan 2022-001: Schedule of Expenditures of Federal Awards All Federal programs Federal Award year: 2021 Management?s Response Management agrees with the finding as it relates to the inclusive of expenditures of State awards. As part of the preparation and review of the schedule of expenditures of federal awards (the ?Schedule?), processes were in place to reconcile total expenditures under the program to the general ledger as well as the consolidated financial statements. In addition, analytical review was performed of variances in expenditures year-over-year, by program, to assess reasonableness of reported expenditures. During review of the 2021 CHIP program expenditures, management reconciled total expenditures to the general ledger and consolidated financial statements without exception, as both the general ledger and consolidated financial statements include total program expenditures (i.e., both federal and state are included). In addition, upon review of variances in total program expenditures in comparison to the previous award year, variances appeared reasonable as they remained relatively consistent year-over-year and with historical data. In fiscal year 2022, management has implemented additional steps into its reconciliation process to bifurcate the total expenditures between Federal and State expenditures prior to agreement to the general ledger and consolidated financial statements to ensure exclusion of State amounts when preparing the Schedule. In addition, within the analytical review process management utilizes the bifurcated totals to assess for reasonableness at the more detailed level regarding year-over-year variances. Anticipated Completion Date Additional reconciliation steps and bifurcation of amounts were implemented during the preparation and review of the 2022 Schedule. Responsible Parties ? Matthew Bazzani, Chief Accounting Officer, Highmark Health

Finding 2022-002 Material Weakness, Inaccurate Schedule of Expenditures of Federal Awards (SEFA) Personnel Responsible for Corrective Action: John Moore, Director of Finance and Leon Hanhardt, Superintendent Anticipated Completion Date: September 30, 2023 Corrective Action Plan: District personnel will agree amounts reported on the SEFA to the corresponding expenditures recorded in the general ledger and an individual independent of preparation of the SEFA will review the report.

The transit will implement a standard operating procedure and do training on how to properly calculate the SEFA amounts for future audits.

Grady’s corrective action plan: 1. Going forward, Grady will have a formal agenda to discuss and approve the SEFA prior to submission. 2. The SEFA will be reviewed, approved and attested by the Grady’s VP Of Fiscal Services and the Executive Director of Internal Audit. 3. Differences above established thresholds will be reviewed and addressed

Action Taken/to be Taken: Accounting staff will be responsible for the preparation of the SEFA in the future, this had been done by operations staff in the past. Appropriate training will be sought as necessary. An outside accountant will be consulted for guidance and recommendations on the 2023 SEFA prior to submission.

The IDOC plans to correct and record appropriate expenses in the FY23 SEFA. When preparing documentation for future SEFA reporting, the IDOC will endeavor to use the appropriate dates that fall within the proper guidelines for reporting.

The IDHS will design and implement a reconciliation of Federal grant receipts and expenditures by assistance listing number included in the financial reporting forms submitted to the IOC to the IDHS’ financial reporting system.

During 2023, the newly elected County Auditor took on an active role in tracking the Coronavirus State and Local Fiscal Recovery Funds by preparing and maintaining spreadsheets so that the Commissioners have the most current information for making decisions. The County Auditor attends or watches/listens to the Commissioners’ meetings to make sure that she is updating the spreadsheets with all action taken by the Commissioners. Before submitting the Schedule of Expenditures of Federal Awards for the 2023 audit, we will consult with the Commissioners’ Office and the County Auditor to make sure that we are reporting the transactions correctly based on the spreadsheets prepared and maintained for such purposes.

Views of Responsible Officials and Planned Corrective Actions: USTTI will prepare its SEFA on a quarterly basis and we will reconcile the expenses reported on the SEFA with general ledger amounts. We will also review the chart of accounts coding to be sure all eligible expenses are clearly identified.

Criteria: According to 2 CFR Subpart F Section 200.510b, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period that includes all amounts spent on federal programs during the reporting period. Condition: The SEFA under-reported the expenditures for Charter Schools Program (CSP) by $24,206. Cause: The School prepared the SEFA based on the federal revenue recorded, rather than the actual federal expenditures incurred. Effect: An audit adjustment of $24,206 was made to increase the federal expenditures reported on the SEFA for the CSP program. Recommendation: We recommend that the School implement procedures whereby the SEFA is prepared based on federal expenditures incurred on a GAAP basis. Action Plan: The School has hired an accountant who will follow the accounting rules and standards for financial reporting using GAAP (generally accepted accounting principles).Persons Responsible: Tammy Chaney, Accountant

Federal Agency: U.S. Department of Agriculture, U.S. Department of Justice, U.S. Department of the Treasury and U.S. Department of Homeland Security Program Name: Emergency Watershed Protection Program; Drug Court Discretionary Grant Program; COVID-19 Coronavirus State and Local Fiscal Recovery Funds; Emergency Management Performance grants Assistance Listing Number: 10.923, 16.738, 21.027 and 97.042 Responsible Official: Courtney Campbell, County Clerk Views of Responsible Individuals: The SEFA monies had been reported wrong in the past. With this being my first year as County Clerk and my first experience with the budget I also went by what was reported in the past. I am working toward correcting this mistake and tracking the money better so it can be reported correctly.

YMCA of San Juan Response The Organization agrees with the finding. YMCA maintains a detailed accounting system subject to periodical reviews by the grantee in each individual grant. The system includes separate bank accounts, job ledgers, individual transactions are registered and in the CDBG-DR program a live platform exists with written procedures adopted by the subgrantee to be eligible to have access to the reimbursement expenses. In order to improve the supervision and reporting the organization is in the active recruitment process and review of individual requirements of the grants such as the CFDA among others. Corrective action plan The Organization is currently implementing a procedure to review the information presented in the SEFA, to segregate from schedule the nonfederal funding expenditures. Name (s) of person (s) responsible for corrective action Ms. Mabel Román, YMCA Executive Director YMCA Finance Director Anticipated completion date December 2023

CONDITION: The ROE did not have sufficient internal controls over the preparation of the Schedule of Expenditures of Federal Awards (SEFA) to ensure all federal expenditures during the fiscal year were reported and information in the SEFA was accurately reported. PLAN: The ROE will work with their contracted accounting firm to review financial statements, including the schedule of expenditures of federal awards, to ensure program titles, assistance listing numbers and other pertinent information is accurate for financial statement presentation. ANTICIPATED DATE OF COMPLETION: The anticipated date of completion is December 2023. CONTACT PERSON: Ms. Jill Reedy, Regional Superintendent

Assistance listing number and program name: N/A Agency: Department of Education Name of contact person and title: Mark Belanger, Budget Director Anticipated completion date: October 31, 2023 Agency’s Response: Concur The Department agrees with this finding and will implement the following: • Train designated staff responsible for preparing the Schedule of Expenditures of Federal Awards (SEFA) on State of Arizona Accounting Manual (SAAM) requirements. • Establish a reconciliation process to validate expenditures prior to submitting report • Staff will review federal resources for Assistance Listing Numbers (formerly CFDAs) to ensure proper title reporting • Designated staff will stay current on all federal regulations and SAAM requirements for reporting

Views of Responsible Officials and Corrective Action Plan: Management agrees with this finding and identifies federal funding based on contract language. The contracts do not include a percentage of funding that is not federal. To ensure proper spending of federal funds, Rainbow Health Minnesota treats all funds as federal funds.

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to ensure compliance and availability of funds. A monthly federal request for reimbursements with all grantee information will be used and reconciled monthly with QuickBooks. This report will mirror the SEFA form so auditors will receive the information in a timely manner. For any quarterly reports, the three months of reporting will again be reconciled prior to submission. All new processes and compliance will be updated in the policies and procedure manual. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department will be sought. A new position to prepare and work on all federal grant tasks will be hired and report to the Business Operations Manager. In the meantime, the Business Operations Manager has started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designation Of Employee Position Responsible For Meeting Deadline: Business Operations Manager

The finance department of NorthPoint Wellness Center Inc. is incorporating as part of the annual financial closing process a reconciliation directly with the grantors to confirm the financial expenditures, contract agreements and to determine the correct Assistance Listing Numbers (ALN). The reconciliation must be completed by January 20th following the close of the fiscal year, as well as at the end of the contract period. A Government Contract Reconciliation template has been created as part of the verification process and supporting documentation for the grantee organization.