Corrective Action Plans

This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding in conjunction with Finding 2024-005 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. The new Finance Team leadership have reinstated use of the class system in our general ledger to allocate direct costs to specific programs and clearly separate non-reimbursable expenses. Monthly reconciliations will be performed to ensure qualifying costs align with cash draw requests. Accounting staff have or will receive targeted training on cost allocation principles and documentation standards to support this effort.

Finding 2024-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended December 31, 2024, management did not properly accrue federal grant expenditures that were incurred during the fourth quarter of fiscal year 2024. As a result, federal grant expenses on cost reimbursement grants and related revenues were understated as of December 31, 2024, and required year end audit adjustments to properly reflect expenditures incurred but not invoiced or recorded as of year end. Recommendation We recommend that individuals overseeing the accounting and finance department continue to review the Organization’s current accounting policies and update existing policies or implement new policies, as needed, to ensure that federal grant expenditures are accrued for and recorded in the proper period and reconciliations between incurred expenditures, invoices submitted and amounts recorded in the general ledger are completed and reviewed monthly or quarterly, as appropriate. Management’s Corrective Action Plan Management is working to improve the timeliness of reconciliations and has implemented procedures to identify and accrue grant expenditures incurred but not yet invoiced at period end, as needed. Management will perform periodic reconciliations between incurred expenditures, invoices submitted to grantors, and amounts recorded in the general ledger, and will ensure such reconciliations are reviewed and approved by the appropriate personnel. Management is confident that the issues that have been noted have been rectified. Contact Person: Patricha Paul, Finance Director Anticipated Completion Date: June 30, 2026

CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Audit Finding Reference: 2024-003 Document Policies and Procedures Over Federal Awards Views of responsible officials: The Town agrees with the recommendation to implement written policies and procedures to be in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action: The Town plans to implement recommendations for the next fiscal year. Official Responsible for Implementing Corrective Action: Kurt Ginthwain Finance Director/Town Accountant

Corrective Action Plan: Management acknowledges the lack of documented evidence of review and approval for disbursements. The organization has implemented a process requiring email-based approvals from appropriate managers to ensure all expenditures are reviewed and authorized. In addition, the organization is in the process of evaluating and implementing an electronic system to streamline and document approvals for accounts payable and credit card transactions. These steps will strengthen internal controls and ensure proper documentation of all approvals in accordance with organizational policies and federal requirements. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: May 31, 2026

Corrective Action Plan: Management acknowledges that federal grant revenue was recorded based on reimbursement timing rather than when related expenditures were incurred. To address this, the organization will implement procedures to ensure grant revenue is recognized in accordance with accrual accounting principles, aligning revenue with the period in which eligible expenditures are incurred. A year-end cutoff review will be performed to identify and record any receivables for incurred but unreimbursed costs. Additionally, grant tracking schedules and reconciliation processes will be enhanced to ensure accurate and timely revenue recognition. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: December 31, 2025

Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with federal cost principles. Actions include: • Enforcing segregation of duties within the AP workflow. • Implementing standardized invoice naming conventions. • Requiring secondary review for all grant-related invoices. • Conducting quarterly post-payment audits to detect and correct errors. • Implementing ERP system enhancements to flag potential duplicates. • Hiring an AP Manager to manage and improve the AP processes. Responsible Staff Chief Financial Officer (CFO) Target Completion Date June 30, 2026

CDBG Performance Reporting (ALN 14.228) Condition The PR28 and CAPER reports were submitted 11 months late. This is a repeat finding and resulted from insufficient controls and inadequate staff training. Corrective Action Plan To ensure timely and compliant reporting, the following actions will be taken: • Developing written procedures for PR28 and CAPER preparation and submission. • Implementing a compliance calendar with required reporting deadlines. • Assigning both primary and secondary preparers to ensure redundancy. • Providing HUD IDIS training to relevant staff. • Conducting supervisory review prior to submission. • Hired a Grants Compliance Specialist to support ongoing compliance.(10/2025) Responsible Staff Grants Administrator Target Completion Date August 31, 2026

Finding 2024-001 Allowable Cost Principles and Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need for a formalized, written policy governing expenditures charged to federal awards. To address identified material weaknesses, Wabash is committed to implementing a comprehensive written policy by June 30, 2026. This policy will formalize the coding, review, and reporting processes for all federal expenditures. Key improvements will include: • Enhanced Internal Controls: We will establish a clear segregation of duties to ensure oversight and accuracy. • Timely Reporting: We are refining our payroll allocation process. Previously, payroll expenditures were withheld pending budget verification, which occasionally led to reporting delays. New controls will ensure that all expenditures, including payroll, are reported within the required quarterly timeframes. • Monitoring: The Controller will oversee the development of these procedures and remain responsible for ongoing monitoring and compliance. These steps will ensure our financial practices meet federal standards and provide rigorous oversight of project funds. Contact person(s): Cheryl Gaither, Controller Justin Gephart, Chief Operating Officer

Management acknowledges the finding. During the initial stages of administration of the FEMA Public Assistance Program (ALN 97.036 – PA-4339), the Company relied substantially on existing operational, administrative, and accounting procedures while management worked to further tailor, document, and formalize grant-specific compliance policies, procedures, and internal controls required under Uniform Guidance and FEMA regulations. Management notes that the Company maintained supporting documentation for expenditures and transactions related to the grant and that no questioned costs resulted from this matter. Management has substantially developed and implemented a significant number of corrective measures, policies, procedures, and internal controls designed to strengthen the Company’s internal control environment and support compliance with applicable federal award requirements. These actions included: Development and formal documentation of Financial Policies and Procedures; Implementation of procedures related to allowability of costs, disbursements, cash management, and property/equipment management; Enhancement of internal compliance monitoring procedures; Documentation and communication of grant administration responsibilities; Implementation of employee training and compliance guidance processes related to federal award administration. Management continues to enhance and formalize certain grant-specific controls, procedures, and compliance documentation as part of its ongoing efforts to further strengthen its federal award administration framework. Certain policies and procedures that had not yet been fully finalized remain in process and/or have been scheduled for completion and implementation. Management will continue periodically reviewing and updating these policies and procedures to ensure continued compliance with applicable federal regulations, FEMA guidance, and grant requirements.

The City will develop written procedures to implement the requirements of 2 CFR § 200.305 Payment.

Corrective Action Plan (CAP) Name of auditee: Amsterdam Housing I, Inc. TIN: 014-EE264 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: June 30, 2024 CAP prepared by: Henry Rodriguez, Jr. President Corvus Property Intelligence, LLC (410) 896-6770 Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2024-002 (a) Comments on the finding and recommendation: Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. (b) Action taken: Management will deposit the underfunded amounts when a cash flow surplus is realized. Management is actively working with HUD to collect retroactive subsidy payments.

The School Board agrees that, while the reimbursable expenses did not include personnel costs, the Wage Rate (Davis Bacon Act) was not included in the contract language as required for federally funded projects. Management has implemented processes to ensure that any current and future contracts for federally funded projects will include the Wage Rate (Davis Bacon Act) and DOL regulations to ensure compliance.

The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. This finding has since been resolved in 2025, with a new policy developed and implemented on April 1, 2025.

Management agrees that the amount needs to be deposited as soon as possible.

Finding No.: 2024-053 Special Test and Provisions – Project Accounting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures in compliance with applicable special tests and provision requirements. GHS will also identify department personnel responsible.

Finding No.: 2024-036 Cash Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Federal and Compliance section will establish a Standard Operating Procedure for drawdowns. As well as, conducting drawdowns daily to minimize the time between the drawdowns of federal funds and the disbursement for federal program purposes.

Finding No.: 2024-033 Cash Management Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Request to DOA will require immediate collaboration between Guam EPA and DOA, as all Guam EPA reimbursement requests are accompanied by the FGIA balance report and, currently, the GFMIS expenditure reports.

Finding No.: 2024-030 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to make sure reports are submitted on time. BBMR will also retain documentation of submitted reports.

Finding No.: 2024-010 Cash Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Federal and Compliance section will establish a Standard Operating Procedure for draw downs. As well as, conducting drawdowns daily to minimize the time between the drawdowns of federal funds and the disbursement for federal program purposes.

Management will monitor major programs and ensure that they are tested when necessary. The grant in question was tested during 2024.

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-012 1. Finding Summary The auditor determined that the institution disbursed Pell Grant funds more than 10 days prior to the first day of classes, in vio]ation of federal Title IV disbursement timing requirements. As a result, the institution could not demonstrate compliance with applicable federal regulations governing the timing of Pell Grant disbursements. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that Pell Grant funds were disbursed earlier than permitted under federal Title IV disbursement timing requirements due to a miscalculation of the days. 3. Root Cause Analysis The root cause of this finding resulted from by inaccurate or prematurely scheduled disbursement dates, limited coordination between the Financial Aid and Business Offices on the approved disbursement calendar, and insufficient controls to ensure Pell Grant funds were released in accordance with federal timing requirements. 4. Corrective Action(s) Management will implement a standardized calendar of disbursement dates annually based on the academic calendar. Description of Corrective Actions Management will prepare an annual disbursement calendar based on the academic calendar, which will be reviewed by both the Business Office and Office of Financial Aid to ensure compliance to federal Title IV disbursement timing requirements. 5. Risk Mitigation (Required - Even if Disagreeing) These corrective actions reduce the risk of early federal disbursements by strengthening oversight, implementing a disbursement calendar, and reinforcing staff understanding of federal timing requirements. 6. Responsible Party • Office/Department: Business Office • Title of Responsible Official: Senior Accountant • Name (optional): ___ _________ _ 7. Implementation Timeline • Corrective action implemented: (Yes) No • If not fully implemented, expected completion date: June 30, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) (Fully implemented) Partially implemented Not yet implemented Evidence of Implementation Academic Year 2026-2027 Disbursement Calendar. 9. Monitoring and Sustainability The University will continue to prepare a disbursement calendar annually before any new year disbursements are made.

Assistance listing numbers and program names 97.024 Emergency Management Performance Grants Agency: Department of Emergency and Military Affairs (DEMA) Name of contact person and title: Keith Tagaban, Audit Supervisor Anticipated completion date: September 18, 2026 Agency’s Response: Concur The Department of Emergency and Military Affairs (DEMA) will maintain complete, accurate, and auditable documentation to support all federal award expenditures, matching contributions, and financial reporting in accordance with 2 CFR Part 200 and applicable award terms and conditions, with records retained for a minimum of three years following submission of the final Federal Financial Report (FFR). DEMA will ensure all FFRs are reviewed for accuracy, completeness, and compliance prior to submission and will promptly correct any identified discrepancies in coordination with the federal awarding agency. The Department will implement and enforce written policies and procedures governing reimbursement requests, financial reporting, matching requirements, and record retention, including management review to ensure costs reported are allowable, allocable, reasonable, and adequately supported, and will maintain sufficient staffing and oversight to sustain ongoing compliance.

Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Anticipated completion date: December 31, 2027 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiatives to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for comprehensive, system-wide strategies. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Actions Taken: ● Increased scrutiny of claims based on claims volume. ● Issued a moratorium on new provider registrations for impacted provider types. ● Prevented Reimbursement of Claims for Impossibly Rendered Services. ● Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment. ● Set thresholds for services to initiate a prepayment review. ● Required claims to be billed for specific dates of service rather than ranges. ● Flagged claims for services of the same style/overlapping codes. ● Created a prepayment review process for providers utilizing suspicious billing practices. ● Eliminated retroactive billing. ● Credible Allegation of Fraud suspensions include both provider entities and owners/ behavioral health (BH) practitioners. ● Implemented ID.Me identity verification for AHCCCS Online. ● Required providers to disclose any third-party billing relationships. ● BH Providers are now considered high-risk provider types for provider enrollment. ● Per Diem codes have been set to only be able to be billed once per day. ● Practitioners, including BH Technicians, can no longer be patients at the same provider. ● Worked with the Arizona Corporation Commission to flag suspicious registrations. ● Ensured AHCCCS coding adhered to National Correct Coding Initiative standards and confirmed no edits had been turned off. ● Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. ● Creation and publication of the Covered Behavioral Health Services Guide to connect all relevant AHCCCS policies and explain how they interact in the Behavioral Health System of Care. ● Robust changes to our AHCCCS Provider Enrollment System to address fraud, waste and abuse (FWA) issues. ● Update to the Behavioral Health Residential Facilities policy (to be published shortly) to provide greater detail and clarity for providers and members about what should and should not be included in services rendered by this provider type. ● Creation of the prepayment review process for fee for service claims and inclusion of data measurement to allow for agile modification going forward to respond to over utilization or abuse of codes. ● Creation of the Community Partner Assistor Organization Reviews to prevent abuse of access to the Health-e-Arizona Plus system. ● Designated pathways of partnering on large scale quality of care investigations between the Division of Fee for Service and managed care organizations to prevent unnecessary member impact. ● Social media campaign to encourage the public to report FWA/abuse & neglect. ● Requirement of all providers to transition to Electronic Funds Transfer. ● Removed the phone attestation option for American Indian Health Program (AIHP) enrollment, and are in the process of implementing the AIHP verification process with tribal partners and Indian Health Services based on utilization. ● Memorandums of Understanding with AZ Board of BH Examiners and Board of Nursing to promote interagency information sharing and referrals, as well as the close referral relationship with the Arizona Department of Health Services. ● Regular Public BH System Cross-Agency Collaboration meetings including all agencies, boards, commissions and the GO in the public health space ● Updates to the provider enrollment policy in AMPM 610, explicitly requiring many more disclosures of providers, and making it clear without full and transparent registration information, providers will be terminated or denied enrollment with AHCCCS. ● Implemented policies which required BH Professionals, required to oversee the clinical services provided at Behavioral Health Residential Facilities and Outpatient Behavioral Health Clinics, to be reported upon registration and be listed on claims submissions ● Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements ● Linking BHP to BH companies and facilities they work for Actions Remaining (but not limited to): Implementing eligibility integrity requirements for AIHP enrollment. ● Implementation of Alivia – a new AI powered data analytics platform for pre-pay and post-pay claims analysis, currently in the development and planning stage ● Conduct onsite quality of care reviews for patients in treatment longer than 90 days. ● Require medical records to define specialized services. ● Implement a new pre/post pay claims system. AHCCCS continuously monitors our systems and investigates instances of fraud, waste or abuse. Any areas of concern which are identified are then addressed and system improvements are made. Furthermore, AHCCCS utilizes data analysis to confirm that these system improvements are having the intended impacts and that provider networks remain robust.

Recommendation: The Organization should contact HUD to facilitate the remittance of excess residual receipts. Action Taken: The management of Edsil’s Place Apartments, Inc. accepts the recommendation of Deming, Malone, Livesay & Ostroff and, accordingly, management will contact HUD to ensure that all excess residual receipts are remitted to HUD as soon as possible.

Finding 2024-014: Material Weakness in Internal Control and Material Noncompliance – Reporting Condition: For the Community Development Block Grants (CDBG) Entitlement/Special Purpose Grants Cluster (14.218), For the entitlement funding allocated to the City, they were required to submit four quarterly reports during the year and two annual reports. Of the three entitlement reports selected for testing, each one was submitted after the deadline. For the COVID-19 funding allocated to the City, they were required to submit quarterly reports duringthe year for two separate awards, for a total of eight quarterly reports, and one annual report. None of the required COVID-19 funding reports were submitted during the current year. Contact Person: Kara Prunty, Assistant Director of Finance – Grants, City of Danbury Corrective Actions Completed: We agree with the finding. The City has implemented a centralized reporting process under a designated grants/finance lead, including a recurring quarterly close schedule and a two-level review (preparer and approver) prior to submission. All submitted reports, supporting documentation, and submission confirmations are retained in a central repository.