Corrective Action Plans

Finding 2024-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025

The Project acknowledges the finding regarding the interproject payable. Management has developed the following corrective action plan: Repayment of Payable - The outstanding payable balance ot the related HUD project will be repaid in full by September 30, 2025. Documentation of repayment will be maintained and made available for audit verification. Elimination of Interproject Borrowing - Effective immediately, the Project has ceased the practice of borrowing funds from other HUD-assisted projects. Future interproject transactions will not be initiated unless expressly authorized by HUD. Polidy Development and Implementation - The Project will adopt a written policy governing cash management and interproject transactions by September 30, 2025. The policy will prohibit interproject loans without HUD approval and establish procedures for timely monitoring of accounts payable. Training and Oversight - Project staff responsible for financial reporting will receive training on HUD requirements and Uniform Guidance within 120 days. In addition, management will review monthly financial reports to ensure no interproject balances exist.

Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible Contact Person: Rick Smith, Executive Director

Finding #2024-003 Section 202 Supportive Housing for the Elderly – (Capital Advance); ALN 14.157: Recommendation: We recommend that management implement procedures to ensure that required funds are deposited into the residual receipts reserve account in the future within the 60-day requirement. Action taken: Byrne Manor Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely and accurate deposits in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.

Management response/corrective action: The Town of Gorham does not have a grant manager. The Finance Department consists of two staff and are unable to manage all the Town’s grants. The Town was awarded this grant in March 2023, but the grant application was not fully approved by HUD until 2/28/24, due to HUD staff turnover. Until the grant was fully approved, the Town did not have access to the HUD portal to do the progress reports. The Town had trouble accessing the HUD portal which took months of troubleshooting. The Town was in constant contact with HUD in the progress reporting and voucher reimbursement process, so HUD was aware that the reports would be late. The Town will emphasize the importance of filing reports on time and putting the deadlines in their work calendars.

Recommendation The Company must deposit $116,553 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2025 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

Finding Reference Number: 2024-1 Recommendation The Company must deposit $223,644 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2025 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

Finding 2024.003 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur to ensure accuracy. Not a repeat finding. Action Taken Since September 2023, the Center has implemented weekly grants management reviews with the grants team and key executives. Action items are tracked through meeting agendas, minutes, and NMH’s project management platform, Monday.com. Meetings include invoice approvals for grant-funded expenditures, and review of allocations, payroll dates, and stipends for drawing down calculations. The meetings going forward will document the amounts for federal grants drawdowns and will be logged within Monday.com and through an external verification spreadsheet. Starting May 2025, an updated verification spreadsheet along with an itemized attestation was implemented.

Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend the entity evaluate its procedures and implement an additional control to ensure reports are submitted timely and reviewed prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Avivo will implement an enhanced internal review process to ensure timely report submission and accuracy prior to submission. This will include assigning dedicated personnel to track submission deadlines and conducting pre-submission reviews for completeness and accuracy. Name(s) of the contact person(s) responsible for corrective action: Heidi Kammer-Hodge & Kristen Bewley. Planned completion date for corrective action plan: December 2025.

Condition: During the year, the Organization did not have appropriate review procedures and controls in place related to cash management and reporting over federal programs Planned Corrective Action: Finance has recent changes in leadership roles and with the change in leadership, has put into place improvements in oversight of cash management and reporting. LSS has a philosophy of continuous improvement and with the current management LSS will ensure that all guidelines and requirements for cash management and reporting for federal programs are met. Contact person responsible for corrective action: Julie Fratianne, CFO Anticipated Completion Date: September 30, 2025

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2024, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Department of Public Health (ADPH) passed through a portion of the Immunization Cooperative Agreement federal award to subrecipients. A total of fourteen subrecipients requested and received reimbursement of program expenses during the fiscal year. Based upon procedures performed, we noted that of the fourteen subrecipients who received federal award reimbursement, three did not provide adequate detailed documentation to support their request for reimbursements. In addition, sixteen of the fifty-four invoices submitted for reimbursement by the subrecipients did not have adequate documentation, resulting in question costs of $5,072,637.00. The documentation which was submitted by the subrecipients and approved by ADPH for payment consisted only of summary information and did not contain detailed information to ensure that reimbursement request costs were necessary and reasonable for the performance of the federal award. The ADPH did not have adequate policies and procedures in place to ensure that all requests for reimbursement were supported by adequate detailed documentation to ensure all costs are allowed under the federal award. Recommendation: The Alabama Department of Public Health should take action to ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and to ensure costs are allowable under the federal award. Response/Views: We agree with the Examiners' finding; adequate documentation did not exist at the time of the audit to substantiate payments that resulted in questioned costs and improper payments. To confirm the total amount of questioned costs, ADPH's Office of Program Integrity initiated its own ongoing investigation. ADPH also requested the Examiners of Public Accounts to conduct a special program audit which is ongoing. As this process continues, ADPH is requesting additional documentation from the subrecipients, which may affect the questioned costs of this program. Corrective Action Planned:ADPH will continue to strengthen its internal control system for grant management by conducting ongoing grant training internally and externally which is available for all employees who handle grants. ADPH is strengthening the internal control system for grants management. ADPH has and will continue to develop internal grant training for all employees who handle any phase of grant activities or have managerial responsibility for a grant. ADPH is working to make this training mandatory. The Bureau of Financial Services is continuing to work on staffing up a Grants Management Office and grant tools are being distributed or added to document library for use by ADPH programs such as Risk Assessment Forms and monitoring forms. Corrective Action within the Immunization Division Completed and Ongoing through August 2025: There has been a reorganization in leadership within the Immunization Division, however the Department remains committed to hiring additional staff to support grant review and monitoring. Immunization implemented the following procedures: • Reviews grant guidance semi-annually, or when updated, with program grant monitoring staff to ensure compliance. • Invoices and supporting documentation are being reviewed for source documents against grant guidance as received by program staff and approved by Operations Manager or Division Director to ensure costs to the grant are reasonable, allowable, allocable, and consistently applied before forwarding to Finance. Finance is conducting further reviews before uploading into STAARS for payment. • Grant monitoring staff ensures that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and costs are allowable under the federal award. • Invoices or vague requests requiring additional documentation will be held until the necessary information is provided. • All program grant staff have access to attend all available Finance and Grant training courses. • Engages assigned Grant Accountant on a quarterly basis or more frequently as requested. • There were no new subrecipients to conduct a Risk Assessment within 30 days of a signed grant agreement which will be forwarded to OPI for review. • Immunization staff conducted Risk Assessments on all the current subrecipients within 60 days which was forwarded to OPI for review. • Immunization staff, along with Finance and OPI, developed a subrecipient monitoring plan based on the Risk Assessment of each subrecipient. The monitoring plan was completed within 30 days of the receipt of the completed Risk Assessment. • Copies of all completed monitoring activities, as outlined in the monitoring plan, were forwarded to OPI. Anticipated Completion Date: September 30, 2025 with ongoing strengthening of internal controls and trainings. Contact Person(s): Shaundra B. Morris Chief Accountant & Director of Financial Services Alabama Department of Public Health Financial Services Bureau The RSA Tower, Suite 1068, 201 Monroe Street Montgomery, AL 36104 (334) 206-5464 Shaundra.Morris@adph.state.al.us Burnestine P. Taylor, MD Medical Officer, Disease Control and Prevention Alabama Department of Public Health The RSA Tower, Suite 1418, 201 Monroe Street Montgomery, AL 36104 (334) 206-9380 phone Burnestine.Taylor@ adph.state.al.us

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2024, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Medicaid Agency (“AMA”) operates a Non-Emergency Transportation (“NET”) program for individuals who are eligible for Medicaid benefits. This program helps eligible recipients pay for rides to dental and doctor offices, hospitals and other medical facilities when the service is also covered by Medicaid and the costs are paid with federal Medicaid program monies. Eligible recipients can request and receive reimbursements for the costs of utilizing the NET program. Subsequent to the payments of certain NET claims, AMA received information alleging that falsified information related to certain NET expenditures was being submitted and approved on behalf of a specific recipient. Upon receipt of these allegations, AMA initiated a review of the supporting documentation which had been submitted and approved. The review consisted of a detailed examination of all NET claims associated with the recipient. The results of the examination revealed that an AMA employee was entering and approving falsified information on behalf of a recipient. We reviewed, recalculated and verified information provided to us by AMA and did not note any differences. For the fiscal year ended September 30, 2024, there were 347 NET reimbursement requests totaling $30,501.75 submitted in the name of the specific recipient and of those, all 347 reimbursement requests were based on falsified non-existent documentation. The Alabama Medicaid Agency reimbursed the recipient based on falsified reimbursement requests and, therefore, improperly expended Medicaid Cluster federal award program funds. Recommendation: The Alabama Medicaid Agency should take actions to ensure that all reimbursements of expenses are adequately documented, based on true and accurate supporting documentation, and to ensure costs are allowable under the federal award. Response/Views: The Alabama Medicaid Agency agrees with the above recommendation. Medicaid immediately took action when it discovered an employee was defrauding the program by approving falsified claims. The immediate actions included terminating the employee, referring the employee for criminal prosecution, and making corrective actions. Corrective Action Planned: Corrective actions began immediately when the falsified claims were discovered by the Alabama Medicaid Agency. Employee access to the Non-Emergency Transportation (NET) reimbursement system has been reviewed and updated. Payment override access has been limited to two persons. Also, each NET program employee has been required to update their list of family or acquaintances to ensure each employee does not have a conflict of interest when reviewing reimbursement requests. The conflict-of-interest updates have been entered into the system. Finally, all NET employees have been required to attend training on program operation and policies. Anticipated Completion Date: The above-mentioned Corrective Action was completed in February 2025. Contact Person(s): Stephanie Lindsay, Chief Assistant to the Commissioner, at stephanie.lindsay@medicaid.alabama.gov or (334) 353-3781.

The Town is in the process of reviewing Policies and Procedures as they relate to Federal Awards.

FINDING 2024-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The City submitted four P&E reports during the audit period; however, the controls in place were not effective to prevent, or detect and correct, errors. As a result, errors in reporting were identified. The current period and cumulative expenditures reported consisted of the amounts expended by the beneficiaries who were awarded funds from the City, rather than total amounts expended to the beneficiaries, resulting in current period expenditures and cumulative expenditures being incorrectly reported on all four reports as follows:  Quarterly Report: October 1, 2023 to December 31, 2023 Current period expenditures were overstated by $666,417. Cumulative expenditures were understated by $964,879.  Quarterly Report: January 1, 2024 to March 31, 2024 Current period expenditures were overstated by $860,312. Cumulative expenditures were understated by $104,567.  Quarterly Report: April 1, 2024 to June 30, 2024 Current period expenditures were overstated by $104,567. Contact Person Responsible for Corrective Action: Linda Moeller Contact Phone Number and Email Address: 812-948-5333 and lmoeller@cityofnewalbany.com Views of Responsible Officials and Explanation and Reasons for Disagreement:  We concur with the finding.  However, the issue and non-compliance deals with the interpretation of the federal rules regarding the appropriate amounts to report and when to report them by subrecipients of the monies.  The non-compliance is not related to policies or controls not being effective to prevent, detect or correct errors. In fact, the reporting system initially implemented by the City and put in the federal reports provided the actual expenditures for those periods by recipients of the grants.  However, the City does agree that after full examination and review of the federal rules the initial full amount of funds provided to the subrecipients should have been reported in full versus the actual expenditures during the periods. Description of Corrective Action Plan:  Current period and cumulative expenditures reported will consist of the amounts advanced to subrecipients. Anticipated Completion Date:  The City has already made this correction in its Quarterly Report July 1, 2024 to September 30, 2024.

Recommendation: We recommend that Authority management prepare the required written policies/procedures related to allowability of costs and cash management outlined with the Uniform Guidance. Management Response: Management concurs with finding. Planned Corrective Action: The accounting staff will work with the operations staff to prepare the necessary written policies/procedures. Persons Responsible: Jamie Carnes, Fiscal Controller, SEDA-COG Anticipated Completion Date: October 31, 2025

County department personnel changes have been implemented, which address this deficiency. Additional training from the Auditor’s Office and state grantors has occurred for newer staff in certain departments with large amounts of federal and state awards.

County department personnel changes have been implemented, which address this deficiency. Additional training from the Auditor’s Office and state grantors has occurred for newer staff in certain departments with large amounts of federal and state awards.

Implementation of plan of action - Management will review its internal controls and policies and procedures to ensure that requests for reimbursement are for appropriate program expenditures. Implementation date - Anticipated completion August 28, 2025. Persons responsible for the implementation - The Board of Directors and Head of School.

In Finding 2024-007, a condition was noted in which the Organization did not maintain proper documentation of qualifying expenditures prior to making drawdowns of federal funds. Management recognizes the importance of complying with federal cash management guidelines. In response to Finding 2024-007, procedures will be implemented to ensure that federal grant expenditures are documented prior to drawdowns of federal funds so that advance draws of federal funds do not occur.

Communities In Schools of Georgia acknowledges the audit recommendation and is committed to strengthening internal controls related to journal entries and supporting documentation.Under the leadership of our newly hired CFO, we are continuing to improve our finance processes by implementing the following measures: Internal Controls for Journal Entries Segregation of Duties Workflow Approvals Training and Process Standardization During fiscal year 2025, we took the following actions to improve the integrity of our finance processes and controls over compliance with federal grant requirements: Engaged Senior Finance Contractor Completed Search for Permanent full-time CFO Initiated and Completed Search for an Accounting Manager

Identification of the federal program: Federal Agency: U.S. Department of Homeland Security (DHS) Assistance Listing: 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Through Award Number: 4494-DR-MI Pass-Through Award Period: 7/1/2022-4/30/2023 Summary of Finding: The Personal Protective Equipment (PPE) and other COVID related supplies were not used within the period of performance outlined within the project worksheet. There were three FEMA obligations during FY 2024. An overstatement of expenditures in one of the projects (project 10) was identified with an obligation amount of $6,732,507. The period of performance as specified within the project 10 application is July 2, 2022 to April 30, 2023 and $1,077,759 of costs were not used by April 30, 2023. The overstatement represents approximately 16% of the amounts reported in the project 10 application and 14% of the total FEMA obligations in FY 2024. The total federal expenditures for FEMA for FY 2024 were $7,795,530. Corrective Action Plan: Management agrees that a thorough review of the claim was not completed prior to submitting the Request for Reimbursement to the State of Michigan, thus causing a control deficiency. In the future management will perform, document, and sign off on a thorough claim review to validate that all final adjustments have been submitted prior to submitting the Request for Reimbursement to the State. Individuals responsible for corrective action: Brittany Kruse, Vice President Finance and Assistant Controller Cindy Brink, Director, System Accounting and Reporting. Timing of corrective action: September 1, 2025 and going forward.

2024-002 – Written Policies and Procedures Required by the Uniform Guidance Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): o City Council o City Manager o City Finance Director Anticipated Completion Date: June 18, 2025

CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Compliance Requirement: Special Tests and Provisions – Residual Receipts Funds Supportive Housing for the Elderly (Section 202), Assistance Listing 14.157 Recommendation: Every effort should be made to comply with the residual receipts requirement to make deposits into the account within 60 days following the end of the fiscal year or request waivers by the due date. Planned Corrective Actions: Every effort will be made to deposit the required amount within the allotted 60 day period. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100. Sincerely, MBDM – Drake Senior Housing Corporation Elizabeth Goleski, CEO

CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Compliance Requirement: Special Tests and Provisions – Residual Receipts Funds Supportive Housing for the Elderly (Section 202), Assistance Listing 14.157 Recommendation: Every effort should be made to comply with the residual receipts requirement to make deposits into the account within 60 days following the end of the fiscal year or request waivers by the due date. Planned Corrective Actions: Every effort will be made to deposit the required amount within the allotted 60 day period. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100. Sincerely, MBDM – Epsilon Senior Housing Corporation Elizabeth Goleski, CEO

Effect: The federal awarding agency did not receive interest that could have been earned on the advances. All advances received during 2024 were expended by December 31, 2024. There was no loss from uninsured funds or from lack of segregating funds into separate accounts. Recommendation: The auditor recommends that the Organization implement policies and procedures to ensure that all advance payments are deposited into separate, insured, interest-bearing accounts as required. The grantee should also establish controls to track interest earned on these accounts and remit amounts due to the federal awarding agencies in a timely manner. Training should be provided to staff responsible for cash management to ensure ongoing compliance with federal requirements. 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit findings. 2. Action Planned in Response to Finding: The Organization has implemented procedures to deposit the advance funds into separate, insured, interest-bearing accounts as required. The Organization has also established controls to track interest earned on the accounts and credit the interest back to the grant. 3. Official Responsible for Ensuring CAP: Kari Jo Lawrence, Chief Executive Officer and Jernon Kelly, Chief Financial Officer are responsible for ensuring corrective action of this deficiency. 4. Planned Completion Date for CAP: December 31, 2025.