Corrective Action Plans

As a corrective measure, along with additional staff training, Vanderbilt will be implementing a quality control step to ensure that the notifications are properly made. This step will essentially do a sweep of students whose financial aid awards have been finalized (but prior to the actual disbursement of funds) but have not yet received the required financial aid notification letter. This process will be executed on a weekly basis. Vanderbilt University expects to have this process in place by November 2022. For follow-up questions and information, please contact Brent Tener, Executive Director of Student Financial Aid and Scholarships at Vanderbilt University.

Program: AL 21.023 ? COVID-19 Emergency Rental Assistance ? Allowability & Eligibility Corrective Action Plan: N/A Contact: Lee Will Anticipated Completion Date: N/A

Views of Responsible Officials: We have streamlined and consolidated the payroll allocation file so that such manual errors will not occur in the future. We will also institute a monthly review process of employee timesheets, and the Executive Director will review and approve timesheets on a quarterly basis.

CAP for Finding: 2022-704 Finding 2022-704: Research and Development Cluster?Unallowable Costs Planned Corrective Action: We agree with the condition that expenditures noted by the auditors were posted to federal awards in error. Our institution has robust policies and procedures in place along with multiple levels of review for transactions that post to awards. However, there may be rare instances where a transaction posts to an award for which it is not allowable or allocable. As noted by the auditors, they sampled from a population of $86.9 million from certain expenditure codes and only questioned $650 in costs. These expenditures have now been transferred off the awards to non-sponsored funding. To help Research Administrators manage Research and Development Awards, RSP (Research and Sponsored Programs) offers a variety of tools. RSP maintains a website that houses policies and procedures related to all relevant Research Administration topics. In addition to this, the RSP website has FAQ (Frequently Asked Questions) pages on a variety of Research Administration topics. RSP also offers a comprehensive training program called RED (Research Education Development). We offer courses that include topics such as a basic introduction to research administration, closeout of awards, cost-share, cost-transfers, and many others. We will remind administrators and their staff of all the relevant information our website houses and that they should take any pertinent RED. Lastly, we will remind staff that they can retake courses if they haven?t taken them recently and want to refresh their knowledge. Anticipated Completion Date: 5/31/23 Person responsible for corrective action: Kyle Everard, Manager of NSF-DOE Team Research and Sponsored Programs Kyle.Everard@rsp.wisc.edu

CAP for Finding: 2022-301 DATE: March 21, 2023 TO: Lisa Kasel, Assistant Financial Audit Director Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Medical Assistance Program ? Home and Community-Based Services Unallowable Costs Department staff has reviewed the Legislative Audit Bureau?s (LAB) interim audit memo for Finding 2022-301: Medical Assistance Program ? Home and Community-Based Services Unallowable Costs. This is the department?s Corrective Action Plan. ? Recommendation (2022-301): Medical Assistance Program ? Home and Community-Based Services Unallowable Costs We recommend the Wisconsin Department of Health Services: ? work with the fiscal employer agency that improperly approved the payment we identified to determine how this payment was made, assess whether changes to current processes are needed, document its assessment, and implement corrective actions, as appropriate. Wisconsin Department of Health Services Planned Corrective Action: Based on the LAB findings, the DMS Bureau of Quality and Oversight (BQO) will implement a Corrective Action Plan (CAP) with the IRIS Fiscal Employer Agent (FEA), iLIFE. A review of the LAB findings indicates that iLIFE inadvertently issued a payment to an IRIS participant-hired worker (PHW) based on a service authorization associated with a participant that the PHW did not support. The IRIS provider agreement indicates that FEA?s are responsible for verifying invoices, timesheets, and other claims for payment for services and periods of time authorized by participants? service plans. iLIFE indicated their system?s optical character recognition (OCR) misread a PHW?s employee identification number causing the payment to be sent to the wrong PHW resulting in an overpayment. iLIFE will be required to fix their OCR and review process to complete the CAP. BQO will issue a CAP notification to iLIFE by March 27, 2023. BQO will work with iLIFE to ensure the system errors are corrected to prevent further occurrences and anticipates the CAP will remain open for approximately 6 months. Anticipated Completion Date: September 2023 Person responsible for corrective action: Ann Lamberg, Deputy Director Bureau of Quality and Oversight, Division of Medicaid Services ann.lamberg@dhs.wisconsin.gov

Corrective Action Plan Finding No.: 2022- 001 Condition: Per review of the District's inventory listing containing devices purchased with the Emergency Connectivity Fund Program funding, 876 devices of the 6,000 devices purchased were not distributed to students. This indicates that amounts purchased and requested for reimbursement exceeded the "one device per student or staff member" requirement. The District was unable to provide supporting documentation for the 876 devices to support compliance with the "Special Tests, Restricted Purposes" compliance requirement that states there must be an "unmet need" and that there are "per-user limitations." Plan: When the Emergency Connectivity Fund Program (?ECF?) became available, the district estimated that we needed 6,000 devices in order to meet the needs of students and school staff who would otherwise lack access to connected devices and broadband connections sufficient to engage in remote learning. This estimate was based on the population of students and staff at the time. The estimate also included a provision to address the district?s mobility rate of 13.6% (many students who transferred out of the district did so without returning the resources they had been provided). Additionally, approximately 20%+ of the devices in the past would be returned with damage or would not be returned at all and families were unable to pay for them. It was never the intention of the district to over-order devices. Instead, we had a reasonable expectation (based on the factors listed above), that additional units would be necessary to ensure that no student is left without access to a device so that the district can continue to meet the educational and social-emotional needs of ALL students. As of the date of this response, of the original 876 devices that were not assigned, the district now has only 719 of those devices remaining and fully anticipates the remaining devices to be assigned by the beginning of the 2023-2024 school year (September 2023). Anticipated Date of Completion: September 1, 2023 Name of Contact Person: Jennifer Brumback, Chief Academic Officer Management Response See Above

Views of responsible officials and planned corrective action: Management agrees with the above finding. Management plans to report their 2022 fiscal year appropriately using the correct reporting deadlines for 2022, and improve internal controls over program reporting requirements accordingly. Management will inquire with their CDFI representative regarding any additional actions needed for their 2021 reporting components submitted in the prior period.

Single Audit Report: Corrective Action Plan Year ending June 30, 2022 Finding 2022-001 Allowable Costs Grant Program/ALN#: Disaster Grants ? Public Assistance (Presidentially Declared Disasters) 97.036 Federal Agency: Department of Homeland Security Contact person responsible for corrective action: Joshua Repac Corrective Action: Meritus Medical Center, Inc. identified that the report used to identify contract nursing costs related to nurses that had treated COVID-19 patients was incorrectly including certain costs that were not related to COVID-19. As a result, management updated the report parameters, which resulted in the identification of $572,189 of expenses originally submitted and received that were not allowable costs. The corrective action has been implemented and completed prior to the release of the audit report for June 30, 2022. Report parameters were updated to include only COVID-19 specific infections. The report parameters were reviewed, approved, and additional samples were selected by management to ensure that the allowability criteria were met. In addition, the Company?s internal audit department used the revised submissions to independently select a random sample for testing, this will be done for future submissions as well.

Community Consolidated School District 21 05-016-0210-04 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2022 Corrective Action Plan Finding No.: 2022- 003 Condition: During our audit testing we noted that the District submitted a claim through SPI invoicing for 2,200 laptops ($858,814 in equipment) that exceeded the allowable amount of equipment for reimbursement through the Emergency Connectivity Fund to satisfy the District's unmet need. Plan: Management will develop a process with the Information Services Department to determine that the District is meeting all grant requirements, including measuring unmet need, in order to fully comply with the terms and conditions of a funding vehicle. Anticipated Date of Completion: 6/30/2023 Assistant Superintendent of Finance & Operations/CSBO Management Response: See above

Views of Responsible Officials, Corrective Action Plans, and Contact Information For the 2021-22 school year, the Food Services Division used federal waivers to support students and families by providing meals under multiple programs. Starting August 2021, COVID concerns resulted in the district discontinuing breakfast in the classroom. USDA waivers permitted the distribution of breakfast and supper meals to students as they left campus for consumption at home. As the school year progressed, the after-school supper program was reinstated for a small group of students at some schools, and this group of students was given a breakfast to take home. Additionally, we distributed weekend meals comprising of supper and snacks. Lastly, the district requested Food Services to serve a morning snack (at the District?s expense) for hungry students. The snacks were tracked manually for reimbursement from ESSER funds by the district. Each meal service required a different form to count meals and multiple sheets for the same meal period depending on how the meal bags were distributed (exit gate vs. classroom). The managers had many forms that had to be put together and summed up to come up with the reimbursable counts. Manually compiling and uploading the information is the reason for the variances. Each time there was a change in the operation, the Food Service team had to create a new training module for the change in operation, which created additional forms leading to the errors seen in the audit review. We want to state respectfully that our error rate for meal counts was 0.4% which, given the multiple food distribution channels to support students, is understandable. To address the audit findings, Food Services will review and modify our procedures and be stringent in monitoring our existing systems and procedures: 1. Food Services Division will add steps to our current meal claiming procedures to ensure accuracy of claims. a. Food Service Manager will utilize the Meal Count Consolidation Form for meal periods that have more than one meal count sheet. b. Food Service Manager will input meal counts into CMS based on information from the Consolidation Form. c. Food Service Manager will run a weekly Meal Counts Report generated from CMS. d. Food Service Manager will compare daily meal count documents to the five-day Meal Count Report for accuracy. e. Area Food Services Supervisors (AFSS) will randomly check meal counts entered in CMS and compare them with the numbers entered in daily meal count sheets. Each school will have a random review every 2-3 months, and where errors are found there will be additional follow up. 2. Food Services will follow the review steps as indicated in Corrective Action Response #1 and confirm the claim for accuracy prior to submission to CNIPS. a. Food Services Central Office Staff will provide a daily meal count report to all Supervisors for review to identify any inputting errors. b. Food Service Managers will review and adjust meal counts prior to the CNIPS claim submission, based on AFSS feedback. The target date for the implementation of the above corrective action plan is by the end of February 2023. Name: Manish Singh Title: Director, Food Services Division Telephone: (213) 241-2993

Corrective Action Plan The University will update written procedures to include an additional manual process, which identifies and updates withdrawals within the National Student Clearinghouse with a higher frequency. These procedures are targeted for the summer term, in which the current year lapse was identified. This will ensure that no one is reported outside of the 60 day window.

U. S. Department of Housing and Urban Development (Pass-through from Virginia Office of Community Planning and Development) Assistance Listing #14.267 Finding: 2022-003 Known Questioned Costs for a Federal Program Not Audited as a Major Program Criteria: In accordance with 2 CFR 200.516(a)(4) known questioned costs that are greater than $25,000 for a program that is not audited as a major program must be reported as an audit finding in the federal awards section of the schedule of findings and questioned costs. In September 2022, the U. S. Department of Housing and Urban Development, identified $1,463 of unallowed expenditures and a deficit of $27,464 in the required cash match under the Continuum of Care program for the year ended December 31, 2021, as a result of monitoring. Rapid Rehousing Requirements: Criteria: 24 CFR 578.51; 24 CFR 578.57 Condition: The Federal awarding agency has determined, in accordance with 24 CFR 578.51; 24 CFR 578.57; $1,463 of allowable HMIS expenses were not documented and that in accordance with 2 CFR 200.1; 2 CFR 200.103(a)(11); 2 CFR 200.306; 24 CFR 578.73 the grantee failed to match $27,464 on its Continuum of Care rapid rehousing project. Corrective Action Plan: The CFO will ensure that the HMIS expenses are being captured in financial documents be setting up a new account code in the financial software. Staff members that have HMIS hours will also record those hours separately on their timesheets each pay period. NRCA will be submitting copies of timesheets which record data entry by line item as further documentation of the HMIS expenses submitted in answers to the monitoring report. While NRCA respects the position of the Department of HUD, NRCA also believes management followed the grant agreement as submitted. NRCA sees resolution to this matter with the Department of HUD and is currently seeking counsel to ensure this resolution in an acceptable and appropriate manner. Persons Responsible: Michelle Cox, Chief Financial Officer and Krystal Thompson, Chief Executive Officer Timing for Implementation: Immediate

Prairie-Hills Elementary School District 144 07-016-1440-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS21 Year Ending June 30, 2022 Corrective Action Plan Finding No.: 2022- 002 Condition: The District reported the wrong month of meal counts for March 2022. As a result, the March 2022 claim for meals served did not match the March 2022 meal counts retained by the District. The February 2022 meal counts were submitted once in February 2022 and then again for the March 2022 reporting period. Plan: Prior to reports being transmitted, the District Project Coordinator (as a third set of eyes) will review the meal count report for each month. An additional review of the meal count before transmission will avoid incorrect meal counts being reported. Anticipated Date of Completion: 11/30/2022 Name of Contact Person: Terry O?Brien; Chief School Business Official

Southeastern Arizona Behavioral Health Services, Inc. (SEABHS) became part of the La Frontera family of companies as of 10/01/2019. Effective with fiscal year ended September 30, 2021, SEABHS has filed the required Single Audit report as part of their annual audit cycle. Michael Prudence, EVP/CFO and Connie Prince, Director of Finance, are currently in discussions with the Department of Housing and Urban Development to determine the appropriate approach to filing the audit for the fiscal year ended September 30, 2020 and expects to have a resolution reached by June 2024. SEABHS will continue to file their single audit if the required filing thresholds are met.

FINDING 2022-002 Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Director, Georgia Alliance of Boys & Girls Clubs Corrective Action: Management will continue to closely monitor the situation and implement more stringent internal controls and administrative oversight with respect to subrecipient monitoring. Anticipated Completion Date: December 1, 2023

U.S. Department of Treasury. Program Name: COVID 19: Emergency Rental Assistance Program. Assistance Listing Number: 21.023. Finding: 21.023. Criteria: In accordance with Uniform Guidance 2 CFR 200.516 - Audit Findings, known or likely fraud affecting a Federal Award, as well as known questioned costs that are greater than $25,000 must be reported as audit findings in the schedule of findings and questioned costs. Condition: Although the County has controls in place to ensure compliance with their Emergency Rental Assistance Program's policies and procedures, which include fraud prevention procedures, fraud did occur. During 2022, the County discovered (and reported to the auditors) that eight (8) landlord applicants committed fraudulent activity that included the submission of documents that were modified electronically prior to their submission, stolen identity, misrepresentation and inability to repay funds within a timely manner. Funds were disbursed to these applicants prior to the County becoming aware of the fraud. Cause: Eight (8) landlord applicants committed fraudulent activity. Effects: Eight (8) applicants received funding, although the fraudulent activity was committed by the applicants. Questioned Costs: $144,692. Recommendation: We recommend the County strengthen procedures and/or implement additional procedures to reduce the potential of fraud occuring. Auditee's Reponse: In addition to continuing to follow the County's policies and procedures developed in accordance with Emergency Rental Assistance guidelines established by the U.S. Department of Treasury, the County implemented additional procedures in May 2022 to enhance fraud prevention activities. The updated procedures required HomeFirst Gwinnett, the subrecipient managing the Emergency Rental Assistance Program, to perform additional verification and approval procedures to detect fraudulent applications before they are presented for payment. HomeFirst Gwinnett would no longer accept documentation that had been completely generated electronically as sole proof of property ownership and added another level of file review of property deed records for landlord property owners utilizing the authorized property deed record website. All assistance above $10,000 will require final review/approval by the HomeFirst Gwinnet director or manager. As new applicants input their information into the County's vendor portal, the Treasury Division in the Department of Financial Services would verify the validity of those records and would not allow the registration to complete unless they met the required criteria. Any suspicious activity was reported to management promptly, and for suspected fraudulent applicants, those applicants accounts were locked as a preventative control so that no future transactions could be processed while the account was under investigation. For individual landlords, ACH payment was no longer an option and they were required to physically present present a valid picture ID to receive a check at the Program Office. Additional training on the revised procedures was provided to program staff. While the additional prevention measures noted above did deter fraudulent attempts made on the program, Gwinnett County tracked and reported eight landlord cases of suspected fraud in 2022. The suspected fraud was forwarded to the Gwinnett County Police Department's (GCPD) Financial Crimes Unit. Any funds recovered will be returned to the U.S. Department of the Treasury. Gwinnett County's emergency rental assistance program, Project RESET 2.0 (PR2.0), concluded on Thursday, December 29, 2022.

Finding 2022-002: Late Residual Receipt Payment Auditee?s Response: Shalom II Housing, Inc. (the Organization) is in agreement with the finding and the recommendation. During 2021, the Organization did on review their surplus cash calculation on a regular basis, resulting in a late deposit. Subsequently, the Organization deposited $13,939 to their residual receipts account. Planned Corrective Action Plan: The Organization will deposit $13,939 to their residual receipts account. Name of Responsible Person: Renee St. John, Chief Financial Officer Name of Department Contact: Renee St. John, Chief Financial Officer Current Status: In Progress. Management is working on depositing the necessary funds into their residual receipts account. In addition, management is working on developing a procedure to calculate surplus cash on a monthly basis to ensure surplus cash is properly calculated. This is expected to be completed during fiscal year 2023.

Oak Park Elementary School District 97 06-016-0970-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2022 Corrective Action Plan Finding No.: 2022 - 004 Condition: The District procured $125,877 in goods from a vendor and did not comply with their internal procurement policy. Plan: The Senior Director of Finance will work with the Food Service Coordinator to review vendor contracts and solicit bids from multiple vendors to ensure compliance with the District?s internal procurement policy and federal requirements. Anticipated Date of Completion: 6/30/2023 Name of Contact Person: Patrick King, Senior Director of Finance

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2022 through December 31, 2022 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Recommendation. Uniform Guidance stipulates that reimbursements are paid to subrecipients in a timely manner. The Organization did not pay subrecipients in a timely manner for the months of April through December 2022, resulting in $234,254 of untimely reimbursements. b. Action Taken or Planned on the Finding The Organization will meet with subgrantees to establish increased control processes, including outlining documentation requirements, timeframes for reimbursement submission, identifying correct staff contacts for timely communications, and formalizing a timeframe for approving/distributing subrecipient disbursements. The Organization has paid all reimbursements through December 2022 as of August 30, 2023.

Cause Kirkhaven was experiencing significant cash constraints and was not able to make debt payments and escrow payments as they were due. Effect Kirkhaven is out of compliance with the HUD regulatory agreement. Recommendation We recommend that Kirkhaven utilize grant funding if allowable to become up to date in debt principal payments and escrow payments. Management Response Kirkhaven was and continues to be in communication with both HUD and mortgage servicer (Berkadia) with regards to the lack of payment of the October to December mortgage and escrow required payments amounting to $192,947 due to the cash flow challenges. They are aware of the executed CHOW Letter of Intent. Subsequent to year-end, Kirkhaven has made the required interest only payments for October to December and continues to make the monthly interest payments. Kirkhaven also has applied for relief of the required escrow payments, but was subsequently denied. Management will continue to monitor cash flow and if feasible make mortgage principal and escrow payments as able, however, the VAPAP grant proceeds did not include funds for debt payments. Managements position is that since the executed CHOW, intention is to use proceeds to pay of the mortgage balance, that paying the principal earlier versus later is less critical.

Finding 2022-004: Allowable Costs - Significant Deficiency in Internal Control over Allowable Costs/Cost principles Official's Response and Corrective Action Plan: Prior accounting staff was gone by December 2021. New financial staff was hired and in place in the 4th quarter of April 2022. We made changes in the accounting department during the past year to improve the overall functionality. Since we tripled our amount of grants, it was necessary to increase the accounting staff to maintain them, as well as increase overall efficiencies. We now have a staff of 4 accountants, as well as a new CFO with nonprofit/grant experience. The late filling of vacant positions delayed some of our internal processes during their training. We added monthly meetings with internal staff to make sure we have a good communication flow and appropriate documentation for new and existing grants which are monitored monthly Anticipated Completion Date: June 30, 2023

Brookwood School District 167 07-106-1670-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2022 Corrective Action Plan Finding No.: 2022-002 Condition: The District's expenditure population was less than amounts claimed by $5,617. The District was unable to identify and support expenditures for this difference. Plan: The District will implement additional review procedures to ensure that expenditure claims submitted for reimbursement agree to supported transactions within the accounting system for allowable costs under the award. Anticipated Date of Completion: June 30, 2023 Name of Contact Person: Mr. Kevin Slattery, C.S.B.O. Business Manager

Management should implement procedures to ensure that deposits are made in a timely manner.

Funding Summary: The district needed to create, update, and/or implement procedures for Inventory & Procurement of Equipment purchased with federal funds. Responsible Individual: Teresa Taylor, Business Manager Corrective Action Plan: The district made every attempt to follow the federal requirements for 2 CFR 200.317-327 related to procurement, 2 CFR 200.3613 (d) related to Inventory tracking, while the actual written procedures were either created or updated as required and implemented. The Superintendent and/or Business Manager review all requisitions to ensure they meet federal compliance. Anticipated Completion Date: January 26th, 2023

Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end date of the PHE, as MDHHS completes renewals for existing cases. MDHHS could not terminate Medicaid benefits during the PHE, and annual renewals have not been completed since the start of the PHE, resulting in most Medicaid cases not being touched until the 14-month unwind period allotted by the Centers for Medicare and Medicaid Services at the end of the PHE. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children?s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 31, 2024 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Erin Emerson, MDHHS