Corrective Action Plans

The Office of the Chief Financial Officer/Office of Finance and Treasury (OCFO/OFT) for Department of Human Services (DHS) concurs with this finding. Strict procedures and practices are in place to ensure contract compliance. OFT manages quarterly audit reviews of UPO practices to ensure proper handling of DHS referral forms and intake documents up-holds to policy and procedures governed in order to mitigate the errors. OFT will continue this practice with UPO EBT Card Distribution sites to secure the EBT cards and document reconciliation. All Intake Procedures and Processes found in the EBT Manual are followed thoroughly by all employees. As practice, UPO will continue to enforce the progressive disciplinary process for errors or omissions identified during daily operations. Contact - Valencia Gregory, Program Analyst, OCFO/OFT Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

The Department of Human Services (DHS) and Department of Health Care Finance (DHCF) DC Access System (DCAS) Program Management Administration team agree with the findings. For the fifteen (15) findings, DHS/ESA has identified the description of the deficiencies, examined the magnitude and geographic extent of the deficiencies, identified the actions completed to eliminate the deficiencies. The District will focus on efforts that will create the maximum impact, which includes creating new options for collaboration, streamlining current communication, and introducing cross-functional prioritization. These strategies will help the District move projects toward completion and are rooted in continuous quality improvement. To guide its strategic efforts and track its impact, DHS has outlined the following four phases of corrective action plans to be taken to ensure the deficiencies will be eliminated: • Review and Prioritization, • Design and Development, • Implementation, and • Monitor and Evaluation. Each phase has several process steps including a completion document that signals the permission to move to the next phase. The detailed process steps are documented under DHS’ Consolidated Semi-Annual SNAP Advance Warning Letter Corrective Action Plan and FFY2024 Quality Control Corrective Action Plan reports dated April 2024. The corrective action plan is facilitated by the Quality Improvement Program and since implementing this process in January 2021, the District has identified root causes for errors and gaps in internal auditing and evaluation processes. Therefore, the flow of the semi-annual corrective action plans reflects the District’s commitment to a collaborative corrective action plan - expanding the data analysis section to include data and analysis of internal methods, a complete summary of each phase completed, and a timeline for upcoming phase/project completion. Contact - Stephanie Bloch-Newman, Deputy Administrator for Innovation & Change Management Estimated Completion Date - September 30, 2025 See Corrective Action Plan for chart/table

Project Legal Name: Booth Residence, Inc., a Georgia Corporation HUD Project No.: 061-11293 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2022-9/30/2023 Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and has taken steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding An experienced third-party management agent approved by HUD was hired to maintain tenant file documentation and to ensure compliance with HUD eligibility requirements.

Project Legal Name: Evangeline Booth Residence, Inc., a Florida Corporation HUD Project No.: 063-EE011-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2022-9/30/2023 Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-002 a. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding Procedures for accruing revenue, as appropriate, will be put in place as the accruing of expenses is already done. 2. Finding 2023-002 c. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. d. Action(s) Taken or Planned on the Finding Access to the Enterprise Income Verification (EIV) system [the system used to access Social Security information and Health and Human Services information] was not available due to the incorrect tax ID being identified to The Salvation Army personnel who had transitioned from another The Salvation Army HUD Project location. It took considerable efforts to get this corrected with HUD. The appropriate access to the system has now been given to the new personnel of this Ocala HUD Project. This lack of access impacted the early part of FY 2023 B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Audit Findings, Questioned Costs and Recommendations 1. Finding 2022-001 In Process. See finding 2023-001 2. Finding 2021-001 In Process. See finding 2023-001

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The Pentucket Regional School District respectfully submits the Following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF EDUCATION Passed through Massachusetts Department of Elementary and Secondary Education Special Education Cluster Special Education Grants to States Federal Assistance Listing No. 84.027 Special Education Preschool Grants Federal Assistance Listing No. 84.173 2023-001: Controls for Monitoring Payroll Charged to the Grant Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Compliance and Internal Control Over Compliance – Other Matter Criteria or Specific Requirement: Grantees must provide reasonable assurance that Federal Awards are expended only for allowable activities and that the costs of goods and services charged to Federal awards are allowable and in accordance with applicable cost principles. Condition: Payroll expenditures charged to the Special Education Cluster grant are required to be supported with documentation (i.e., semi-annual certifications and personnel activity reports) substantiating that the employees are eligible to be charged to the grant and that the payroll charged relates to time spent accomplishing grant objectives. The District does not utilize semi-annual time and effort certification forms to document the eligibility of the employees paid out of the grant. Context: The District did not maintain sufficient documentation to demonstrate compliance with federal and state time and effort reporting requirements in accordance with the provisions of Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. Effect: The District has not complied with the federal and state time and effort reporting requirements. Cause: Management has established written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. The written guidelines and procedures outlined by management are not being followed as designed. Questioned Costs: Total payroll costs charged to the grant in 2023 totaled $703,789, which was paid on a bi-weekly basis throughout the year. Three of the pay periods were selected for testing, which totaled $117,345 for 61 employees paid out of the grant during those pay periods. From the pay periods selected for testing, the following known questioned costs were identified: Recommendation: The District should follow their written policies and procedures outlining the time and effort reporting and documentation requirements that must be adhered with to ensure compliance with federal and state time and effort reporting requirements. Management should adopt and implement standardized forms that include all data required by federal and state guidelines and provide training to ensure that program personnel understand the time and effort reporting requirements. Views of Responsible Officials and Planned Corrective Actions: The School District immediately began designing the form used for time and effort reporting related to special education grants, and the School District will begin issuing and collecting the forms for the special education grant for 2024, and future periods. If the Oversight Agency has questions regarding this plan, please call Suzanne Wallace, School Business Manager, at 978-346-7424, extension 126. Sincerely yours, Suzanne Wallace School Business Manager Pentucket Regional School District

Finding 2023-001 (Scope Limitation - Eligibility and Special Tests and Provisions) (Assistance Listing 93.767) UPMC follows the processes and procedures set forth by Pennsylvania Department of Human Services. As such, no corrective action will be taken.

Timestudy Testing Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2024

The Authority will implement and execute strengthened controls over tenant file documentation maintenance processes and procedures. Erial Branch, Executive Director, has assumed the responsibility of executing strengthened controls over tenant file documentation maintenance as of September 1, 2024.

Beginning in 2024, the Organization’s General Manager has implemented a process to ensure annual re-certifications and income verifications completed by the Property Manager. Utilizing the property management system, the Property Manager will track those tenants whose annual re-certifications and income verifications are coming due. The Property Manager will complete the re-certification and income verification process and then update the tenant file, as required by the regulatory agreement. Winslow Village, Inc. 1520 Ocean St. Marshfield, MA 02050 The General Manager, Marianne Correia, will oversee this under the guidance of Three-Kay Consulting, LLC. This will be implemented by year end of 2024. Marianne Can be reached at 781-837-5998.

El Proyecto will implement monitoring measures by grant supervising staff to ensure that typos entered into any system are reviewed before final submission. Person Responsible: Haimanot Fekadu Position of Responsible Party: Youth Source Center Sun Valley Completion Date: September 30, 2024

El Proyecto will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. El Proyecto will continue to provide ongoing training to clinic staff who evaluate the sliding fee application at its clinic locations. The training will consist of reviewing sliding fee program policies and procedures along with all applicable patient forms, sliding fee scale, and patient eligibility. Person Responsible: Leticia Vasquez Position of Responsible Party: Billing Manager Completion Date: September 30, 2024

Name of contact person – Peter Krieger, Housing Development & Construction Director Corrective action – Management will implement the suspension and debarment testing procedures for all contracts as part of the vendor selection process going forward, and are in the process of updating the financial policies to include this language. Proposed completion date – Management will implement the above procedures immediately. The procurement policy will be within the Financial Policies that will be presented to the finance committee no later than July 2024 for recommendation of Board approval at the next Board meeting (no later than September 2024).

Mid-East Regional Housing Authority Corrective Action Plan for the year ended September 30, 2023 Section II - Financial Statement Findings - None Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Lynn Alligood Executive Director Corrective Action: We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Proposed Completion Date: Immediately

Federal Award Findings and Questioned Costs: 2023-101 Reporting Recommendation: We recommend that the PRF Reports are reviewed and approved by a management team member who is not involved in the preparation, and has sufficient knowledge of the program's requirements. Action Taken: The Center concurs and has implemented the recommendation. Contact Person: Controller Completion date: Fiscal year ending 2024.

Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the State of New Jersey, Department of Law and Public Safety Program Titles and Assistance Listing Numbers (ALN): Disaster Grants – Public Assistance (Presidentially Declared Disasters) – ALN 97.036 Federal Grant Numbers: State of New Jersey pass-through number: UH1WX, Project Worksheet #1822 – Award Year 2023 (Application 553330) Contact Person: Donna Wilser, Deputy Executive Director, 732-750-5300 Corrective Action: Management agrees with the finding. We are committed to strengthening our processes to ensure that all physical timesheets related to FEMA-declared disaster events are properly maintained and readily accessible. To achieve this, we will implement enhanced procedures and controls to ensure full compliance with the Uniform Guidance requirements. Anticipated Completion Date: December 1st, 2024

Finding 2023-002 - Continuumof Care Tenant Files - Eligibility - Internal Control over Tenant Files - Noncomplianceand Material Weakness Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the follow ing by our fiscal year-end September 30, 2024: a. Program Coordinators will maintain all Contin uum of Care Tenant files in individual file folders designated by special purpose voucher programs. All loosedocuments will be anchored in tenant files. b. An action plan has been developed for the Continuum of Care programs to ensure that all program files are HUD, State, and GHA compliant starting with October l, 2023, files through the current. c. Continuum of Care fiscal year 2024 (October 2023-September 2024) re­ exams and interim s will be caught up and complete as they become effective. All tenant files will be reviewed and compliant by FYE2024. d. All la te/overdue re-exams will be compliant by FYE2024. e. During FYE2024, the Deputy Executive Director/COOwill perform qualit y controls on all Continuum of Care tenant files processed each month prior to ini tialization c2_5th 3olh of each month). f. File checklist sheets will be placed in each file upon quality control review to be signed off by the Deputy Executive Director/COO. g. Additional training will be required and ongoing for Program Coordinators. h. Other internal control measures will be implemented to elim inate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2024

Finding 2023-001 - Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance andSignificant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fisca l year-end September 30, 2024: a. Hous ing Choice Voucher tenant files will be reviewed and quality controlled each mo nth prior to initiali za tio n (25t 11- 30 111 of each month) by the Deputy Executive Director/COO. b. An action pla n has been develo ped for the Housing Choice Voucher department to ensure that all Housing Choice Voucher files are HUD and GHA compliant starting with October 1, 2023 files through the cun-e nt. c. Hous ing Choice Voucher calendar-year 2024 (October 2023-September 2024) re-exams are substantially complete, as they become effective. All tenant files will be reviewedand HUD-co mpliant by FYE2024. d. During FYE2024, the Deputy Executive Director/COO will perform 40% quality controls of the monthly re-exams processed by the Housing Specialists. e. File checklist sheets will be placed in each file upon quality control review to be signed off by the Deputy Executive Director/COO. f. Additional training has been and will be made available as necessary. g. Other interna l control measures will be implemented as deemed necessary by the Deputy Executive Director/COO, to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2024

Finding 2023-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS originally expected to have all cases corrected at the end of the PHE unwind (July 2024), however, due to some of the mitigation strategies that CMS developed to ensure children did not lose eligibility, not all cases had their coding updated when they were renewed. MDHHS expects that all existing cases will be updated by May 2025, as MDHHS completes renewals for existing cases. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children’s Health Insurance Program (CHIP) in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing the Community Health Automated Medicaid Processing System (CHAMPS) payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date May 2025 Responsible Individual(s) Brant Cole, MDHHS Logan Dreasky, MDHHS Erin Emerson, MDHHS

Finding 2023-057 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with BSCs to discuss common errors, answer questions, provide guidance, and on a quarterly basis discuss the results of the SER case reads. In addition, based on the results of the quarterly case reads, MDHHS updated SER policy on October 1, 2023 to require additional verification sources. MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support SER processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Anticipated Completion Date Ongoing Responsible Individual(s) Nicole Denson-Sogbaka, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS Nick Sakon, MDHHS Erich Holzhausen, MDHHS

Finding 2023-056 Low-Income Home Energy Assistance, ALN 93.568 - Client Benefits in Excess of Fiscal Year Cap Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to provide guidance to the local MDHHS offices and BSCs related to the processing of State Emergency Relief (SER) applications. MDHHS developed job aids and trainings that were distributed to local MDHHS offices and BSCs and added to the LIHEAP SharePoint site for reference during May 2024. Anticipated Completion Date Completed Responsible Individual(s) Nicole Denson-Sogbaka, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS Nick Sakon, MDHHS Erich Holzhausen, MDHHS

Finding 2023-052 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action For part a., MDHHS will issue a memo to BSCs and local offices and provide training to local office staff regarding the requirements to maintain sufficient documentation to support Refugee and Entrant Assistance State/Replacement Designee Administered Programs eligibility. For part b., MDHHS corrected the reporting defect and properly adjusted the accounting records. MDHHS already had a process in place to identify the reporting defect and make necessary accounting adjustments. MDHHS will ensure that accounting adjustments are prioritized for any future reporting defects. Anticipated Completion Date a. September 30, 2024 b. Completed Responsible Individual(s) a. Mariah Schaefer, MDHHS b. Trish Bouck, MDHHS

Finding 2023-050 Temporary Assistance for Needy Families, ALN 93.558 - Child Support Non-Cooperation Management Views MDHHS disagrees with 4 of 5 exceptions identified. The MDHHS Bridges technical team reviewed each cited case and determined that Bridges was functioning as intended for four cases identified because each case was in a non-ongoing mode at the time the automated interface occurred. A case is placed into this status if the client circumstances have changed for any MDHHS program within Bridges and the case requires a redetermination. TANF policy cannot mandate Bridges to change the non-ongoing mode because each impacted program is required to be certified prior to changing the status. MDHHS policy does not mandate a specific length of time that a case can be in a non-ongoing status. The results of the redetermination can impact the client’s non-cooperation status and therefore the client should not be sanctioned until the certification by all programs is complete. For two of the cases, the client was appropriately sanctioned after the case review was complete and for the other two cases, the client was determined to be in compliance once the case was removed from the non-going status mode. Planned Corrective Action The MDHHS Bridges technical team will follow the Departmental Work Intake Process to prioritize the identification of potential system modifications that may be needed to help ensure that Bridges is appropriately applying the one-month sanction period for child support non-cooperation. After identifying potential solutions, the MDHHS Bridges technical team will report their findings to MDHHS ESA policy staff and determine the best solution for remediation. Anticipated Completion Date August 31, 2024 Responsible Individual(s) Kenton Schulze, MDHHS Brian Sanborn, MDHHS

Finding 2023-048 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF-Funded Adoption Subsidy Rate Management Views MDHHS disagrees with the finding. Although the appropriate negotiated rate was not used to calculate the initial payment, MDHHS disagrees that a deficiency exists. MDHHS ensures that the appropriate negotiated rate is used during an annual review process that occurs each year and is based on the child’s birth month. The annual report process includes a thorough payment history review for each adoption assistance case to ensure payments are issued accurately. This involves verifying cases are paid at the correct rate and identifying any overpayments that occurred for adoption assistance agreements that were entered into between January 21, 2014 through June 18, 2015, prior to the MiSACWIS system update to automate the clothing allowance offset. The overpayment noted in the finding was identified by the auditor during the month prior to MDHHS’s annual review process, which was scheduled for April 2024, and the negotiated rate for the month the child turned 13 was manually corrected and recouped by MDHHS in March 2024. MDHHS believes this is a timing issue and disagrees that a deficiency exists. Planned Corrective Action MDHHS disagrees with the finding and does not intend to take further action. Anticipated Completion Date Not applicable Responsible Individual(s) Kathonya Rice, MDHHS

Finding 2023-047 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS’s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing staff training and a memorandum sent to local offices and Eligibility Specialists. ESA leadership will reach out to managers of individual Eligibility Specialists regarding issues identified with the Family Automated Screening Tool and Family Self-Sufficiency Plan completion and verification of school enrollment and provide additional guidance as needed. Anticipated Completion Date August 31, 2024 Responsible Individual(s) Brian Sanborn, MDHHS Kenton Schulze, MDHHS

Finding 2023-045 Temporary Assistance for Needy Families, ALN 93.558 - MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a. and c., MDHHS will continue to provide training for local office security coordinators (LOSCs) via quarterly webinars to emphasize the appropriate procedures for granting access, reviewing, and comparing access. All new information related to security access is presented to the LOSCs during the webinars and one-on-one assistance is available as needed for additional support. For part b., MDHHS currently has a process in place to review the user narrative describing the incompatible role exceptions within the DSA Michigan Statewide Automated Child Welfare Information System (MiSACWIS) request as part of the approval process. MDHHS will continue to work on adding an incompatible role form in the DSA MiSACWIS request with automated routing for appropriate approval. Anticipated Completion Date a. and c. Corrective action is ongoing. b. MDHHS has not yet determined an anticipated completion date because implementation is dependent on funding, approval, and prioritization of other proposed system changes. Responsible Individual(s) Alana Lowe, MDHHS Deon Nelson, MDHHS