Corrective Action Plans

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2023–009 - Adoption Savings Name of the contact person responsible for corrective action: Sheena Frazer Anticipated completion date for corrective action: N/A Recommendation: The DSS through the DFAS strengthen internal controls and procedures to ensure Annual Adoption Savings Calculation and Accounting Reports are accurately prepared and submitted to ensure compliance with federal adoption savings requirements. DSS Response: The DSS agrees with this finding. The DSS has experienced staff transitions and actively works to ensure staff familiarity with federal workbook instructions and desk procedures. Corrective action planned is as follows: The DSS plans to implement the SAO’s recommendations to further strengthen internal controls and procedures and will adhere to these processes to ensure the federal report is accurate and compliant.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2023-016 Child Care Payments Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion date for corrective action: 12/31/2024 Corrective action planned is as follows: DESE agrees with the auditor’s finding. It has been challenging to have adequate internal controls over the child care program with two separate state agencies trying to administer different aspects of the program. The Department of Social Services (DSS) has been implementing eligibility and authorizations for families, while DESE has been administering rates, rules, licensure, and provider agreements. Effective July 1, 2024, eligibility and authorizations for families transfers under DESE’s authority to ensure all facets of program implementation are within one state agency for better internal controls. In addition, DESE transitioned to a new Child Care Data System (CCDS) for provider payments in the beginning of January 2024. Access, interfaces, and updates within the older systems has created multiple barriers and payments issues for the program. This single system, CCDS, allows parents to have a streamlined process for eligibility determinations, report changes in address or income, find or change providers, while also giving providers one place to apply for a contract, view authorizations, update contact information, view payment remittances, and make payment adjustments. By December 31, 2024, the CCDS will have combined all functions of FAMIS, FACES, and CCBIS attendance system into CCDS. DESE users can easily and efficiently make family and rate changes as necessary and view all information in the system, which will also strengthen internal controls. DESE also continues to revise and clarify internal procedures to ensure consistent and accurate eligibility determinations and claims processing. CCDF regulations specifically state pursuant to 45 CFR 98.21(a)(1) that because a child meeting eligibility requirements at the most recent eligibility determination or redetermination is considered eligible between redeterminations, any payment for such a child shall not be considered an error or improper payment due to a change in the family's circumstances. Based on this regulation, DESE will work with the Administration for Children and Families to repay any claims considered questioned costs.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Missouri National Guard (MONG) Audit Finding Number: 2023-018 – MONG Cooperative Agreement Extensions and Final Accounting Name of the contact person responsible for corrective action: Lindsey Hedges Anticipated completion date for corrective action: October 2024 Recommendation: The MONG establish controls and procedures to ensure a final accounting of all funding and disbursements and/or a written request(s) for extension is filed for each CA appendix in compliance with National Guard regulations. Corrective action planned is as follows: Missouri National Guard will implement internal controls and procedures for ensuring final accounting and extension requests are filed timely through regular monitoring of Cooperative Agreement (CA) appendices to identify upcoming lapses in completion of final accounting of all funding and disbursements or for extension request.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-012 CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: CACFP Subrecipient Reimbursements DHSS disagrees. The DHSS through BCFNA maintains a strong system of internal controls over meal reimbursements to CACFP facilities/sponsors to ensure costs are allowable and supported. The system is in compliance with Uniform Guidance and USDA program requirements. The system includes subrecipient monitoring based on risk assessments per the substance and spirit of Uniform Guidance, initial and ongoing training and technical assistance opportunities, and reviews of invoices. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This goes against the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher ranking requirements set forth by specific federal grant funders and awards. The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve its process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. The DHSS’ strong system of internal controls which is documented in the Nutritionist Manual is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. The increased claim testing and recoupment suggested by the SAO would create a significant barrier to participation for sponsors/facilities (many of which are small child care centers, day care homes, emergency shelters and adult day care centers) which is prohibited by USDA. Reviewing supporting documentation with every individual reimbursement claim at the time of submission as suggested in the finding is not feasible given the number of reimbursement claims processed monthly by program staff already functioning at capacity. Neither is it required by Uniform Guidance, the USDA or standard subrecipient monitoring procedures. The BCFNA already requires claims to be paid on a reimbursement basis rather than in advance and performs various reviews of the claims in CNPWeb, so the additional step of requiring supporting documentation with every reimbursement claim at the time of submission is unnecessary and is intended as a specific condition to remedy high risk subrecipients per 2 CFR 200.208. Furthermore, BCFNA offers technical assistance training and reviews in addition to regular monitoring reviews. In addition to the edit checks within the CNPWeb system which validate such things as capacity limits and licensing, BCFNA staff has, and continues to perform, additional verification such as spot-checks for inconsistencies (i.e. a greater number of enrolled participants as compared to licensed or total capacity or suspicious claim irregularities or patterns). Each claim submitted also requires a certification of truthfulness, accuracy, completeness with potential criminal, civil or administrative penalties in accordance with U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812. As noted by the SAO, the risk based monitoring approach implemented by BCFNA has been effective in identifying significant issues and claim errors in recent years. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required and in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies. For example, fifty five percent of the monitoring reviews completed during fiscal year 2023 were graded as a B or C and were give additional technical assistance and/or monitoring follow up as a result.

023-005 –ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third-party management company to ensure compliance with 24 CFP 960.259 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

023-003 –ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third-party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

Finding 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program, Federal Catalog Numbers: 14.871 Noncompliance - E - Eligibility Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of forty-three (43) tenant files, the following information was unavailable for examination at the time of audit: (3) Verification of Income (2) Verification of Assets HUD Form 50058 Our sample size is statistically valid. Known Questioned Costs: 7,162 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Section 8 Housing Choice Voucher Program is in non-compliance with the eligibility type of compliance requirements of the program. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Philisa Smith, HCV Director, is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring by December 31, 2024.

HSD acknowledges the identified weakness and implemented an updated Accounts Payable control procedure in 2024, that includes an additional standard monthly report and review process to ensure that reimbursements are processed with the required 30-day period.

2023-001 ALN 14.871 – Housing Voucher Cluster – Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Tyronnda Bethune, Executive Director Projected Completion Date: December 31, 2024

Management will implement a system to monitor and review tenant file gross rent changes occurring during the year.

Federal Awards Finding - Significant Deficiency in Internal Controls and Compliance Finding 2023-002 – Eligibility Assistance Listing No. 14.867 – Indian Housing Block Grant Condition: Pursuant to testing of eligibility and internal controls over eligibility, auditors noted the following control deficiency and noncompliance: • One tenant did not have an annual recertification or inspection completed. Recommendation: Wipfli LLP recommends that the Agency strengthen its internal controls over eligibility to monitor all relevant information and documentation affecting the eligibility process. Corrective Action Plan: Letter will be sent to the tenant for the recertification to be completed. Inspection will be scheduled with the inspector, inspections were put on hold during the pandemic. This was lifted in June of 2023 but would was not completed in October 2023, this will be scheduled and completed by the end of October 2024. Name of Contact Person Responsible for Corrective Action Plan: Raven Rosin Anticipated Completion Date: November 1, 2024

Broomfield agrees with the auditors' recommendation to follow the documented internal control process or adjust process for over review of eligibility determinations. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

Finding 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions. Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Of a sample size of fifteen (15) Section 8 Housing Choice Vouchers' new move-ins, one (1) could not be traced to the Authority's waiting list. Known Questioned Costs: $4,336 Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Ann Malfavon, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

NEED FROM CLIENT….

2023-003: Housing Voucher Cluster – Eligibility – Document Retention Name of Contact Person(s): Allison Gallagher, Director of Housing Choice Vouchers Management’s Views and Corrective Action Plan: Signed HAP contracts and lease agreements are required for every new lease up and MaineHousing will not release payment to the owner until those signed documents are received. These agreements state the contract rent and subsidy amounts at the time of the initial lease. Annually, each tenant is recertified and a contract amendment is generated with the current contract rent and subsidy amounts listed. These amendments are filed with the original documents. Management is certain that proper rent and subsidy payments were made based on annual and interim recertification documents on file. A new electronic file retention process was implemented in 2022, which involved organizing and converting volumes of physical files to electronic files. Since implementation of the new process, we have determined that some unit information for certain tenants was inadvertently discarded during conversion. Program staff are identifying missing unit information as they process annual recertification or when an outside party requests it and reaching out to the owner to obtain a copy of the signed original documents. The two HAP and lease contracts identified in this finding have been obtained. Management believes that the electronic file retention process currently in place is working well and this was isolated to the period of time when files were being organized and scanned from physical files to electronic files. Proposed Completion Date: Completed

Corrective Action Plan for Current Year Findings Finding 2023-001: Timely Processing of Participant Applications: Department of Health and Human Services - AL #93.568 Low Income Home Energy Assistance Program #Ll-023-024 Corrective Action: WICAA has developed a streamlined approach for assessing incoming applications, differentiating between complete and incomplete applications at the beginning of the processing cycle. This will ensure that complete applications can be promptly processed. Additionally, if a substantial number of unprocessed applications are nearing 10 days of the deadline for processing, our staff will be notified that there is a need for overtime. Overtime requirements will be assessed weekly. These modifications are anticipated to result in applications being processed within the allowable number of days. Person Responsible: The Energy Assistance Director has primary responsibility with oversight by the Executive Director. Timing for Implementation: Immediately

Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Eligibility Recommendation: We recommend that the Commission review its process for collecting third party income support to ensure the accurate data is used as part of the tenant rent and HAP calculations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Corrected data is essential in determining the correct rent responsibility and HAP. To ensure that the data and rent calculations are correct, HCHC has taken the following steps: • Staff members have taken additional Housing Specialist training offered by Nan McKay. • HCHC has created and hired a quality control specialist who selects housing specialist 50058 actions to ensure that HCHC has data integrity, and all information is true and accurate. • The supervisor also selects housing specialist 50058 actions for review, ensuring that all required documentation is intact and that the proper rent responsibility and HAP calculations are correct. Name(s) of the contact person(s) responsible for corrective action: Crystal Gorham, Director of Rental Assistance Completion date for corrective action plan: 6/30/2024

Hamlet Housing Authority Corrective Action Plan For the Year Ended December 31, 2023 Section II - Financial Statement Findings None Reported. Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Gary Jones Executive Director Corrective Action: Management will review the recertification process and plan to monitor recertifications. Proposed Completion Date: Immediately

Finding 2023-001: Material Weakness over Subrecipient Monitoring and Required Filings The Uniform Guidance requires organizations to establish internal controls to detect potential noncompliance. Management had existing controls related to subrecipient monitoring. However, these controls were not sufficiently detailed relative to the collection of audited financial statements and eligibility to receive funding. During 2023, for one subrecipient, HESI did not retain evidence of the review performed of the subrecipient’s eligibility to receive funding and did not retain evidence of the monitoring of the subrecipient’s audited financial statements. Planned Corrective Action: The subrecipient’s audited financial statements and Report on Federal Awards in accordance with Uniform Guidance were subsequently requested and reviewed in September 2024. Procedures have been put in place to ensure that subrecipients are eligible to receive Federal funding and a subrecipient’s audited financial statements and compliance reports will be requested and reviewed annually. Name and Person Responsible: Beth-Ellen Berry, Chief Financial Officer Anticipated Completion Date: September 3, 2024

Corrective Action Plan For the year ended December 31, 2023 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Becky Tatum Interim Director Corrective Action: Mangagement will implement proper internal control procedures for the Housing Choice Voucher Program eligibility requirements. Proposed Completion Date: Immediately

Finding No. 2023-001 Eligibility: Public Housing Tenant Files Public and Indian Housing Program – CFDA Number 14.850 Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Condition: Out of a total tenant population of 1,275, 25 files were selected for testing. Exceptions were noted as follows: • 3 out of 25 tenants where an outdated flat rent was used instead of the current amount. • 1 tenant where wage income was calculated as paid bi-weekly when it was actually paid semi-monthly. • 2 tenants where the prior year social security income was used when the current year amount was known. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding and will implement review procedures and provide ongoing training to staff. The cited files have been corrected. Effective Date: September 19, 2024 Contact Information Brian Griswell, Executive Director SC Regional Housing Authority No.1 218 Spring Street Laurens, SC 29360 (864) 984-6568

Finding Number: 2023-005 Finding Title: Eligibility – METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Corey Remiger – Eligibility Supervisor Ashley VanOverbeke- Eligibility Supervisor Corrective Action Planned: The planned corrective action is to continue reminding and reviewing with staff on a regular basis and at unit meetings the need to utilize checklists with all applications and renewals so all required documentation is on file, verify income and asset requirements, and complete case transfers correctly. Supervisors and/or Lead Workers will also complete case reviews for accuracy. Anticipated Completion Date: October 31, 2024

Finding Number: 2023-004 Finding Title: Eligibility – MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Corey Remiger – Eligibility Supervisor Ashley VanOverbeke- Eligibility Supervisor Corrective Action Planned: The planned corrective action is to continue reminding and reviewing with staff on a regular basis and at unit meetings the need to utilize checklists with all applications and renewals so all required documentation is on file, verify income and asset requirements, and complete case transfers correctly. Supervisors and/or Lead Workers will also complete case reviews for accuracy. Anticipated Completion Date: October 31, 2024

3. 2023-003; Eligibility for Individuals – The PHA will provide ongoing training to housing choice voucher staff to instill compliance in the policy and procedures for Occupancy requirements. The PHA housing choice voucher staff has attended a HOTMA implementation training, as well as an EIV training from recognized housing compliance organizations. The PHA staff will continue to supplement eligibility requirements education from recognized institutions as well as the HUD Exchange site. The PHA housing choice voucher staff will be implementing a checklist for certifications to ensure program compliance. The PHA is committed to the success of the Section 8 HCV Program and will continue to monitor and improve as we transition a new Director of Leased Housing. We are in constant contact with our HUD representatives who continue to provide great support. Planned Implementation Date: Effective Immediately Corrective Action Responsible - Team Effort: Benjamin Gold, Executive Director (978)537-5300 Adam Gautie, Assistant Executive Director Lila Fernandez, Director of Leased Housing Sue Bonney, Director of Finance

RECOMMENDATION: MANAGEMENT OF THE PROJECT SHOULD UPDATE THEIR UNDERSTANDING OF THE INCOME LEVELS ALLOWED AND IMPLEMENT A CONTROL TO HAVE OVERSIGHT ON NEW TENANT QUALIFICATIONS. ACTION TAKEN: HOUSING STAFF AND MANAGEMENT ARE NOW AWARE OF THE "VERY LOW INCOME" LEVEL REQUIREMENT FOR THIS PROPERTY. MOVING FORWARD, ALL TENANTS WILL BE REVIEWED WITH THIS INCOME LEVEL.