Corrective Action Plans

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department for Children and Families (KDCF) Federal Program Name: Adoption Assistance Title IV-E Assistance Listing Number: 93.659 Award Number: 2402KSADPT, 2502KSADPT Award Period: July 1, 2024 through June 30, 2025 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Condition: During testing of eligibility requirements, it was noted that three participants out of forty tested did not have supporting documentation in their case files for nonrecurring adoption expenses paid on their behalf. Recommendation: We recommend that KDCF strengthen internal controls to ensure that supporting documentation for nonrecurring adoption expenses is obtained, reviewed, and retained prior to payment to mitigate the risk of noncompliance in the future. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: KDCF policy requires that all case files contain documentation supporting state expenditures and all associated payments, in accordance with Policy #0430 Contents of Foster Care, Adoption and Independent Living Services Case Records. Additionally, staff must follow the procedures outlined in Policy #6924 Payment Procedures for Non-Recurring Expenses. Non-recurring expense payments are made according to the authorization provided on forms PPS 6140 or PPS 6130. A PPS 2833 Client Purchase Agreement must be completed by PPS staff, with a copy of the PPS 6130 or PPS 6140 attached to document the authorization for payment. An itemized bill should also be attached when available. While this policy is in place, this finding indicates the need to reinforce internal controls to ensure full compliance. To address the deficiency and prevent recurrence, KDCF will implement the following corrective actions: 1. Reinforcement of Documentation Requirements: Adoption program and I-VE program leadership will review the audit findings with regional adoption staff, I-VE payment specialists, Regional I-VE Administrators and Regional Foster Care Administrators. During this meeting Adoption program and I-VE program leadership will review the corrective action plan and emphasize the importance of the need for complete and accurate documentation in regard to adoption assistance. 2. Enhanced File Review Process Prior to Payment: KDCF will implement a detailed Adoption Assistance Packet Checklist. This is an internal double-check step requiring staff to verify that all required supporting documents for non-recurring adoption expenses are present before submitting or approving payment. This verification will be incorporated into the existing payment workflow to ensure consistency across regions. 3. Targeted Training and Guidance: Updated reminders and written guidance will be issued to all adoption staff outlining specific documentation requirements and the procedures for retaining them. Training will emphasize the allowable cost requirements under Title IV-E and the purpose of maintaining complete records for federal compliance and audit readiness. 4. Ongoing Monitoring: Program leadership will conduct periodic spot checks of adoption subsidy files to validate that required documents are consistently included and will address any identified gaps with staff promptly. These actions will strengthen internal controls and help ensure that documentation supporting nonrecurring adoption expenses is properly obtained and retained in all adoption case files moving forward. Name(s) of the contact person(s) responsible for corrective action: Adoption Program Manager and Kim Fay, I-VE Program Manager Planned completion date for corrective action plan: January 1, 2027

Recommendation: We recommend the University enhance its procedures for reviewing professional judgement decisions to ensure that evidence of review is documented and retained Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will review its procedures and document retention practices to ensure that key controls related to professional judgment determinations are documented and evidenced for audit purposes. The University will evaluate existing processes and supporting records and will implement any needed improvements to strengthen documentation and audit support. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Director of Financial Aid Planned completion date for corrective action plan: Completed

FINDING 2025-003 Finding Subject: Child Nutrition Cluster, Internal Controls Audit Findings: Material Weakness Contact Person Responsible for Corrective Action: Jennifer Felke & Amy Kraszyk Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will oversee and review the process in place to ensure accuracy of eligible students. The Food Service Director will approve the uploaded Direct Certification reports after reviewing to ensure directly certified students were properly processed. The Business Manager/Treasurer will be the final approver of all Direct Certification reports. The Food Service Director will verify that contractors and subrecipients of the federal award are not suspended, debarred or otherwise excluded. The Food Service Director will complete this task for any expense expected to exceed $25,000 by checking SAMS exclusions, collecting a certification from that vendor or adding a clause or condition to the covered transaction with that vendor. The Business Manager/Treasurer will be the second reviewer/approver for suspension and disbarment. Anticipated Completion Date: March 1, 2026 and ongoing

We concur with the recommendation. We acknowledge Meals on Wheels of Wake County was understaffed in eligibility staffing during this period. Thus, some assessments were delayed. We have since added 1.5 FTE to assist in this process. However, it should be acknowledged that we see our clients in their home or at congregate sites on a routine/daily basis, therefore are completely aware of their condition and eligibility. Additionally, Title III Nutrition programs do not mean test. For Home Delivered Meals, there are criteria for being considered homebound. For congregate the only requirement is to be 60 years of age and sign up for meals. We have implemented procedures to ensure the meal recipients are evaluated and assessed in a timely manner.

Condition: Out of 22 students tested for Pell eligibility we identified one student whose student aid index (formerly known as expected family contribution) was changed, however the additional award was never disbursed to the student. Planned Corrective Action: System generated ISIR’s and corrections will be reviewed for changes and then given to the Director for weekly review to ensure the updates and awards are accurate and complete Contact person responsible for corrective action: Nikki Jewell Anticipated Completion Date: June 30, 2026

FINDING 2025-003 Finding Subject: Child Nutrition Cluster- Eligibility and Reporting Contact Person Responsible for Corrective Action: Chris Goris Contact Phone Number and Email Address: 765-395-3341, christengo@ohusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will review eligibility of students for the free and reduced meal program through the state level system that identifies Direct Certification eligibility. The district will have a secondary individual from the food service department review the eligibility determination for both financial applications and through Direct Certification following the initial review by the Food Service Director. Both the director and the secondary individual will sign off on the determined eligibility status of free/ reduced applications submitted by households and Direct Certification eligibility through the Child Nutrition Program. The secondary individual will additionally review to ensure accuracy of the eligibility determination entered in the student information system by the Food Service Director. The district will prepare monthly meal claims and submit them to the Child Nutrition Program by following the listed steps: 1. The Food Service Director will prepare the meal claim numbers from the district’s student information system. 2. The CFO, or secondary individual from the food service department, will review the reports prepared by the Food Service Director. 3. The Food Service Director will enter monthly meal counts for reimbursement into CNP.4. The CFO or secondary individual from the food service department will review the CNP entry of meal claim information before submission. 5. The Food Service Director and CFO and/ or secondary individual will sign off on the preparation and entry of the monthly meal claim reimbursement. Anticipated Completion Date: 3/31/2026

Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Staff Training Quality Assurance and Monitoring To ensure sustained compliance, the organization is implementing the following monitoring process: • Monthly random chart audits of sliding fee documentation. • Minimum sample size of 40 patient records • Audit elements will include: o Income documentation present o Household size documented o Correct FPG calculation o Correct discount level applied • Findings will be reported to senior leadership and the compliance committee. Corrective coaching is provided when deficiencies are identified. Comprehensive training is being conducted for all relevant staff including: • Patient access / front desk staff • Financial counselors • Billing staff • Site managers Training topics include: • HRSA Sliding Fee Discount Program requirements • Determining household size • Calculating FPG percentage • Acceptable income documentation • Proper EHR documentation • Self-attestation procedures

Finding 2025-002 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid and Mr. Jared Peterson, Financial Aid Counselor Corrective Action: As a result of Audit Finding 2025-002, Financial Aid will use a daily credit change report generated automatically from academic records to make any manual credit updates in the PowerFAIDS financial system. Additionally, Financial Aid will use selection sets within PowerFAIDS to identify any credit hour mismatches between what is manually reported versus what is integrated from Power Campus, the academic records database. Anticipated Completion Date: March 19, 2026

FINDING 2025-002 (Auditor Assigned Reference Number) Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Stefanie Grandstaff, Director of Business Services Contact Phone Number and Email Address: stefanie.grandstaff@epulaski.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: The Food Service Director will continue uploading the state-provided file into Skyward and verifying the accuracy of the imported information. After this review, the Food Service Director will notify the Director of Business Services via email to independently confirm that the data from the state file was uploaded and processed correctly in Skyward. This email correspondence will serve as documentation of the verification process. In addition, we will address the issue related to the 30-day rollover and students who withdraw. We will work with Skyward to adjust system parameters so that both active and inactive students are included, ensuring the rollover is accurate. The Food Service Director will also review each newly enrolled student to confirm the eligibility status by verifying whether a parent submitted an application through the school or the state. Based on the documentation available, she will update eligibility status as needed and then email the Director of Business Services to review and confirm accuracy. Anticipated Completion Date: June 30, 2026.

We agree with the auditor's comments. While we have retroactively searched for suspension and debarment, not all subrecipients were able to finalize their registration on SAM.gov. We determined that 7 of the 27 recipients were confirmed to have no suspension or debarment, totaling $514,450 of the grant total. Our office of Law has drafted and amendment to the agreement that requires the subrecipient certify that they have not been suspended or debarred. We will have each subrecipient sign the amendment. We anticipate completion of this by March 31, 2026.

FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100 ext 1002, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will implement a documented secondary review, the FSD will print a before and after report from Skyward, and the direct certification download. The MS/HS ECA Treasurer will review the reports, verify Skyward, and sign off on the reports for the second check. The FSD and MS/HS ECA Treasurer will receive annual compliance training. Anticipated Completion Date: June 2026

Finding: 2025-001: Special Tests and Provisions – Eligibility – Significant Deficiency in Internal Control over Compliance Corrective Action Plan – The University conducted a review of affected students and identified 19 additional students with enrollment intensity that was incorrectly calculated. The University has returned a total of $2,448 to the Pell Grant program and has written off the corresponding balances on the affected students’ ledgers. In January 2025, the University fully implemented a new, integrated Student Information and Financial Aid System that automates enrollment intensity calculations based on real-time data from the Registrar’s Office. This eliminates manual entry and ensures Pell Grant disbursements are automatically and accurately calculated. There is no option to manually change the Pell enrollment intensity or award amount in the new system. The Financial Aid staff involved in Pell packaging and processing have been retrained on enrollment intensity calculations and system functionality. Contact Person Responsible for Corrective Action: Sally Mickelson, Director of Financial Aid Completion Date: November 13,2025

The ECIWDB acknowledges the merit of this recommendation and commits to taking the following action: The establishment of a procedure that incorporates the utilization of an “Orientation Acknowledgement Form’ to demonstrate completion by each individual participant. This procedural change shall be implemented on or about November 1, 2025.

Management has implemented additional review procedures over Pell Grant calculations, including documented manual recalculations and supervisory approval prior to disbursement. These controls will remain in place until Pell calculations are automated through the planned SIS implementation.

The Department acknowledges the recommendation and agrees that maintaining secure and accurate documentation of beneficiary eligibility is important for program integrity and compliance. At this time, the Program is operating in accordance with the guidance provided by the federal grantor and is utilizing the resources and systems currently available to the agency. Action planned/taken in response to finding: The Department has identified resource gaps affecting grant compliance and has engaged with the federal grantor to present these findings and request additional resources, including access to tools for verifying veteran appointments. The Department recognizes the importance of maintaining secure and accurate documentation to confirm eligibility for veteran benefits and will continue to work with the grantor to secure the necessary resources to support auditable appointment verification and ensure full compliance with program requirements. Name(s) of the contact person(s) responsible for corrective action: Danelle Lucero, CFO/ Jamison A. Herrera, Cabinet Secretary, and the HealthCare Director that manages oversight of the program. Planned completion date for corrective action plan: The Chief Financial Officer, ASD staff, and Federal Grant Director will collaborate with the federal grantor to secure additional resources necessary to address the audit recommendations for the next grant period beginning Sept.15, 2026

Finding No. 2025-001 Corrective Action Plan: The University concurs with this finding. The Financial Aid office is in the process of tightening its policies and procedures to identify all students subject to the required exit counseling, with the goal of delivering said counseling within the prescribed 30-day window. Responsible Official: Dane Fuhrman, CFO Anticipated Completion Date: June 2026

Name of auditee: Niagara Community Action Program, Inc. TIN: 16-0919885 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2024 - October 31, 2025 CAP prepared by: Paul Wilson pwilson@niagaracap.org Finding 2025-001 Corrective Action Plan The Agency acknowledges and is aware of this information in regards to the two files. Program departments are responsible for complete eligibility verification and documentation. Program personnel are trained and will continue to follow its policies and procedures to maintain complete eligibility documentation for future periods.

Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program including implementation of formal policies, reconciliation procedures, and enhanced oversight of interfund activity to ensure that established internal control policies are being followed on a timely basis. Steve Arlinghaus, Executive Director, is responsible for implementing this corrective action by June 30, 2026.

To prevent future errors in eligibility determinations, the School District will implement a secondary review process. All eligibility applications will be reviewed by a second qualified staff member to verify household size, income calculations, and comparison to the National Income Eligibility Guidelines before final approval.

Date: February 9, 2026 FINDING 2025-001 Finding Subject: Child Nutrition Cluster-Eligibility Contact Person Responsible for Corrective Action: Paula Powers, Food Service Coordinator Contact Phone Number and Email Address: 812-347-3905 ppowers@nhcs.k12.in.us Views or Responsible Official: We concur with the findings. Description of Corrective Action Plan: With future processing of Direct Certification downloads, the Food Authority will generate and IT department will input Direct Certification to software System (Harmony). A second person will review the approval process to ensure Direct Certification input was downloaded correctly. After reviewing, second person will sign the Direct Certification download list in order to maintain proper checks and balances. Anticipated Completion Date: August 2026

Training with all Medicaid Income Maintenance Caseworkers was conducted on January 28 and 29, 2026, to address the deficiencies noted above. All seasoned Medicaid workers have a minimum of two cases reviewed through a second-party process each month. Any errors found are addressed with the caseworkers individually and are used for training during monthly unit meetings held with all of our Medicaid caseworkers. Currently, Carteret County has 9 unseasoned workers who are being 100% second partied.

Action Plan: CCC implemented its corrective action plan immediately upon communication of the original FY24 finding in January 2025. As noted in the status of prior year finding 2024-02, new participants after January 2025 have evidential review of eligibility by a program manager or director and internal controls are operating effectively after implementation of the corrective action plan.

2025-001 Eligibility Over Title I Program: Title I - Grants to Local Educational Agencies Federal Assistance Listing Number: 84.010 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 25FT1TTI-511375-01A Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: E. Eligibility Condition/Context: During our testing of school eligibility and funding, we discovered the District did not maintain records that agreed to the low-income student counts as reported to the Arizona Department of Education to properly allocate Title I funding by poverty level. Corrective Action: The District will ensure in future periods that records are maintained to support lowincome students and the allocation of Title I funding as reported to the Arizona Department of Education. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Jenette King, Business Manager

2025 – 004 Eligibility Correctiveaction:ThisfindingislistedfortheWorkFirstCashAssistanceandWorkFirstEmploymentProgramsfor this physical year. This root cause for this finding is new supervisors and workers transitioned into both program areas. Limited experience among staff and instances of worker oversight led to errors in evidence entered incorrectly, missing or incomplete income, kinship or residency verifications, missing application documentation, missing required forms, unenforced or noncompliance with child support unresolved, and misinterpretation of policy from the Work Fist Electing County Plan. Staff were uncertain about when and how to obtain certain verifications when applying the Work First policy to case actions. To help mitigate these areas of concern, Lenoir County will implement the following for the Work First case actions cited for the Single County Audit Fiscal Year ending June 30, 2025. Staff meeting will be held Wednesday, February 18, 2026 and the following training materials will be discussed and provided to the Medicaid staff to ensure continued understanding and knowledge of program requirements. Section 104 (Cash Assist. Application Process & Procedures) Section 112 (Kinship & Living Requirements) Section 116 (Child Support Services) Job Aide (Requesting & Viewing Online Data) Section 104D (Family Violence Option) Section 105 (Federal & State Time Limits) Section 1 14 (Income & Budgeting) Section 108 (State/County Residence Rule) Review of Work First Electing County Plan Providing staff with copies of the Single County Audit findings, the Corrective Action plan and staff expectations to ensure that staff is well informed of the findings and what is expected from the Corrective Action Plan implementation. A new Lead Worker was hired for this program during the past fiscal year and is now completing 2nd party reviews on case actions. Supervisors and/or Lead Worker will complete 100% 2nd party reviews on all new hires until each worker receives a 98% or higher accuracy processing rating and will complete a minimum of 5 2nd party reviews for each existing worker to target these key areas of concern until all workers reach and maintain a 98% or higher accuracy processing rating. Supervisors and Lead Workers will continue to monitor case actions and provide monthly statistical data detailing case findings. The Supervisor and Lead Worker will provide a list of findings and maintain scheduled monthly meetings with staff to provide feedback and coaching to ensure continued compliance of program requirements. The meetings held will consist of staff unit meetings and/or individual conferences provided by the Supervisors in an effort to effectively catch and manage error trends that have been discovered from 2nd party review findings. All documentation will be submitted to the Administrator for review and will be discussed and reviewed with the Supervisors during monthly conference meetings. The Administrator will provide monthly updates on case actions and findings to the Director. Proposed Completion Date: Training will be held with Work First Cash Assistance Staff on Wednesday, February 18, 2026 for eligibility issues cited. Corrective Action Plan will be implemented immediately after training and significant improvement of all areas cited must be maintained by June 30, 2026.

Name of contact Person: Brittany Naylor, Director of Social Services Corrective action: This finding is listed as a repeat finding on the Food and Nutrition Services program and was a citedfindinginpreviousaudit2024-003.LenoirCountyhasdiscoveredtherootcausesforthesecontinuedfindings and have made the following updates to alleviate these issues. The root causes for these findings stems from ineffective processes from the time documentation is received to when it is transferred to the worker, staff in training and worker oversight and error when documenting case actions. Lenoir County will implement the following for theFood and Nutrition Servicescaseactionscited for theSingleCounty Audit Fiscal Year ending June 30, 2025. Staff meeting will be held Wednesday, February 18, 2026 and the following training materials will be discussed and provided to the Food and Nutrition staff to ensure continued understanding and knowledge of program requirements. With new staff in training, the following documentation from prior year will be provided again. This will include documentation and guidance of policy/DSS Administrative letter. The DSS Administrative letter EFS_FNS_AL-35-2020 will be provided detailing the Telephonic Signature for Food and Nutrition Services Applications and Recertifications (amended) as of September I, 2020. (Where to document on applications and recertifications and must have a standalone note and cannot contain any additional characters or spaces). Verbally explain and provide the DSS-8569 form and ensure that staff are creating and mailing required documents to clients as required by policy. Training will include explanation and guidance on how the case file must be documented with the date the notice was verbally explained, how the notice was given, if by hand deliver or mailed. Verbally explain and provide policy 130.01 Documentation/Record Retention and policy 130.03 Case Record Documentation to ensure that staff understand how to correctly document case actions, attach documents in NCF AST and provide detailed information on how income was verified. Providing staff with copies of the Single County Audit findings, the Corrective Action plan and staff expectations to ensure that staff is well informed of the findings and what is expected from the Corrective Action Plan implementation. Front Desk Staff will train on how to effectively complete Telephonic Signature Standalone verifications correctly before submitting to ongoing workers. Staff will be required to check documentation and case notes thoroughly before proceeding with case disposition to ensure Telephonic Standalone Signature has been added, if applicable. Supervisors and/or Lead Worker will complete 100% 2nd party reviews on all new hires until each worker receives a 98% or higher accuracy processing rating and will complete a minimum of 5 2nd party reviews for each existing worker to target these key areas of concern until all workers reach and maintain a 98% or higher accuracy processing rating. Supervisors and Lead Workers will continue to monitor case actions and provide monthly statistical data detailing case findings. The Supervisor and Lead Worker will provide a list of findings and maintain scheduled monthly meetings with staff to provide feedback and coaching to ensure continued compliance of program requirements. The meetings held will consist of staff unit meetings and/or individual conferences provided by the Supervisors in an effort to effectively catch and manage error trends that have been discovered from 2nd party review findings. All documentation will be submitted to the Administrator for review and will be discussed and reviewed with the Supervisors during monthly conference meetings. The Administrator will provide monthly updates on case actions and findings to the Director. Proposed Completion Date: Training will be held with Food and Nutrition Staff on Wednesday, February 18, 2026 for eligibility issues cited. Corrective Action Plan will be implemented immediately after training and significant improvement of all areas cited must be maintained by June 30, 2026