Corrective Action Plans

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Health and Human Services Temporary Assistance for Needy Families (TANF) - AL #93.558 Passed through Camden County Health Department: Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through Cumberland County Office on the Aging and Disabled Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through Salem County Board of Social Services Grant No. None Available 1/2022 12/2022 Grant No. None Available Passed through Gloucester County 1/2023 12/2023 Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through New Jersey Department of Human Services Division of Family Development Grant No. SF22009 10/2021 9/2022 Grant No. SF23009 10/2022 9/2023 2023-005 - Activities Allowed and Allowable Costs and Eligibility (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria TANF funds monthly cash assistance payments to low-income families with children. The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102-590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. ,,o,s::::;: C:h.1riries USA. www.catholiccharitiessouthjersey.org 1845 Haddon Avcll1le, Camden, NJ 08103 I Td: 856-342-4100 I Fax: 856-342-4180 Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. • Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I Td: 856-342-4100 I Fu.: 856-3424180 Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org stions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone ii address above.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Veterans Affairs Direct Award: Grant No. 12 NJ 053 55 Grant No. 12 NJ 053 22 VA Homeless Providers Grant and Per Diem Program AL# 64.033 9/2021 9/2023 10/2021 3/2023 Grant No. 12 NJ 053 HL 9/2021 9/2023 Grant No. 12 NJ 053 LT 8/2022 9/2026 Grant No. 12 NJ 053 23 9/2021 9/2023 2023-004 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102 590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive' assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: Theim.proper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to­ day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in Febr·uary 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB. Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Housing and Urban Development Emergency Solutions Grant Program AL# 14.231 Passed through State of New Jersey Department of Community Affairs: Grant No. 2019 02156 036106 8/2020 3/2023 Grant No. 2022 02156 0337 00 7/2021 7/2023 Grant No. 2022 02156 0339 00 4/2022 7/2023 Grant No. 2022 02156 0338 00 4/2022 9/2023 Grant No. 2022 02156 0052 08 12/2019 9/2023 Grant No. 2020 02156 0042 08 12/2019 9/2023 Grant No. 2020 02156 0042 04 12/2019 9/2023 Grant No. 2019 02156 0361OS 12/2018 9/2023 2023-003 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria ESG funds may be used for five program components: street outreach, emergency shelter, homelessness prevention, rapid re-housing assistance, and HMIS; as well as administrative activities. The five program components and the eligible activities that may be funded under each are set forth in 24 CFR 576.101 through 576.107. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. www.catholiccharitiessouthjersey.org 1845 Haddon A\-enue, Camden, NJ 08103 I Tel: 856•342-4100 I Fu: 856---3424180 Serving si.,;: counties of Southern Nev,1Jersey: Atlantic, Camden, Cape May; Cumbedand, Gloucester & Salem View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETD Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above. Robert T Waite, Controller

2023-001 – ALN 14.871 – Housing Voucher Cluster – Activities Allowed and Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024 2023-002 – Significant Deficiency in Internal Controls over Financial Reporting Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024

Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record

Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record

2023-001 Emergency Food Assistance – Assistance Listing No. 10.569 Recommendation: We recommend the Organization follow its procurement policy that includes procedures for suspension and debarment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Second Harvest North Central Food Bank will update its procurement policy to reflect the review over the required procedures related to suspension and debarment. Name of the contact person responsible for corrective action: Shaye Moris Planned completion date for corrective action plan: December 31, 2024 If the Minnesota Department of Human Services Office of Economic Opportunity has questions regarding this plan, please call Shaye Moris at 218-336-2300.

Management has implemented a filing system to ensure current client information is collected and recertified regularly. CSFP/SNW staff have maintained a system organizing all clients by month and year of registration, site of service, and then alphabetized by client name to aid in certification & recertification. Certification and recertification are occurring at CSFP/SNW distribution sites during service, and CSFP/SNW staff randomly audit files of active clients as they are being served to confirm their certification. CSFP/SNW staff also leverage a tracking system in our TJOP Salesforce Software System to reinforce client certification and recertification status. We will implement an internal audit at lease once annually to ensure participant files have all required documents and certifications.

U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Eligibility Repeat Finding: Yes Auditee’s Corrective Action Plan: Condition #1 Response MOHS acknowledges the finding that 14 out of 40 files did not have management review. Corrective Action: The Program Manager will conduct quality control reviews for 30% of files that have been recertified each month. The quality control review will verify all eligibility components under the program were met. Condition #2 Response MOHS acknowledges the finding that 25 out of 40 selections did not have the supporting thirdparty documentation of income. MOHS followed the HOPWA guidance outlined in the Self- Certification of Income and Credible Information on HIV Status waivers released by HUD for September 2021 and March 2023. The waiver permits HOPWA grantees and project sponsors to rely upon a family member’s self-certification of income and credible information on their HIV status. The HUD-CPD notices are referenced in Exhibits A-B of this response. The program accepted the self-certification of income until the waivers from HUD ended for COVID-19 on March 31, 2023. Corrective Action: MOHS has resumed following the process of requesting third party verification of income, assets, and medical expenses to ensure proper calculation of tenant rent. Client records are being updated with the appropriate verification of income documentation from the third-party source. Condition #3 Response MOHS acknowledges the finding 6 out of 40 selections did not have documentation of the rent reasonableness. Corrective Action: MOHS uses GoSection8, an online rent comparable website to conduct rent reasonableness. Rent reasonableness is conducted at the initial move-in and with each rent increase request. Documentation of the comparison is maintained in the client record. Contact Person: Lakeysha Williams – 410-396-4887 or Lakeysha.williams@baltimorecity.gov Completion Date: July 2024

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate an internal reviewer to continually review the casefile eligibility determinations throughout the year. Name of the contact person responsible for corrective action plan: Jill Frisell, Finance Director Planned completion date for corrective action plan: December 31, 2024

#1 - 1 case continued to receive monthly benefits during 2023 when records indicated that the case should have closed in 2022. Consolidated Report Listing FB021 will be reviewed by supervisor to ensure WFNJ cases are redetermined appropriately. #2 and #3 - 1 case was incorrectly coded as being exempted from lifetime limit. 1 case was coded as being exempted from lifetime limit; however, the GCDSS cannot locate supporting documentation. Share Data Warehouse (SDW) ‘TANF and GA Clock’ report & SDW ‘WFNJ Clock’ report will be reviewed by supervisor to ensure correct exemption coding. #2 and #3 Staff will receive refresher DIMs case separator training. All clerical DIMs staff will receive refresher DIMs procedure and indexing training. In-house QC spot checks by Supervisors.

The Treasurer and the Food Services Supervisor will work together to complete and check the verifications for accuracy.

Finding Number: 2023-007 Finding Title: Social Service Fund Reporting (DHS-2556) Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal Supervisor Corrective Action Planned: After speaking with State Auditors and DHS, expenses that had been listed as “other” are now part of services rendered. A change in process of backup reports will be done to make this move of costs in the future. Fiscal Year 2023 reports are being corrected to match this new requirement. Any reports that are past the year cut off I am working directly with DHS to correct. Anticipated Completion Date: December 31, 2024

Program: Coronavirus State and Local Fiscal Recovery Funds Finding: 2023-010 Contact Person: Arlen Crabtree Business Operations Manager Economic Development Department Phone: (562) 570-5024 Email: Arlen.Crabtree@longbeach.gov Planned Actions: In April 2024, Economic Development Department worked with the vendor to implement improved evaluation processes related to the income eligibility verification process, including: a. Enhanced Training: The vendor will provide comprehensive training to all reviewers involved in verifying income documentation. This training will emphasize the importance of accurately inputting pay period frequency and using gross income for calculations. b. Secondary checks: The vendor will establish additional quality assurance checks to validate the accuracy of income calculations before final eligibility determinations are made. This may include double-checking calculations by a second reviewer or implementing automated systems to flag potential errors. Additionally, in May 2024 the Economic Development Department has re-evaluated and revised its policy for additional review by staff; increasing the number of applications reviewed by the Economic Development Department from 10% to 30%. In the view of Management of Economic Development Department, increasing the review sample size to 30% sufficiently mitigates the risk of further error while preserving the benefits and efficiencies that utilizing a contract processor provides. Further, the Economic Development Department worked with the vendor to review all applications manually qualified by the vendor to identify any further ineligible applications not found in the sample. Regarding the questioned costs, the Economic Development Department implemented a second round of the Guaranteed Income Program that was funded by non-grant funds. Costs associated with the ineligible applications identified in the audit were reclassified from American Rescue Plan Act funding to the City’s General Fund, and replaced by costs from confirmed eligible applications in the second round of the program. Finally, the City has sought restitution from the vendor on August 29, 2024 for administrative costs of the improperly vetted applications. The City will not seek repayment from the ineligible applicants. The applicants were not responsible for the error. Expected Completion Date: 9/30/2024

Program: Section 8 Housing Choice Vouchers Finding: 2023-009 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To address delays in reexamination processes, in fiscal year 2024, HACLB has contracted with an agency to assist in processing overdue reexaminations, and HACLB has submitted recruiting requisitions to its Human Resources department to hire additional housing specialists to improve upon its management of the high volume of HCV program participants, documentation and processes, and to meet various requirement deadlines. Regarding the testing of HUD-50058 forms, the HUD-50058 form is generated after information is inputted into HUD’s system. Error warnings are produced from the system if information is missing. Accuracy is based on the information inputted. HACLB will provide additional training to staff inputting the information, and reviews will continue to be done by the supervisor. To further improve upon the process, HACLB implemented new housing software in August 2024, which enhances reporting and tracking of payments, of HUD-50058 forms and of contract amendments. Housing Assistance Coordinators will use these reports to identify and address discrepancies. Regarding the City’s control with the HAP register’s required signatures, HACLB’s internal procedures do not require all six Housing Coordinators to approve the check run/HAP register, as KPMG assumed. There are only three assigned Housing Assistance Coordinators that have designated staff who are allowed to make adjustments and review the check-run adjustment register to confirm the work of their respective teams. If one of the approvers is absent, another approver may review and approve the adjustments that can be completed via email. No further change or action is necessary for this process. Furthermore, supervisors will continue to review completed files and train staff on errors identified in the review process. Expected Completion Date: 9/30/2024

Program: Section 8 Housing Choice Vouchers Finding: 2023-008 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To ensure that required repairs are completed within the 30-day time period, in fiscal year 2024, HACLB has implemented a process to ensure reinspection dates occur before the expiration of the 30-day remediation period. By January 31, 2025, HACLB will also establish clear criteria and standards for the Inspections Housing Assistance Coordinator who is responsible for timely abatement entries, ensuring compliance with operational and regulatory requirements. The Inspections Housing Assistance Coordinator will receive additional training on abatement procedures to enhance their skills and understanding by May 2025, or earlier, depending upon the availability of training opportunities. Furthermore, by January 1, 2025, the Housing Assistance Coordinator will conduct weekly reviews of deficiencies that exceed the 30-day remediation period to ensure timely action for abatement or proration. Regarding the City’s control with the HAP register’s required signatures, HACLB’s internal procedures do not require all six Housing Coordinators to approve the check run/HAP register, as KPMG assumed. There are only three assigned Housing Assistance Coordinators that have designated staff who are allowed to make adjustments and review the check-run adjustment register to confirm the work of their respective teams. If one of the approvers is absent, another approver may review and approve the adjustments that can be completed via email. No further change or action is necessary for this process. Expected Completion Date: 1/1/2025

Program: Section 8 Housing Choice Vouchers Finding: 2023-005 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To address delays in recertification processes, in fiscal year 2024, HACLB has contracted with an agency to assist in processing the overdue recertifications, and HACLB has submitted recruiting requisitions to its Human Resources department to hire additional housing specialists to improve upon its management of the high volume of HCV program participants, documentation and processes, and comply with various deadlines. Regarding the Intake forms, HUD does not require an Intake/Eligibility sheet be completed. However, HACLB has typically included an Intake/Eligibility sheet to help ensure quality control. Recently, this was not consistently done, due to staffing shortages. To maintain this internal control in the process, staff will be reminded to ensure that an approved Intake/Eligibility sheet is included in the participant’s file. Effective November 29, 2024, a reminder will be sent to staff to ensure that an approved Intake/Eligibility sheet is included in the participant’s file. Expected Completion Date: 12/31/2024

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: Auditor recommends that KOM review all participant files to ensure proper documentation is retained supporting eligibility of applicants. We noted that there is currently a process in place to perform an annual review of random files to ensure that only eligible participants are being served, but we recommend that a process is implemented to ensure that there is proper review and approval of all applicants prior to the individual receiving services and that this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will provide staff training on documentation required to support participant eligibility, including for participants referred by other organizations. Program Managers will review files for newly enrolled participants to ensure eligibility and appropriateness of the service plan. Name(s) of the contact person(s) responsible for corrective action: Alexis Walstad and Eh Tah Khu, Co-Executive Directors Planned completion date for corrective action plan: 11/30/2024

2023-002 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance This is a repeat finding of 2022-003, reported as a Material Weakness from March 31, 2022 (initially occurred as Finding 2021-003, Significant Deficiency) Condition: Out of a total tenant population of approximately 1,775 tenants, 25 files were selected for testing. Exceptions were noted as follows: • 1 tenant file error for one missing 214 affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o General assistance income was included in income when it should have been excluded. Correcting this error would increase the HAP rent from $958 to $1,027. o One missing 214 affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o Two members of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificates, the two household members are U.S. citizens. o The tenant’s medical expense was misreported on the 50058. However, the error had no effect on the HAP rent. • 1 tenant file had the following errors and correcting the errors would decrease the HAP rent from $846 to $724: o Miscalculation of social security income reported on the 50058. o Miscalculation of medical expense reported on the 50058. o Miscalculation of the tenant’s annual unreimbursed childcare costs reported on the 50058. • 1 tenant file error where a member of the household over the age of 18 did not sign the 9886. • 1 tenant file had the following errors and correcting the errors would have no effect on the HAP rent: o Food assistance was included as income when it should have been excluded. o The tenant’s utility allowance was misreported on the 50058. • 1 tenant file error where the tenant’s utility allowance was misreported and correcting the error would decrease the HAP rent from $1,198 to $1,183. • 1 tenant fille error where the tenant did not sign the lease agreement. 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: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.

Inadequate procedures were the underlying cause. The Authority will establish a quarterly quality review procedure to randomly slect tenant files to ensure program participants are qualified and HUD program regulations are followed. Additionally, HCV Specialist training and further HCV Rent calculation training will be offered to tenured employees when available.

Brightside Up, Inc will review the procurement policy and document considerations for any vendors that meet the thresholds and verify the vendors' compliance through sam.gov. Contact person Keely Weise, CFO, 518-426-7181, kweise@brightsideup.org. The anticipated date for resolving the audit finding is December 31, 2024. Brightside Up, Inc will research through sam.gov, every vendor that is paid with Federal funds.

Management agrees with the finding. The amendment in the Subrecipient Agreement to increase the grant awards from $50,000 to $150,000 resulted in new information provided by customers replacing in the Award Management Application’s, (Canopy), old information used in the original grant award. The bank established new procedures/requirements to avoid duplicate disbursements and/or confirm customers' bank accounts before processing transactions. All resources working on the CDBG-DR Small Business Financing (SBF) project have been trained to perform their role in accordance with the Program Guidelines, SOPs, and regulations. Cases identified with deficiencies, as part of the 2023 Single Audit at the Grant Awarding and Closing Stages, will be used as examples to prevent this situation from repeating in the future and to establish additional quality control (QC) by Team Leaders. Additionally, recapture (repayment by the Grantee of any Grant amount received) of awarded and disbursed funds will apply when there's failure to comply with the SBF Program Guidelines.

none

Recommendation: The Center should maintain copies of the eligibility information provided by the families each year during initial determination and subsequent redetermination and retain the information in each child’s file View of Responsible Officials and Planned Corrective Actions: The Center agrees with the finding. The Center is in the process of implementing the recommendation.