Corrective Action Plans

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance; Significant deficiency in internal control over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (CFDA# 14.157) Condition. Out of a sample of 8 tenant files, it was noted: 1. One out of eight instances where a tenant EIV was not run within 90 days of move in; 2. One out of eight instances where a tenant's saving and checking accounts were not verified by a third party; 3. One out of eight instances where the incorrect balance was used to determine the tenant's checking account balance; 4. Two out of eight instances where a copy of the tenant's security deposit was not maintained in the tenant file; Effect. As a result of this condition, certain tenant files did not contain all required supporting documentation. Plan. Management agrees with finding 2023-001. All files are to be inspected in the current fiscal year to ensure compliance with HUD regulations. File maintenance will be competed following each move in and annual recertification. In addition to one-on-one training, the housing administrator has signed up for additional training including a WebEx on annual recertification and a basic EIV course. Additional training sessions are forthcoming. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2024

CORRECTIVE ACTION PLAN Finding 2023-001 - Housing Choice Voucher Tenant File s - Eligibility - Int ernal Control over Tenant Files - Non compliance & Significant Deficiency - Housing Choice Voucher Program - ALN 14.871 CORRECTIVE ACTION PLAN: 1. All of Jonesboro HCV Specialists and HCV Manager took a Nan McKay Workshop, HCV and Public Housing Rent Calculation Course. The dates of this course were May 7, 2024 - May 9, 2024. 2. JHA has discussed the issues of the 13 files discovered during the audit and spoken to staff about making sure they know what to do. Additional training and discussion of the errors has been scheduled for next Wednesday, May 29, 2024. This was delayed due to JHA recently hiring a new full time HCV Specialist and JHA wanted to ensure all caseworkers were present and had proper training on the specific errors we incurred during the audit. 3. Peer Review - Janet Wiggins was the only one reviewing caseworker files. Janet reviews about 20 files per month. JHA has had discussion and will be expanding the number of files that are reviewed on a monthly basis. Janet Wiggins will still randomly select files as she has been doing, but each caseworker will also audit up to 5 random files from other caseworkers throughout the month to double the amount of files per month that are reviewed, which will also help us catch errors if they exist. PERSON RESPONSIBLE: N an M cKay / Paul G. Wright / Janet Wiggins ANTICIPATED COMPLETIO N DATE ( See Below ): 1. #l from above was Completed May 7, 2024 through May 9, 2024 by a Trainer from Nan McKay. 2. #2 was discussed in a staff meeting on May 29, 2024. I, Paul Wright, went over the 13 files with staff and discussed the importance of making sure that we ensure proper documentation is in the file whether full time status of children or EIV that is used to make a computation, we ensure that we are using the appropriate and proper amount of check stubs and that they are consecutive, we discussed making sure that our calculations themselves are correct if weekly, bi-weekly,monthly or annual income is used. We discussed making sure if working on a file that already has had an annual that we make sure any interim is inserted properly and we pay the correct amount on our HAP check run. 3. #3 was discussed during staff meeting on May 29, 2024 by Paul G. Wright and Janet Wiggins. I had previously spoken with HCV Manager, Janet Wiggins, and Assistant HCV Manager, Nora Schmidt, about increasing the number of files that we audit on a monthly basis. Janet examines each file when she performs a move or transfer, which is typically over 20 per month. All caseworkers will review 5 files per month from another caseworker for accuracy and make sure everything looks and is correct. This will about double the amount of files that are being reviewed on a monthly basis. This is being implemented currently and will continue moving forward. All the steps listed in the corrective action plan have been addressed and staff has been advised and trained. Peer review has begun and will continue moving forward to help increase the number of files that audited/ reviewed on a monthly basis. It is with these efforts that JHA hopes to reduce and hopefully eliminate the errors that we received during the 2023 Fiscal Year Audit.

The finding is a result of not correctly reviewing provided eligibility documents and ensuring the application corresponds to the documentation during the review process after the initial application was completed. To prevent this and other potential issues from happening in the future, the Corporation will conduct a review of all 2023-2024 student CACFP eligibility forms and applications to ensure the required eligibility documents match the selections made on the application. Staff will also verify that all applications are appropriately signed. This process will be included for future year eligibility calculations. Responsible Official: Paul Chapman, Chief Operating Officer Anticipated Implementation Date: July 2024

Auditor Description of Condition and Effect: Internal control procedures are required to ensure that the costs and activities are allowable under the grant. The County is required to have evidence that the costs and activities are reviewed and allowable. During our testing, all invoices tested did not have evidence they were reviewed to ensure they were for an allowable activity and cost. This condition is a result of the County not having tangible evidence that invoices are reviewed and in line with the allowable activities and costs of the grant. As a result of this condition, the County is exposed to an increased risk of having ineligible expenditures. Auditor Recommendation: The County should adjust their procedures to ensure there is tangible evidence expenditures are being reviewed to ensure they are in line with grant requirements. Corrective Action: We agree with the finding and will implement this procedure going forward.

Farmville Housing Authority Corrective Action Plan For the Year Ended September 30, 2023 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Wendy Ellis Executive Director Corrective Action: We will implement proper internal control procedures for the N/C S/R Section 8 program eligiblity requirements. Proposed Completion Date: Immediately

Management Response: Southeast Louisiana Legal Services Corporation has reviewed these concerns and is in agreement that it should obtain a signed retainer agreement and signed citizenship attestation form in accordance with the compliance requirements of the Legal Services Corporation. Corrective Action Plan To correct this problem, Southeast Louisiana Legal Services Corporation will require that all retainers and citizenship attestations be uploaded to the electronic case file in our case management system, Legal Server. Legal Server has the capability to send out retainers and citizenship attestations electronically to clients. These will automatically be uploaded to the e-signature log in the electronic client file. Hard copies of retainers with wet signatures can also be scanned and uploaded to the case management system. We will provide additional training to all staff on the requirement of obtaining retainers and citizenship attestations as well as how to send retainers and citizenship attestations electronically from Legal Server and how to upload scanned retainers and citizenship attestations to the case management system. The training will be recorded and circulated via email to all staff along with training materials. The training recording and materials will also be uploaded onto our internal “intranet” for all staff to access between quarterly training sessions. The training will also be incorporated into our adult learning management system. Contact Person Responsible for Corrective Action: Roxanne Newman, Deputy Director Southeast Louisiana Legal Services Corporation Ph. (985) 345-2130 x708 Anticipated Completion Date: Ongoing. Southeast Louisiana Legal Services Corporation already has written materials on how to send retainers electronically from Legal Server. We will develop additional written materials on how to send citizenship attestations from Legal Server and how to scan and upload retainers and citizenship attestations to Legal Server. Training materials will be completed by May 3, 2024 and training will take place on May 7, 2024 and be repeated quarterly on August 12, 2024; November 4, 2024; and February 10, 2025.

Finding 2023-003 – Reporting Cluster: Student Financial Assistance Federal Agency: Department of Education Assistance Listing Title and Number: 84.268 - Federal Direct Loan Program Award Year: Fiscal year 2023 Management concurs with the auditors’ finding. The academic year end date was reported incorrectly for Direct Loan borrowers enrolled in Law School. All affected records have been identified and were limited to students seeking professional degrees. All incorrectly reported dates have been corrected in the COD system as of June 13, 2024. Though the University had procedures in place to monitor the correctness of information submitted to the COD system, this error in one of our smallest student groups was overlooked during our office’s transition back to normal operations from COVID-19 procedures. To prevent a recurrence of this error, a separate review process will be added to our office workflow to annually ensure the accuracy of academic dates entered into the Banner student information system. Ronald Price, Associate Director, Student Financial Aid, Fiscal Operations and Loans of the University of Alabama (ronald.price@ua.edu), is responsible for implementing the corrective action planned. The University expects to complete this corrective action plan by July 31, 2024.

Finding 2023-002 – Timeliness of Enrollment Reporting Cluster: Student Financial Assistance Federal Agency: Department of Education Assistance Listing Title and Number: 84.268 - Federal Direct Loan Program Award Year: Fiscal year 2023 Management concurs with the auditors’ finding. The University began discussions with the National Student Clearinghouse (“Clearinghouse”) in February 2024 concerning graduation reporting, and changes have been made to the process of reporting student graduations. Per the recommendation of the Clearinghouse, a “Graduates Only” file will now be reported by the University in addition to the Clearinghouse’s “Degree Verify” files. Management has verified with the Clearinghouse that this change will eliminate the occurrence of records not being properly applied and provides easier identification and resolution of any errors. This new method of reporting was implemented on June 10, 2024, with the reporting of Spring 2024 graduates. For the remaining status change issues, management has collaborated with the Clearinghouse on the University’s schedule of future enrollment reporting submissions to prevent any further timing issues with NSLDS reporting. Daniel Strickland, Associate University Registrar (daniel@ua.edu) completed this corrective action plan on June 10, 2024.

Planned Corrective Action: The Seattle Indian Health Board has adopted a sliding fee program that provides discounts to eligible patients and Indian tribes. To address the auditors' concerns and further strengthen our internal controls, we are implementing a comprehensive corrective action plan. Firstly, we will ensure that all personnel involved in eligibility checks, including front desk staff and benefits specialists, are fully trained and aware of federal regulations and internal policies. This will be achieved through comprehensive training sessions and the development of a detailed training manual outlining eligibility criteria, documentation requirements, and procedural steps. Periodic refresher training sessions will reinforce adherence to these policies. Secondly, we will establish a robust internal audit system to regularly review and verify compliance with eligibility requirements. This includes integrating a monthly audit of eligibility determinations into the month-end reporting process, conducted by the clinical operations team. The clinical operations team will use a standardized checklist during these audits to ensure consistency and thoroughness. They will document findings and follow up on any issues or discrepancies with the relevant personnel to ensure timely corrections and adherence to procedures. Management believes that we have adequate internal control systems to safeguard the organization's assets and comply with federal and local regulations. However, we remain committed to further strengthening our controls and processes where necessary. Name of Responsible Party: Zecharias Mesgane, CMA, Director of FP&A Anticipated Completion Date: September 30, 2024

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Elementary and Secondary Education The Old Colony Regional Vocational Technical High School respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC 100 Quannapowitt Parkway, Suite 101 Wakefield, MA 01880 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 Number 84.027 2023-001 – Controls for Monitoring Payroll Charged to the Grant Views of Responsible Officials and Planned Corrective Actions: Management agrees with the findings and for the school year 2023-2024, the District will ensure that all payroll expenditures charged to the special education grant are supported with documentation regarding the eligibility of the employees paid out of the grant, as well as documentation that payroll charged to the grant was time spent on accomplishing grant objectives (i.e. time and effort certifications).

Finding 2023-002 – Preparation and Maintenance of Equipment Population The single audit report included the following recommendation: To address the Condition identified above, we recommend Amtrak to continue integration of the systems in such a way that appropriate funding source would be tagged to each asset automatically and that required property records would automatically be consolidated into one system of record and updated in that system. Ensure that adequate IT interface and business process application controls over the completeness, accuracy, validity, confidentiality, and availability of transactions and data during application processing (input, processing, output, etc.) are in place. Additionally, management should consider breaking out large purchase orders containing multiple items of equipment and tools under one purchase request, by creating separate level 2 WBSE codes in order to distinguish between different types of items being acquired, in order to be able to provide more appropriate classification. Identification as a repeat finding: Not a repeat finding Management Response/Status of Action Plans: Amtrak will implement the following to mitigate the finding related to the equipment population. 1. To prevent errors regarding the mapping of grant funding to equipment, the Capital Accounting Department will be implementing additional procedures and validations in the preparation and approval of the equipment review population file. This will include additional cross checks to validate mappings from fund sources to equipment and an additional review by EAMDT. The additional review and approval steps will be formalized with documented steps before September 2024. 2. To prevent errors related to missing asset numbers, the Capital Accounting Department, in coordination with EAMDT, has implemented an additional review of the single audit eligible indicator and inclusion of an asset unit number at the time the equipment asset is recorded in the fixed asset ledger. Additionally, EAMDT and Capital Accounting are now utilizing automated reporting that allows real time review of single audit equipment additions and data fields from the Company’s systems. This reporting allows for a timely view of key data fields from the related systems including Asset Equipment Description, Asset Unit Number, Single Audit Flag, Last Audit Date and Conditions. All equipment with missing asset unit numbers will be investigated and corrected. If any equipment marked as single audit eligible appears as not being eligible, Capital Accounting will investigate and resolve. The contacts for this item are Carol Hanna, VP Controller and Michele Millsaps, Assistant Controller, Capital and Inventory Accounting. Amtrak anticipates that changes above will remediate this finding in the fiscal year ending September 30, 2024 and beyond.

2022-004 – Reimbursement Claims Reported Meals Delivered to Unidentified Participants Corrective Action – GYAC has purchased an electronic system that assists with the tracking of meal count sheets and attendance rosters. This system compares the names on the roll with the number of meals being claimed, ensuring that participant rosters are accurately maintained and matched with meal delivery records, thereby preventing discrepancies and reducing the error rate in submissions.

2023-003 Compliance of Special Tests and Provisions – National Service Criminal History Checks: Management Response: Management will ensure an individual who does not perform the adjudication will review and document whether information was entered correctly and whether the adjudications are proper and documented prior to a member’s start date. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

Finding: 2023-002 Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2023 Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the HRA implement controls over all areas of the federal program so that controls are in place and working. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The HRA will assess the controls over the federal program and make changes as deemed necessary. Name of the Contact Person Responsible for Corrective Action Plan: Rhonda Moen, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2024.

In June 2021, a procedure was implemented to ensure thorough documentation of participant eligibility within the program. The current audit revealed deficiencies in documentation for clients enrolled in the grant prior to June 2021. The organization will conduct a comprehensive review of all grant participants to address and rectify any documentation gaps, including those enrolled before June 2021.

Finding 2023-001, Significant Deficiency - Eligibility Corrective Action Plan: Goal: To ensure necessary Medicaid corrections are made by caseworkers in a timely manner and verified as completed by Medicaid management and/or Quality Assurance staff. Plan: The County will include a due date to the auditing tool so that correction tasks request can be tracked and monitored for completion and accurateness. Eligibility, Internal Control and Procedural Errors will be given 5 business days to be corrected by workers. Performance Improvement Strategies: 1. Training will be given to supervisors, lead workers, and QA staff on proper usage and monitoring of due date requirements added to the audit tool. 2. Copies of reports will be stored in the shared Teams Channel for Medicaid Services. 3. Supervisor will follow up with caseworkers on 6th business days to ensure corrections have been made. 4. Every month, program managers will select 10 examples from the Medicaid Audit Finding spreadsheet to make sure supervisor have handled the error corrections made by their team. Responsible Parties: Medicaid Program Mangers Amanda Burdge, Jennifer Hurdle and Alison Westbrook Timeframes: A Medicaid Division Meeting will be held with all supervisors to discuss the expectation of monthly audits, corrections, and staying in compliance with State requirements. Also, explain the expectations of the Program Managers audit. Held no later than June 15, 2024.

Disbursements to Ineligible Students Planned Corrective Action: With the new automation process we have exceptions that will prevent the funding from posting if there is no LDA listed. We have also updated the Disbursement Criteria Approval to help prevent inaccurate disbursements from posting. Person Responsible for Corrective Action Plan: Ingrid Ortiz, Director of Financial Aid Anticipated Date of Completion: Implemented as of Fall 2023.

Condition: The Organization did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 7 of the 8 students in the sample (87.5%). We consider this condition to be a material weakness in internal control over compliance relating to the Eligibility compliance requirement. Statistical sampling was not used in making sample selections. Corrective Action Plan: The issue regarding reporting of loan disbursement dates occurred as the result of a miscommunication between the Financial Aid officer at SIEAM and our CPA. Our accountant was unaware that the specific disbursement date reported by Campus Ivy was required to be the disbursement date recorded in our student ledgers. All disbursements occurred very close to the date, but were not recorded on the exact date. This miscommunication and knowledge gap has already been remedied. At this time, both our CPA and our Financial Aid officer understand the statutory requirement for this reporting and have made the needed changes. Responsible Person for Correction Action Plan: Craig Mitchell, President, in conjunction with Sabu Kallingal, Dean of Students and Financial Aid Officer, and Franz Aponte, CPA. Implementation Date for Corrective Action Plan: The CAP was implemented on May 17, 2024.

Low-Income Home Energy Assistance– Assistance Listing No. 93.568 Recommendation: We recommend that the organization implement additional review process over the Fuelware System information when changes are made to family size to ensure the system is updated timely and correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: If a household member is removed from the energy application, the Energy Staff will be required to double check the income guidelines and the household composition to make sure that wrong benefits are not given to clients. With the updates to the energy software system, the awards will be based on the new household composition. In addition, when staff encounter this situation, they will have the ability to manually cancel the award and recertify the application in order to approve the correct award amount. Name(s) of the contact person(s) responsible for corrective action: Michelle James Planned completion date for corrective action plan: May 21, 2024 If the Department of Health & Human Services has questions regarding this plan, please call Michelle James at (203) 744-4700.

Steps to resolve: We will perform a complete review of all Low Income Public Housing and Housing Authority policies over disbursements to ensure compliance with these policies. Management will implement procedures and staffing changes to clear this finding in FY 2024. Timeframe: By FYE September 30, 2024 Individual responsible for correction: Tarena Grant, Interim Executive Director

Steps to resolve: We will perform a complete review of all Low Income Public Housing, Capital Fund Program and Housing Authority policies over disbursements to ensure compliance with these policies. Management will implement procedures and staffing changes to ensure this finding will be cleared by the 2024 FYE. Timeframe: By FYE September 30, 2024 Individual responsible for correction: Tarena Grant, Interim Executive Director

Identifying Number: CF 2023 – 001 Finding: Reporting Corrective Action Taken: The corrective action taken to resolve the reporting finding was an enhancement to the grant monitoring and reporting procedures by adding a scheduled review of the reporting requirements. Contact Name(s): Candida Heater, Administrative Services Division Director; Michelle Quigley, Finance Bureau Chief; Julie Maytok, Budget Bureau Chief Corrective Action Completion Date: 04/17/2024

Identifying Number: IC 2023 – 002 Finding: Reporting Corrective Action Taken: The corrective action taken to resolve the reporting finding was submittal of the quarterly report to the Florida Department of Environmental Protection. Contact Name(s): Candida Heater, Administrative Services Division Director; Michelle Quigley, Finance Bureau Chief; Julie Maytok, Budget Bureau Chief Corrective Action Completion Date: 04/17/2024

Finding 2023-001: Eligibility Finding Type: Significant Deficiency in Internal Controls over Compliance Federal Program Title and AL Number: The Emergency Food Assistance Program (TEFAP) Commodity Credit Corporation Eligible Recipient Funds (10.187) and the Food Distribution Cluster (10.565, 10.568, 10.569). Criteria: Per 7 CFR 251.5(c), a state agency may delegate to one or more eligible recipient agencies with which the state agency enters into an agreement the responsibility for the distribution of commodities and administrative funds. Per the State’s agreement with the Food Bank, the Food Bank shall submit household reports monthly. Condition and context: As part of our eligibility testing, and in order to determine whether the onsite check-in forms were complete, we agreed the onsite check-in forms for our eligibility selections to the household distribution reports. For six out of the 38 statistically valid samples, the number of unduplicated households serviced on the check-in forms did not agree to the household distribution reports. This condition was noted for five out of 11 months selected for completeness. Cause: The Food Bank did not have controls in place to ensure the accuracy of the Household Participation reports. Effect: The number of eligible households that received food distributions was not accurately reported to the State. Questioned Costs: None. Repeat finding: No. Recommendation: We recommend that the Food Bank implement controls to ensure the accuracy of the Household Participation report.Management Response and Planned Corrective Action: The Agency Relations Management team created a procedure to ensure all agency and program TEFAP household distribution reports are accurately entered into the CDSS reporting platform. The TEFAP Specialist will run a CERES report by the 5th of every month showing all agencies and programs that received TEFAP the previous month. This report will be used as the checklist to ensure a TEFAP report is received and that the household information gets entered into the CDSS household reporting platform. Once the TEFAP Specialist enters the reports into the CDSS platform, the Agency Relations Specialist will double-check the entered entries in the CDSS platform against the agency/program report to ensure accuracy before the CDSS portal is locked for the month. In order to ensure the effectiveness of these procedures, the Agency Relations Supervisor will audit 25 reports randomly every month. The Agency Relations Supervisor will review the audit results with the Agency Relations Manager on a monthly basis. For the Food Bank’s TEFAP direct to individuals programs, the Programs Coordinator will tally all TEFAP food recipients from the TEFAP sign-in sheets and complete the HHP TEFAP report form. Before submitting the TEFAP HHP report to the TEFAP Specialist, a different Programs Coordinator will double-check the total number of persons served from the TEFAP sign-in sheets and verify the HHP TEFAP report form is correct. After the second check is completed, the Programs Coordinator will send the monthly LARFB TEFAP reports via email to the TEFAP Specialist with a copy to the Programs Manager and Programs Director. The Agency Relations Manager will oversee the processes completed by the Agency Relations Supervisor, TEFAP Specialist, and Agency Relations Specialist assigned to these procedural tasks. The Programs Manager will oversee the work of the Programs Coordinators for the Food Bank’s direct to individuals programs. We will implement this corrective action on or before June 30, 2024. Individuals responsible for corrective action: Elizabeth Cervantes – Sr. Director of Product Acquisition and Agency Relations 323.974.0073 Hilda Ayala – Sr. Director of Programs & Policy 323.353.0114 Steven Meisberger – Chief Financial Officer 323.318.0319

The tenant recertifications will be monitored by the owner to ensure they are being completed in a timely manner.