Corrective Action Plans

1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and informal review procedures that were not consistently documented. Following organizational restructuring and personnel transitions, management has begun a broader effort to formalize and strengthen compliance monitoring, supervisory review procedures, and documentation practices across our housing portfolio. b. Action(s) Taken or Planned on the Finding: 1. Monthly Compliance and Financial Oversight Meetings: We are establishing recurring monthly oversight meetings with executive leadership, finance, and housing management personnel to review financial reporting, reserve activity, compliance requirements, tenant-related matters, and operational performance. We plan to document these meetings and retain evidence of supervisory review as part of our compliance monitoring procedures. 2. Expanded Finance and Compliance Oversight Structure: We have added a Director of Housing and Compliance responsible for operational and regulatory compliance oversight and have contracted an Interim CFO who is a licensed CPA. We plan to continue refining roles and further segregating responsibilities among the accounting, compliance, and operational functions to strengthen internal controls and management review. 3. Formalized Compliance Monitoring Procedures: We are developing standardized compliance monitoring procedures, including monthly reserve deposit tracking, supervisory review checklists, documented financial statement review procedures, reconciliation monitoring, and periodic compliance checklists addressing key HUD program requirements. 4. Ongoing Monitoring and Documentation Retention: We will strengthen documentation retention procedures so that evidence of compliance monitoring, supervisory review, and reconciliation activities is consistently maintained and available for future audits and regulatory reviews. c. Anticipated Completion Date: Full implementation is expected to be completed and documented by March 31, 2027.

1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and informal review procedures that were not consistently documented. Following organizational restructuring and personnel transitions, management has begun a broader effort to formalize and strengthen compliance monitoring, supervisory review procedures, and documentation practices across our housing portfolio. b. Action(s) Taken or Planned on the Finding: 1. Monthly Compliance and Financial Oversight Meetings: We are establishing recurring monthly oversight meetings with executive leadership, finance, and housing management personnel to review financial reporting, reserve activity, compliance requirements, tenant-related matters, and operational performance. We plan to document these meetings and retain evidence of supervisory review as part of our compliance monitoring procedures. 2. Expanded Finance and Compliance Oversight Structure: We have added a Director of Housing and Compliance responsible for operational and regulatory compliance oversight and have contracted an Interim CFO who is a licensed CPA. We plan to continue refining roles and further segregating responsibilities among the accounting, compliance, and operational functions to strengthen internal controls and management review. 3. Formalized Compliance Monitoring Procedures: We are developing standardized compliance monitoring procedures, including monthly reserve deposit tracking, supervisory review checklists, documented financial statement review procedures, reconciliation monitoring, and periodic compliance checklists addressing key HUD program requirements. 4. Ongoing Monitoring and Documentation Retention: We will strengthen documentation retention procedures so that evidence of compliance monitoring, supervisory review, and reconciliation activities is consistently maintained and available for future audits and regulatory reviews. c. Anticipated Completion Date: Full implementation is expected to be completed and documented by March 31, 2027.

Corrective Action Plan Audit Finding Reference: 2026 – 001 Planned Corrective Action: The College agrees with this finding and will formalize transfer student monitoring in a stand-alone written procedure. Specifically: • The Director of Student Financial Services will document a written procedure identifying every transfer student subject to NSLDS Transfer Student Monitoring, using admissions and registrar records, at the time the financial aid file is established. • Each identified transfer student will be added to NSLDS Transfer Student Monitoring, and resulting alerts cleared, before any Title IV funds are disbursed. • Completion of the transfer monitoring step will be documented in the student's file separately from the NSLDS financial aid history review. • A second financial aid staff member will review and document this step for each transfer student before disbursement is released. • The Director will train financial aid staff on the distinction between the NSLDS history review and Transfer Monitoring, and will review the transfer student population each term for compliance. Name of Contact Person: Kim Balentine, Director of Student Financial Services, kbalentine@occ.edu Anticipated completion date: The stand-alone written transfer student monitoring procedure will be completed prior to the start of the spring semester, with the monitoring and documentation steps applied to all transfer students beginning immediately.

Sliding Fee Discount Program Eligibility and Application Auditor reference: Schedule of Findings and Questioned Costs, page 39 Finding addressed: In a nonstatistical sample of 25 encounters, two patients received sliding-fee adjustments that did not align with the approved discount category based on their documented household income and family size. The auditor reported no questioned costs related to this finding. Planned corrective action 1. Correct the identified exceptions. By November 2026, designated staff under the CFO’s oversight will review the two cited encounters against the board-approved sliding-fee policy and the discount schedule in effect on each service date, verify supporting records of household income and family size, and document the correct category and required account adjustments. Any patient credit or refund identified as due will be processed in accordance with approved billing and collections procedures. 2. Assess extent and system configuration. By December 2026, Finance will conduct a targeted retrospective review of at least 50 additional sliding-fee encounters across applicable service lines, locations, and discount categories. The review will compare documented income and family size with the assigned discount. EHR and billing-system discount tables, effective dates, and any manual override permissions will be checked against the board-approved schedules. Errors will be corrected, and the review will be expanded if a broader issue is identified. 3. Standardize eligibility verification. By December 2026, NHHC will issue a written step-by-step workflow that requires documentation of income, family size, eligibility determination, and application of the correct sliding fee tier before the adjustment is finalized. Manual adjustments or overrides will require a documented reason and supervisory authorization, with an audit trail retained. 4. Provide competency-based training. By January 2027, relevant front-desk, eligibility, registration, and billing personnel will be trained on the approved Sliding Fee Discount Program policy and on the use of the applicable schedule. Completion records and a brief competency validation will be retained. Any policy revisions will be submitted to the governing board for approval before implementation. 5. Monitor sustained adherence. During January and February 2027, Finance will review at least 25 newly processed sliding-fee encounters per month. Results will be reported to the CFO and CEO, with a goal of 100% agreement between documented eligibility and applied discounts. Any discrepancy will be promptly remediated, including additional staff coaching and further sampling until the control is operating effectively. Responsible contacts: Jason Wallace, Chief Executive Officer; Monica Lerma, Chief Financial Officer Anticipated completion: February 2027 Evidence of correction: Two-case correction log and account documentation; retrospective sampling results; approved policy and schedule; validated EHR/billing discount mapping; updated workflow; training and competency records; monthly quality-control samples; and documented supervisory follow-up.

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has recognized and acknowledges the deficiency in internal controls in regards to the determination, recording, and monitoring of the sliding fee discount process. Along with the safeguards that have been implemented previously, we are implementing a process that includes: - verification, during front desk eligibility check that slide information is complete; - if patient qualifies for the slide, note in billing notes, effective dates, slide category, and fee to be collected; - identify patients that are checking in that day and double check slide category and fee to collect; - if there is a discrepancy with any documentation, reach out to slide coordinator.

The center will perform addional education to ensure proper documentation is retained and sliding fee discount applied.

Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.

Name: CABUN Rural Health Services, Inc. Contact Name: Judy Southall, CFO Contact Phone Number: 870-798-4064 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: March 31, 2026 Federal Program: Health Center Cluster Anticipated Completion Date: October 2026 Response: The Organization concurs with the finding, and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Management and all personnel involved will review and determine the appropriate sliding fee discount in order to be in compliance with Uniform Guidance. All patients will be offered an application to participate in the sliding fee discount. Information will be entered into the system as declined or appropriate to arrive at the sliding fee category. The application will then come to Hampton where a billing clerk will review the application for accuracy. The CHC and Insurance tab will reflect the correct sliding fee category. Corrections to the patient account will be made if there are any inaccuracies found. Education will be provided to those making the error and corrective action taken if continued omissions. In the Organizations PMS, the slide is setup as an insurance, if no other insurance is primary the adjustment is automatically made. The PMS has been checked for accuracy of slide categories, adjustment codes and insurance types. CABUN’s Billing and Collections staff will be re-educated on the entire process of sliding fee; from application to ensuring adjustments are made correctly. Reviews will be made by the CIO on a quarterly basis to assure the correct adjust has been made.

Audit Finding Reference: 2026-001 (Federal) Eligibility - Child and Adult Care Food Program, Assistance Listing 10.558 Planned Corrective Action: • Initial determination and first-level review. Participant eligibility is determined by the Site Director in accordance with the applicable CACFP Income Eligibility Guidelines. Income Eligibility Application forms are reviewed for completeness and accuracy by the Site Director. • Independent secondary review. Beginning September 2026, before any determination is transferred to the Master List used for claim reimbursement, TEAM's Early Childhood Quality Assurance Manager will independently review each determination by recalculating reported household income and household size and comparing the result to the current program-year Income Eligibility Guidelines. This applies to 100% of initial determinations and to every re-determination or mid-year change in reported household income or household size. • Guideline currency. The Quality Assurance Manager will obtain the Income Eligibility Guidelines issued for each program year upon publication, confirm that the table in use is the current-year table. • Documentation. The reviewer initials and dates each Income Eligibility Application. The eligibility category recorded on the Master List is traced to the reviewed form. Reviewed forms are retained for audit. • Correction of the identified errors. The two participants identified in the finding were reclassified as of April 2026. The claims will be amended post CACFP review in September 2026. Name of Contact Person: Jamie Peterson, Lead Director of Early Childhood Jpeterson@teaminc.org Designated backup: Jamie Cullen, Early Childhood Quality Assurance Manager jcullen@teaminc.org 203.757.8888 x3241 Completion date: September 15, 2026

All staff responsible for registration and income verification in all service lines, programs, and sites received training on income eligibility assessment, documentation, and application in October of 2025. Chart Auditing and Staff Coaching and Corrective Action: ▪ Annual competency assessments for all registration staff in all service lines, programs, and sites will be part of clinical compliance training between January 1 and February 28, 2027. Competency assessment includes eligibility assessment, documentation, and application. Failure to complete the assessment in the assigned time or failure to complete the assessment successfully will result in letter of expectation with 14 days to demonstrate improvement, followed by formal disciplinary action in the form of a verbal reprimand and 14 business days to remediate before a written reprimand is issued. Completion date for action: 03/31/2027 ▪ Conducting random audits of 2 percent of patients with a visit in a calendar month across all service lines and programs, or a minimum of 90 charts with a standard audit tool that provides scoring to prompt coaching and additional training for staff who fail to meet a 90% benchmark. Completion date for action: On-going. Will have full 2% compliance by 10/31/2026 ▪ Develop automated audit tool that provides real-time feedback on all patient registration records for consistency and accuracy of SFDS screening and documentation. Completion date for action: 12/31/2026 ▪ Work with OCHIN to allow SFDS and income verification in one service line to flow into accounts for all service lines to mitigate issues stemming from different FPLs depending on service line. Completion date for action: 12/31/2026 Contact person: Angela Hurley, Director of Operations Completion date for action: 03/31/2027

As explained in Management’s response to Finding 2026-002, Baptist Retirement Village had been approved for MFCS’s reduced (25%) monthly sampling of annual recertifications based on the property’s prior compliance history, its continuous 100% review of move-in and interim certifications, and MFCS’s ongoing availability for certification and compliance support. Because errors were identified during this reduced-sample review, the property is returning to 100% file review for all certifications, which will remain in place until Baptist Retirement Village again meets all criteria for reduced sampling — two consecutive years without MOR resident-file findings, a minimum two-year site manager tenure, and at least one year of error-free annual recertifications. In addition, SPM is updating the standardized tenant file checklist and written internal control procedures covering eligibility determination, income/rent calculation, and required certifications, with a documented compliance sign-off required before a file is considered complete

Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.

Finding 2026-002: Compliance, Inadequate Compliance Monitoring, Regulatory Oversight, and Governance Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2025-004 Criteria: Management is responsible for establishing and maintaining effective internal controls over compliance that provide reasonable assurance the Housing Choice Voucher Program is administered in accordance with Federal statutes, regulations, and HUD requirements. Effective controls should include adequate monitoring of compliance requirements, timely implementation of regulatory changes, maintenance of current policies and procedures, and oversight sufficient to compensate for staffing limitations. HUD program requirements and regulatory changes should be reviewed and incorporated into the Authority's Administrative Plan in a timely manner. Similar control expectations are reflected in HCV compliance guidance addressing policy maintenance, Board oversight, monitoring of regulatory changes, and compensating controls where segregation of duties is limited. Condition: The Authority operates only the Housing Choice Voucher Program and employs a single individual responsible for substantially all program administration and compliance responsibilities. Because staffing levels do not permit traditional segregation of duties, the Authority should have established compensating monitoring and oversight controls. However, our audit identified significant weaknesses in the Authority's internal control structure over compliance. Specifically, we noted: • Compliance responsibilities were concentrated in one individual without independent review or documented monitoring procedures. • The Administrative Plan had not been updated to incorporate applicable HOTMA requirements. • Board minutes indicated the Authority was relying upon HUD Notices H-2025-03 and H-2025-07 when evaluating HOTMA implementation. These notices do not apply to the Housing Choice Voucher Program and the Authority was not utilizing the correct guidance in HUD PIH Notices. • The Authority had not established procedures to identify, evaluate, and implement applicable HUD PIH notices and other regulatory updates affecting the Voucher program. • Audit testing identified deficiencies in multiple compliance areas, indicating that compliance monitoring controls were not operating effectively. The existence of compliance deficiencies across multiple program areas demonstrates that the Authority's controls were not reasonably designed or operating effectively to ensure compliance with Federal program requirements. Similar conditions have been identified in other HCV compliance control assessments, including lack of monitoring of regulatory changes, inadequate Board oversight, and insufficient compensating controls where staffing is limited. Cause: The Authority has not established an effective system of internal control over compliance. Management and the Board of Commissioners did not implement sufficient compensating controls to address the risks associated with a single-employee operating structure. In addition, procedures were not established to ensure that changes in HUD regulations, notices, and program requirements were identified, evaluated, and incorporated into Authority policies and operational practices on a timely basis. Effect: The lack of effective compliance oversight increases the likelihood that material noncompliance with Federal program requirements could occur and not be prevented, detected, or corrected timely. Failure to maintain current policies and implement regulatory changes increases the risk of noncompliance in areas including tenant eligibility, rent calculations, utility allowances, inspections, reporting, and other program requirements. The deficiencies identified during the audit demonstrate that the Authority's control environment does not provide reasonable assurance of compliance with Housing Choice Voucher Program requirements. Recommendation: We recommend the Authority: 1. Establish formal procedures for monitoring compliance with Housing Choice Voucher Program requirements. 2. Update the Administrative Plan to incorporate all applicable HOTMA requirements and other current HUD guidance. 3. Develop a process for reviewing HUD PIH notices, regulatory updates, and other program guidance as issued. 4. Implement documented supervisory or independent compliance reviews to compensate for the lack of segregation of duties. 5. Provide periodic compliance reports to the Board of Commissioners and document Board oversight of corrective actions. 6. Establish written procedures to ensure significant regulatory changes are timely evaluated, adopted, and implemented. Views of Responsible Officials The Authority agrees with the finding.

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.

Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2026 Estimated Completion Date: June 2026 Finding #2026-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding, and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Coordination with Revenue Cycle Management has occurred to ensure awareness across teams. Office Managers review all new sliding fee applications on a monthly basis to ensure accuracy, and the Billing Manager conducts quarterly audits of sliding fee claims to ensure adjustments are entered correctly by the billing department. The Organization also continues to provide staff training for all individuals involved in the sliding fee application process. Management has instructed all outsourced billers not to modify sliding fee adjustments; any required changes must be handled by in-house billing staff. Additionally, sliding fee adjustments auto posted in error will be removed. Management is also working with IT to restrict system access for outsourced users to prevent unauthorized adjustments. Additionally, IT will implement a scheduled monthly audit report to identify improper adjustments and monitor user activity.

Management has reviewed the audit finding and acknowledges the allegation related to improper administration of the applicant wait list. The former project manager is no longer with the Project, and management responsibilities have been reassigned. Management plans to review wait list procedures, strengthen oversight and documentation requirements, and implement additional controls to ensure applicants are processed in accordance with established policies and applicable program requirements.

To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.

To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.

Finding: 2025-002 - Special Tests and Provisions: Uniform Relocation Act Condition Reported by the Auditor: OCGDLC did not assess whether the relocation provisions of 49 CFR Part 24 applied to the occupants of the property acquired with federal award funds, did not identify the occupants or retain occupancy records, and did not issue any notice required by 49 CFR 24.203. Corrective Action Planned: Ossining Community Garden of Dreams Legacy Center Inc. (OCGDLC) recognizes the importance of compliance with the Uniform Relocation Act (URA) and acknowledges the documentation and procedural concerns identified during the audit. The federally assisted property acquisition was completed on April 15, 2025. While the prescribed HUD relocation-related form was not utilized during the acquisition process, OCGDLC maintains that communication concerning the property's occupancy circumstances was conveyed to the seller, as reflected in the available transaction documentation. These communications demonstrate that occupancy considerations were addressed during the acquisition process, notwithstanding the absence of the specific form. Furthermore, to the best of OCGDLC management's knowledge and based on the information available, no displacement occurred as a result of the acquisition. OCGDLC has provided HUD with available documentation concerning the completed acquisition and occupancy circumstances. OCGDLC remains committed to ensuring that the documentation and communications surrounding the transaction are appropriately reflected in its federal grant records. OCGDLC will implement the following corrective measures: 1. Documentation of the Completed Acquisition: OCGDLC has maintained the existing acquisition records, including correspondence and documentation reflecting communications with the seller regarding occupancy, together with the supporting materials previously submitted to HUD. These records are maintained as part of OCGDLC's federal grant documentation. 2. Advance Confirmation of Federal Compliance Requirements: For any future federally assisted real property acquisition, OCGDLC will proactively request written guidance from HUD or the applicable federal awarding agency identifying all required forms, notices, certifications, supporting documentation, and applicable submission deadlines. OCGDLC will seek clarification regarding when each requirement must be completed, including any actions necessary before acquisition, during the transaction, or following closing. This process will supplement OCGDLC's internal compliance review and promote clear communication and coordination regarding federal requirements. These measures reflect OCGDLC's commitment to federal compliance while recognizing the distinction between the absence of a prescribed form and the documented communications that occurred during the acquisition. OCGDLC will continue to strengthen its compliance practices through advance clarification of applicable requirements and maintenance of supporting documentation. Anticipated Completion Date: Completed: Existing acquisition documentation, occupancy-related correspondence, and supporting materials have been maintained on file and provided to HUD. Effective Immediately: OCGDLC will proactively request written confirmation of applicable federal forms, notices, documentation requirements, and submission deadlines in advance of any future federally assisted real property acquisition. Name and Title of Responsible Official: Diana E. Lemon Chief Executive Officer & Co-Founder Ossining Community Garden of Dreams Legacy Center Inc.

FINDING NUMBER 2025-005 AUDITOR’S DESCRIPTION WIC/SENIORS FARMERS’ NUTRITION PROGRAMS: REPORTING CONDITION The Data Collection Form and related reporting package for the fiscal year ended June 30, 2025, were not submitted to the Federal Audit Clearinghouse within the timeframe required by 2 CFR Part 200.512. This matter represents a repeat finding from the prior year. AUDITOR’S RECOMENDATION We recommend that AEDA establish a formal Single Audit reporting calendar and designate responsible personnel to coordinate the audit process before year-end. Management should establish deadlines for closing the accounting records, completing subsidiary ledgers and reconciliations, preparing the Schedule of Expenditures of Federal Awards and supporting schedules, responding to auditor requests, and reviewing and submitting the Data Collection Form and reporting package within the federal deadline. CORRECTIVE ACTION PLAN AEDA has implemented a new accounting system and is reorganizing its personnel structure to ensure that all accounting information is complete, accurate, and available on a timely basis, enabling the organization to successfully complete future Single Audits within established deadlines. LEADS PERSONS ACCOUNTABLE FOR ACTIONS ITEM COMPLETION Elmer Perez, Administrator of AEDA, and Yimaries Méndez, Finance Director of AEDA. DELIVERABLE June 30, 2025 EVIDENCE INCLUDED YES/NO NO TARGET COMPLETION DATE Finding 2025-005 should be corrected for the Single Audit pertaining to the State fiscal year ending on 6/30/2027.

HSDD management is committed to strengthening internal controls over participant eligibility documentation, HAP payment support, annual reexaminations, rent-reasonableness determinations, and HUD-50058 reporting. These efforts will include reviewing the identified exceptions, working to retrieve any outstanding documentation from prior records or service providers, enhancing supervisory oversight, and providing additional training to program personnel. HSDD management recognizes the documentation deficiencies identified during the audit, the absence of supporting documentation does not necessarily establish that the underlying participants were ineligible or that HAP payments were improperly calculated. Accordingly, management intends to review the identified exceptions and work with the appropriate parties to resolve questioned costs in accordance with HUD's final management decision. HSDD management, specifically its Director Dorian Rawles, remains committed to implementing corrective actions designed to improve documentation retention, strengthen program compliance, and reduce the likelihood of similar findings in future reporting periods.

CORRECTIVE ACTION PLAN September 25, 2026 Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410 and H8N53897 for 2025 Finding 2025-002 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken and Expected Date of Correction Identified Issue: Brooklyn Plaza Medical Center identified a need to strengthen the consistent application and documentation of the Sliding Fee Discount Program (SFDP), including front-end staff processes related to patient eligibility, documentation, and collection of applicable fees, as well as back-end billing processes to ensure that sliding fee adjustments and write-offs are applied accurately and consistently. Corrective Action Brooklyn Plaza Medical Center will implement a standardized training, monitoring, and reconciliation process to ensure appropriate administration of the Sliding Fee Discount Program from patient registration through final account reconciliation. This will be implemented by December 2026. Front Desk Training and Standardization All Front Desk/Patient Services staff will receive mandatory training on the Sliding Fee Discount Program. Training will include: • Reviewing the current Sliding Fee Discount Program policy and fee schedule. • Determining and documenting household size and income in accordance with established policy. • Identifying patients who may qualify for the Sliding Fee Discount Program. • Properly completing and maintaining required eligibility documentation. • Applying the appropriate sliding fee category based on established income guidelines. • Communicating the program and applicable patient responsibility clearly and consistently to patients. • Ensuring appropriate information is entered into the electronic health record/practice management system so that billing can process the account correctly. Training will be incorporated into the onboarding process for new Front Desk staff and reinforced through periodic refresher training. Billing and Write-Off Reconciliation The Billing/Revenue Cycle team will establish a back-end review process to ensure that accounts approved for the Sliding Fee Discount Program are adjusted appropriately. Billing staff will verify that: • The correct sliding fee category has been applied. • Patient responsibility is consistent with the approved sliding fee schedule. • Applicable contractual adjustments and sliding fee write-offs are accurately posted. • Sliding fee balances are not incorrectly transferred to patient responsibility or collection activity. • Any discrepancies identified between front-end documentation and back-end billing are corrected promptly. Billing will also conduct periodic reconciliation of sliding fee accounts to identify inappropriate balances, missed adjustments, or incorrect write-offs. Monitoring and Quality Assurance Management will conduct routine audits of a sample of Sliding Fee Discount Program accounts to confirm compliance at both the front and back end. Audit findings will be reviewed with Patient Services and Billing leadership, and any identified deficiencies will result in immediate correction and additional staff education as necessary. The organization will monitor compliance on an ongoing basis to ensure that the corrective action is sustained and that eligible patients consistently receive the appropriate sliding fee discount. Responsible Parties: Practice Administration/Patient Services Leadership Revenue Cycle/Billing Leadership Finance Compliance Expected Outcome: Brooklyn Plaza Medical Center will have a standardized and auditable process that ensures Sliding Fee Discount Program eligibility is appropriately determined and documented at the front end and that corresponding billing adjustments and write-offs are accurately reflected on the back end. If the Health Resources and Services Administration has questions regarding this plan, please call Philip J. Onorato, Chief Executive Officer at 718-596-9800, ext. 205.

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: We recommend that the Organization strengthen controls over participant eligibility by implementing procedures to regularly monitor participant eligibility periods, track ORR eligibility dates, and timely close cases that exceed the maximum allowable service period. In addition, the Organization should verify and document Minnesota residency prior to providing services, retain supporting eligibility documentation in participant files, and perform periodic monitoring to ensure compliance with program eligibility requirements. Management should not rely solely on system-generated notifications to identify participants approaching eligibility expiration. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KOM will strengthen its participant eligibility procedures by implementing a process to regularly monitor participant eligibility periods and track applicable ORR eligibility dates. Cases that reach or exceed the maximum allowable service period will be identified and closed timely. KOM will also establish procedures to verify and document Minnesota residency before services are provided and to retain appropriate eligibility documentation in participant files. Periodic monitoring will be performed to confirm ongoing compliance with program eligibility requirements, rather than relying solely on system-generated notifications to identify approaching eligibility expiration dates. Name of the contact person responsible for corrective action: Alice Buckner, Executive Director Planned completion date for corrective action plan: December 31, 2026.

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its controls over Executive Director payroll by requiring payroll timesheets and related payroll records to be reviewed and approved by an individual with appropriate oversight authority, such as the Board Chair, Treasurer, or another designated board representative. Management should maintain documentation of such approval and periodically monitor compliance with the control. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in October 2026, KOM will implement an independent review and approval process for the Executive Director's payroll. A designated Board member will review and approve the Executive Director's payroll records. To facilitate this control, the designated Board member will be established in Paylocity with the appropriate manager-level access necessary to perform the approval. KOM will coordinate with the designated Board member to ensure that the review and approval can be completed within the organization's time-sensitive semi-monthly payroll cycle and that evidence of the approval is retained. Name of the contact person responsible for corrective action: Alice Buckner, Executive Director Planned completion date for corrective action plan: November 30 , 2026.

Recommendation: We recommend the City establish procedures to ensure that the review and approval processes are clearly documented within each tenant file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management recognizes the importance of maintaining adequate documentation to demonstrate the required reviews and approvals are performed timely and consistently at all times. The RBHA established procedures to monitor and ensure proper file review in the prior-year (2023-2024) corrective action by creating a new checklist for a supervising team member to review intake files for accuracy, to document approval, release the Housing Assistance Payments, and maintain a record of the signed checklist in the participant file. To prevent recurrence, new staff will be informed of this requirement. Name(s) of the contact person(s) responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: December 2025