Corrective Action Plans

2023 -001 Eligibility Program: Emergency Rental Assistance (ERA) Program Assistance Listing Number 21 .023 Name of Contact Person: Lisa Coleman, Senior Vice President of Federal Grants Corrective Action: In addition to following the Corporation's policies and procedures developed in accordance with. ERA Program guidelines established by the Treasury; the Corporation implemented additional procedures related to fraud prevention and detection. The Corporation began independent property ownership searches, added additional application review requirements for large tenant-paid payments, and added additional recertification requirements including proof of payment to landlord. All applications were processed by June 30, 2023. The Corporation will utilize the remaining funds from the ERA Program to provide gap financing for the development of affordable housing and to provide funding to domestic violence agencies and legal entities for eviction prevention services. After services are provided and program closeout completed, the remaining federal funds, if any, will be returned to the United States Department of Treasury. Anticipated Completion Date: June 30, 2024

Finding 2023-001 - ISIR transaction 01 was imported on January 21, 2022, with no C fiag. The student was awarded a Federal Direct Unsubsidized Loan on June 22, 2022. The Fall 2022 semester began on September 6, 2022. The Fali 22 loan disbursement ($10,250) was credited to the student’s account on September 6, 2022. - Transaction 02 was imported on September 8, 2022, two days after the start of the semester and loan disbursement. Transaction 02 had a C fiag. - Transaction 03 was imported on October 21, 2022 with the same C flag. - The Spring 2023 semester began on January l7, 2023, and the Spring 23 loan disbursement ($10,250) occurred on January 17, 2023. - The C fiag was resolved April 11, 2023, after the spring loan disbursement and prior to the end of the 2022-23 academic year. The academic year ended on May 11, 2023. Corrective Action Planned: The Graduate Financial Aid Office conducts a comprehensive review of all iSIRs for C flags before proceeding with awarding and disbursing aid. No aid is awarded to a student until the C fiag is addressed. To consistently monitor subsequent ISIR transactions, Graduate Financial Aid receives a daily spreadsheet of that day‘s imported iSIRs, prompting a routine daily review. To further ensure no C flags go unnoticed, Graduate Financial Aid will enhance their current procedures immediately by incorporating the Colleague ISIR Alert Report (IART). This tool highlights any ISIR records that may need review and will be generated weekly. Contact Person Responsible for Corrective Action: DanielleJ Ballantyne, Director, Graduate Financial Aid and Brandon Gumabon, Assistant Director, Graduate Financial Aid.

Contact Person(s) Responsible: Larry Quillen, Executive Director, North Fork Valley Community Health Center and Assistant Ambulatory Director, UK HealthCare Corrective Action Planned for Reference 2023-001: University of Kentucky HealthCare System (UKHC) will review all applicable policies and ensure all personnel responsible for, and involved in the North Fork Valley Health Center (NFV) sliding fee discount program adequately demonstrate their understanding of the sliding fee scale policy in order to improve application of the sliding fee discount program. The NFV sliding fee discount application program will clearly identify to patients their qualified discount percentage as well as the effective period. The application date will be entered into UKHC’s electronic health record (EHR) to automate the processing of the discounts. The UKHC Enterprise Revenue Cycle will conduct monthly randomized audits of the applications to ensure that discounts have been applied correctly. This audit process will also include selections of discounts applied to ensure applications are properly maintained for each patient receiving the discount. UKHC leadership will meet quarterly to review and assess NFV sliding fee discount application program for a period of no less than one (1) year. Anticipated Completion Date: 03/31/2024

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review its procedures related to firsttime borrowers to ensure they are in compliance with the Department of Education's regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We hold all first-time freshman loan funds for 30 days after the start to ensure we are not paying anyone early. Additionally, we will run an entrance term report prior to the start of the semester/term. From this report we can identify all first-time borrowers and tag them in populi. Prior to batching federal funds, the financial aid office will pull a report by said tag and ensure disbursements dates are 30 days from the start of the term/semester. Name(s) of the contact person(s) responsible for corrective action: Lisa Stone, Joyce Hatch and Kelly Reyes Planned completion date for corrective action plan: November 2023

tudent Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University implements policies to review all student award packages at the start of the academic year to ensure no over awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Department will review all student award packages at the midpoint of each semester to ensure no overawards exist. Name(s) of the contact person(s) responsible for corrective action: Lisa Stone, Joyce Hatch, and Kelly Reyes Planned completion date for corrective action plan: May 2024

Caseworker will check task for Ex parte task and work case within 3 days. Caseworkers will received additional training on documentation, NCFAST evidence, resource calculations and countable/noncountable resources to remind workers of the procedures and policies that should be followed at time of application and recertification process. Supervisors will conduct second party reviews on applications and recertification’s to determine that the correction is being taken. Workers will be retrained on NCFAST evidence for resources to ensure procedures are being followed for evidence on dashboard to match the supporting documentation used as verifications. Supervisors will review cased to evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly and accurate needs units in eligibility is used in determination of benefits. Proposed Completion Date: January 31, 2024

Corrective Action: Caseworkers will receive training on appropriate use of forced eligibility. Caseworkers will received additional training on documentation, NCFAST evidence, resource calculations and countable/non-countable resources to remind workers of the procedures and policies that should be followed at time of application and recertification process. Supervisors will conduct second party reviews on applications and recertification’s to determine that the correction is being taken. Caseworkers will received training on the work number (TWN) in NCFAST learning gateway. Caseworkers will receive training on earned income (MA 3300). Caseworker will receive training on third party insurance. Caseworker will receive training on CAP plan of care. Workers will be retrained on NCFAST evidence for resources to ensure procedures are being followed for evidence on dashboard to match the supporting documentation used as verifications. Supervisors will review cased to evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly and accurate needs units in eligibility is used in. Proposed Completion Date: January 31, 2024

Identifying Number: 2023-001 Finding: The provisions of 36 CFR Section 686.31(e) were not followed. Notifications were not sent to TEACH Grant recipients to inform the student of their right to cancel their TEACH Grant and to inform the student of the procedure and time by which the student must notify the institution that he or she wishes to cancel their TEACH Grant or TEACH Grant disbursement. Corrective Actions Taken: We agree with this finding. University staff worked with the University's Enterprise System consultants, Ellucian, to develop a procedure to ensure notifications required by 36 CFR Section 686.31(e) are sent to students who receive TEACH Grant funds, Notifications were updated to include language about the right to cancel TEACH Grants, the procedures and time by which the student must notify the institution that he or she wishes to cancel the TEACH Grant or TEACH Grant disbursement. This procedure was implemented to fully comply with 36 CFR Section 686.31(e) on January 30, 2024. Name of Responsible Person: Dr. Heidi Neal, Assistant Vice President of Enrollment Management Completion Date: January 30, 2024

Pivot, Inc. (“Pivot” or “Organization”), respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: HSPG & Associates, 5400 N. Grand Blvd., Suite 330, Oklahoma City, OK 73112. Audit period: As of and for the year ended June 30, 2023. The findings from the June 30, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINANCIAL STATEMENT FINDINGS – INTERNAL CONTROL Identifying Number: 2023-001; Recognition of Revenue Recommendation: We recommend that the Organization continue to evaluate its procedures to ensure proper revenue recognition performed as part of its monthly and year-end closing processes. Action Taken: At this time we have put into new procedures to review and post all outstanding revenue during our monthly close process in order to ensure proper revenue recognition. Monthly reimbursements are checked off as invoiced in order to be sure that all are completed and posted in the correct month. Anticipated completion date: January 18, 2024 Name of contact person and title: Carolyn Gonzalez, Director of Finance & Accounting FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS – COMPLIANCE FINDINGS Recommendation: We recommend management continue to perform written income certifications for all future participants. Further, we suggest that the certifications include signatures of the staff completing the reviews. Action Taken: We agree with the above finding and plan to continue to require income certification reviews. Anticipated completion date: January 18, 2024 Name of contact person and title: Carolyn Gonzalez, Director of Finance & Accounting

Department of Justice 2023-001 Crime Victim Assistance Program Auditor's Recommendation: We recommend Community Crisis Center, Inc. review its files to ensure that all client files contain the required confidentiality and intake forms. We also recommend Community Crisis Center, Inc. implement a new policy to perform an annual internal audit of the client files for completeness. Action Taken: The Center's midnight Case Manager staff will continue to work through all the intake paperwork for the day to ensure all forms are present, including the confidentiality form for clients. In addition, a monthly audit of client files will be performed by the Compliance Manager and Program Coordinators to review and ensure client files have all necessary completed paperwork. If the funding agency has questions regarding this plan, please call me at 847-742-4088.

Management has provided standard packets for initial, annual and interim packets including coversheets and checklist to assist in minimizing missing documentation in compliance with HUD regulations and CTHC policies. CTHC will also have files randomly audited by Executive Director and a 3rd party quality control contractor who will review LIPH files for for errors. All staff will complete and pass rent calculation training every three (3) years. All utility allowances have been updated.

The Clinton Township Housing Commission Board has been reeducated, by our Fee accountant about the proper use of HUD Funding. The CTHC board understands that HUD funds CANNOT be used in to provide any type of Bonuses to staff and or any of its affiliates. All Commissioners will attend Commissioner’s training to insure proper education on their roles and expectations.

Enrollment Reporting to NSLDS Planned Corrective Action: We have created a process with specific individuals responsible for updating and submitting the roster timely; train staff and create and follow policies and procedures to ensure no delays in reporting a change in status. We have designated an individual to pull a statistical report from NSLDS to verify the reporting is updated for each period of enrollment. Person Responsible for Corrective Action Plan: Marilyn Eason, Registrar Anticipated Date of Completion: This problem should be resolved when Newberry moves to the J1 platform this spring. It is expected enrollment reporting will be automated by the summer of 2024.

Monthly Reconciliations of Pell Grant and Federal Direct Loans Planned Corrective Action: Monthly reconciliations for the Pell Grant and Federal Direct Loan Programs have been completed to date for the 23-24 academic year. The senior associate director is responsible for completing monthly reconciliations and the director will perform if necessary. Person Responsible for Corrective Action Plan: Karen Benfield, Director of Financial Aid Anticipated Date of Completion: This process is being implemented for the 2023-24 academic year.

U.S. Department of Agriculture CFDA # 10.565, 10.568, 10.569 Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations for the CSFP and Emergency Food Assistance Programs. Responsible Individuals: Melissa Sobolik, CEO and David Stachon, CFO Corrective Action Plan: The GPFB will ensure all documents for TEFAP and CSFP programs have proper signatures by necessary parties going forward. An electronic signature process has been implemented to make the dissemination, review and storage of this process easier. Anticipated Completion Date: Immediate

Unified School District #446 Independence, Kansas Corrective Action Plan January 17, 2024 Cognizant or Oversight Agency for Audit Unified School District #446 respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Jarred, Gilmore & Phillips, PA, P.O. Box 779, 1815 S Santa Fe, Chanute, Kansas 66720. Audit period: Year ended June 30, 2023 The findings from the January 17, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Finding: 2023-001 – Verification Condition: During our testing of verification of income of households sampled during the year, we tested all households chosen for verification. During this testing, we noted households whose net income was used to calculate their eligibility instead of their gross income. Recommendation: Procedures should be implemented requiring that all income should be verified using proper documentation and verification results review by at least two or more qualified individuals. Action Taken: We are in agreement with the recommendation and the District has updated review procedures to ensure that free and reduced lunch verifications are reviewed by at least two people and that gross wages are used in the calculations. Anticipated Complete Date: November 8, 2023 Should the Oversight Agency for Audit have questions regarding this plan, please contact Gina Godinez, Director of Finance, at (620) 332-1800. Sincerely Unified School District #446 Unified School District #446

FINDING 2022 – 003: Repeat of Prior Year Finding 2021-008 Name of Responsible Individual: Joyce Lubeck-Sonenberg, Acting Director of Financial Aid Type of Finding: Overaward of Title IV Funds Criteria: Title IV regulations (34 CFR 685.203) states in no case may Direct Subsidized, Direct Unsubsidized, or Direct PLUS Loan amount exceed the student’s estimated cost of attendance for the period of enrollment for which the loans were intended, less (1) the student’s estimated financial assistance for that period and (2) the borrower’s expected family contribution for that period. Condition: During testing the auditors noted two instances where the University awarded a Direct Unsubsidized loan to a student that caused the student’s financial assistance received to be greater than the student’s cost of attendance. Corrective Action: At the time of these findings, all Wheeling University Financial Aid processing operations were being conducted manually. The high level of complexity commonly associated with financial aid processing creates an environment, especially when conducted in a manual format, that is error-intrinsic. Packaging and awarding for each of the federal student aid programs are currently conducted by using the student information system, Colleague, which allows the FA office to perform these processing operations in a fully automated manner. Proper use of the “auto-packaging” feature provides significant assurance that student awards will not exceed financial need based on Cost of Attendance (COA) and Estimated Family Contribution (EFC). Previous audit findings have noted a general lack of accuracy, organization, and documentation regarding the final figure for the COA, which can result in packaging and over-award errors. As such, the Acting Director of Financial Aid has completely extensively researched and input data into the system with an accurate, fair, and equitable formula for arriving at a COA while meeting student need and, consequently, reducing or eliminating the potential for over-awards. This data was obtained from state and local cost of living figures, input from other similar state schools, and by use of the higher education organization, the College Board. This data is available as a reference for future documentation and review in a shared electronic file. Anticipated Completion Date: This process was completed in March of 2023 and is ongoing.

Recommendation: The Organization should implement internal controls to monitor the activities of third-party providers to ensure the services being provided are in compliance with Federal Statues. Action: The Organization has scheduled regular meetings (twice per month) with the property management company to monitor the activities of the provider to ensure we are in compliance with Federal Statues. In addition, twice per year, we will perform an internal audit of each tenant file to ensure compliance.

Recommendation: The Organization, or a third-party provider, should perform annual recertifications timely. Action: Since February 1, 2023, the Organization has been engaged with a new property management company with expertise in the HOME program. As of this writing, over 90% of the 2023 recertifications are complete and appointments are being set for the City of Salem to do a complete file review.

Corrective Action Plan Year Ended June 30, 2023 2023-01 Finding: Eligibility Status: Corrective action in progress Corrective Action: Training and additional oversight Person Responsible for Implementing: Lisa Clark, Director of Finance Implementation Date: January 2024 It was found that an application was identified as reduced status when it should have been free status. When the parent filled out the application in our online applications system, one of the students listed was not matching. This was due to the student not being in our Student Information System at that point. The secretary processed the application without the match. This resulted in the reduced status based on income and the number of members in the household. The student that did not match remained outstanding in the online application portal. Later when the unmatched student was entered into the Student Information System, matched and processed in the online application portal, the system did not update the original application to add the additional member. With the addition of the additional family member, the application resulted in a free status. The corrective action will include additional training for the staff members processing the applications. This will be done during January of 2024. We will implement a secondary check after each upload to catch any applications that may have unmatched students and make the corrections. There will be continued oversight and training. Lisa Clark Director of Finance

Finding 2023-006 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs (continued) Lead Staff along with Supervision will conduct refresher training on how to run all required electronic data matches and how to thoroughly document a case using the developed case note template. This area will continue to be a part of the second party checks conducted by lead staff and supervision to ensure accurate entry. Management along with the Econ Services Administrator will review the current second party/ QA Analysis policy and update any areas to ensure that supervisors and lead staff are sampling an ample amount of work in order to identify any error trends. The county is working toward specializing the Adult Medicaid by function within the Adult Program and will consist of one team that consist of a Intake Application team and a Redeterminationteam. The county currently has a targeted completion date of late spring 2024. Since many of these errors were found within the Adult Medicaid team the county feels that once specialization for this area is complete we will see a reduction of errors in this area. Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medicaid group to be completed by 4/30/2024 if fully staffed.

Finding 2023-005 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medicaid group to be completed by 4/30/2024 if fully staffed. Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period however a parent/caretaker can request assistance with establishing child support at which time the worker would assist by keing the referral. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and will continue to reduce as we go forward. Lead Staff along with Supervision will conduct refresher training on how to add evidence and update evidence to the Evidence Dashboard on a case. This area will continue to be a part of the second party checks conducted by lead staff and supervision to ensure accurate entry. Management along with the Econ Services Administrator will review the current second party/ QA Analysis policy and update any areas to ensure that supervisors and lead staff are sampling an ample amount of work in order to identify any error trends. The county is working toward specializing the Adult Medicaid by function within the Adult Program and will consist of one team that consist of a Intake Application team and a Redeterminationteam. The county currently has a targeted completion date of late spring 2024. While this is a repeat finding from 2022 it is important to note the significant decrease in the total number found in 2023 of one error compared to 8 errors found in 2022.

Finding 2023-004 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2023-005 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medicaid group to be completed by 4/30/2024 if fully staffed. Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period however a parent/caretaker can request assistance with establishing child support at which time the worker would assist by keing the referral. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and will continue to reduce as we go forward. Lead Staff along with Supervision will conduct refresher training on how to add evidence and update evidence to the Evidence Dashboard on a case. This area will continue to be a part of the second party checks conducted by lead staff and supervision to ensure accurate entry. Management along with the Econ Services Administrator will review the current second party/ QA Analysis policy and update any areas to ensure that supervisors and lead staff are sampling an ample amount of work in order to identify any error trends. The county is working toward specializing the Adult Medicaid by function within the Adult Program and will consist of one team that consist of a Intake Application team and a Redeterminationteam. The county currently has a targeted completion date of late spring 2024. While this is a repeat finding from 2022 it is important to note the significant decrease in the total number found in 2023 of one error compared to 8 errors found in 2022. Staff training to be completed by 3/31/2024 Lead Staff along with Supervision will conduct refresher training on how to add and remove household members in a case. This area will continue to be a part of the second party checks conducted by lead staff and supervision to ensure accurate entry. Management along with the Medicaid Services Administrator will review the current second party/ QA Analysis policy and update any areas to ensure that supervisors and lead staff are sampling an appropriate amount of work in order to identify any error trends. The county is in the process of specializing all Medicaid staff by function within the program adminisitered. Currently the Family & Childrens Medicaid department has been specialized into a Intake Application team and a Redetermination team. The Adult Medicaid team is working toward this same specialization model with a target completion date of late spring 2024. While this is a repeat finding from 2022 it is important to note the significant decrease in the total number found in 2023 of one error compared to 10 errors found in 2022. Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medicaid group to be completed by 4/30/2024 if fully staffed.

Finding number 2023-002 – Eligibility-Significant Deficiency Over Internal Controls Over Compliance Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corrective action: The corrective action will be implemented in January 2024. The school's management agrees with the finding and has implemented procedure whereby the Financial Aid department will include the Student Identification and Expected Family Contribution (EFC) on the Work Study log to monitor awards against the student’s EFC.

Management will ensure that tenant files will retain all necessary documentation and required forms to substantiate eligibility and compliance with rent procedures. Files will not be purged of any documentation that supports tenant's eligibility. Anticipated Completion date: January 26, 2024. Responsible person: Michelle N. Thomas, Property Manager.