Corrective Action Plans

Finding Reference Number: 2022-001 Description of Finding: The auditee omitted a federal award under SEMI Foundation with current period expenditures of $240,245 in its preparation of the 2022 SEFA. The SEFA was, therefore, incomplete and impacted the federal audit applicability determination as well as the auditors? major program determination. Corrective Action: The Organization concurs with this finding and provided the current period expenditures of federal awards on a consolidated basis. The organization provided specific information to support its position. We misinterpreted the reporting obligation for the award on the SEFA. We initially planned to first report the award when cumulative expenditures recognized under the award reached the reporting threshold on a stand-alone basis. We stand corrected on our understanding of its obligation to report on the SEFA report and evaluated the consolidated federal expenditures of all awards and their lifetime value against reporting threshold. Each award included in the evaluation that meets or exceeds the reporting threshold is to be first reported in the year of grant. In compliance with 2 CFR 200.514, we recognize that the SEFA report must be looked at the group level and cover the entire operations of SEMI and be presented in relation to the financial statements as a whole. We have coordinated with the appropriate staff to update their understanding and have reinforced our report review process accordingly. In addition, we will include this information in our periodic staff trainings to ensure future compliance. Name of Responsible Person: Kevin Bauer Anticipated Completion Date: The Organization anticipates completing the corrective action by July 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

Department: Grants & Finance Condition: The District did not record expenditures to the 2020-21 or 2021-22 grants in a timely manner, and internal controls over expenditures charged were not in place throughout the period during which such charges were incurred. Expenditures reported for the Title II, Part A grant in their submission to the Michigan Department of Education?s Financial Information Database (FID) did not agree with expenditures reported in the schedule of expenditures of Federal awards (SEFA) for the same period, as the District did not provide accurate information to the auditors nor did they prepare an accurate SEFA. Corrective Action: Internal controls have been implemented over the purchasing process, all grant expenditures are approved by the Grant Coordinator and Teaching and Learning Department. Grant Coordinator meets on a regular basis with the finance department to ensure that all grant related expenditures are being processed with the correct code and in the correct manner. Any discrepancies that arise are addressed immediately. Person(s) Responsible for Executing Corrective Action: ? Grant Coordinator ? Grant Accountant ? Chief of Teaching and Learning ? Finance Office Designee Anticipated Completion Date: 12/31/22

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.

Department: Defense, Veterans and Emergency Management Administrative and Financial Services Title: Internal control over the submission and review of DG ? PA Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Maine Emergency Management Agency (MEMA) will develop and implement a procedure for the review of the following sources to ensure the accuracy of the ALN: award documents, the OMB Compliance Supplement, and other authoritative resources. Where written resources do not clearly identify the ALN, MEMA will seek technical assistance from awarding agency staff, the Office of State Controller, and the Office of State Auditor. MEMA will develop and implement a procedure for the review of Assistance Listing Numbers (ALN) coding in the Advantage financial system. MEMA will develop and implement a procedure for the review of SEFA data before submission to the Office of State Controller. MEMA's procedures will provide for staff training. The training will be documented. MEMA's procedures will provide for the review and approval by a second staff person. The review and approval will be documented. The Office of the State Controller will update or clarify guidance as necessary and will consult with service center and agency financial personnel to help ensure their compilation/review systems are designed to provide accurate information for the SEFA. Completion Date: June 30, 2023 (first through fifth items), and September 1, 2023 (sixth item) Agency Contact: Joe Legee, Deputy Director, MEMA, 207-624-4400 Sandra Royce, Director of Financial Reporting, OSC, 207-626-8451

Department: Health and Human Services Administrative and Financial Services Title: Internal control over submission and review of ELC Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Financial Service Center will work with the Office of the State Controller to develop and implement additional procedures for SEFA reporting. The Office of the State Controller will update or clarify guidance as necessary and will consult with service center and agency financial personnel to help ensure their compilation/review systems are designed to provide accurate information for the SEFA. Completion Date: December 31, 2023 and September 1, 2023 respectively Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626 Sandra Royce, Director of Financial Reporting, OSC, 207-626-8451

Department: Health and Human Services Administrative and Financial Services Title: Internal control over the submission of ICA Schedule of Expenditures of Federal Awards reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Maine Immunization Program (MIP) Senior Health Program Manager will request the data needed for the SEFA from the MIP Planning and Research Associate. The MIP Senior Health Program Manager will review the data prior to the submission to the Service Center, which will include fiscal year accuracy of the report. The Service Center will provide the CDC/Immunization program a summary and back up of what is being reported and the CDC/Immunization program will verify it is accurate. The Service Center will add to the reviewer?s checklist that the preparer has consulted and has the proper backup with the CDC/Immunization program to verify that the information provided was accurate. Completion Date: December 31, 2023 Agency Contact: Jessica Shiminski, Health Program Manager, Maine Center for Disease Control & Prevention, DHHS, 207-287-7087

Department: Education Administrative and Financial Services Title: Internal control over submission and review of ESF Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department of Education will verify individual Assistance Listing Numbers on the SEFA report review. The Office of the State Controller will update or clarify guidance as necessary and will consult with service center and agency financial personnel to help ensure their compilation/review systems are designed to provide accurate information for the SEFA. Completion Date: September 1, 2023 Agency Contact: Nicole Denis, Director of Finance, DOE, 207-530-2161 Sandra Royce, Director of Financial Reporting, OSC, 207-626-8451

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

Department: Health and Human Services Administrative and Financial Services Title: Internal control over the submission and review of SNAP and P-EBT Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Office for Family Independence (OFI) will verify the Assistance Listing Number (ALN) for the P-EBT Benefit expenditures with the USDA SNAP program. OFI will report SNAP and P-EBT Benefit expenditures for the associated ALN to the DHHS Financial Service Center. The DHHS Financial Service Center will provide OFI a summary and backup of what is being reported and OFI will verify it is accurate. The DHHS Financial Service Center will add to the reviewer?s checklist that the preparer has consulted and has proper backup with OFI to verify that the benefits are reported under the correct ALN. The Office of the State Controller will update or clarify guidance as necessary and will consult with service center and agency financial personnel to help ensure their compilation/review systems are designed to provide accurate information for the SEFA. Completion Date: June 30, 2023 (first and fifth items), December 31, 2023 (second, third and fourth items) Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104 Sandra Royce, Director of Financial Reporting, OSC, 207-626-8451

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

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.