Corrective Action Plans

Recommendation: Training of staff should be performed to bring the staff up to date with the implementation of all tenant file compliance requirements. Action Taken: The Organization did not retain all required information in the tenant file. Going forward the Organization will retain all tenant file information and will review its current tenant files.

Recommendation: Training of staff should be performed to bring the staff up to date with the implementation of all the tenant file compliance requirements. Action Taken: The Organization did not retain all required information in the tenant file. Going forward the Organization will retain all tenant file information and will review its current tenant files.

2023-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their policies to ensure all required documentation is maintained for all individuals who are on the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: NOHA has reviewed its policies regarding documentation maintenance for all individuals on the waiting list. Quality control review of waiting list data entry was put in place after October 2020. The oldest application on the current HCV waiting list is dated 2019. NOHA anticipates this finding may continue until the waiting list application dates reach 10/2020. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 1/31/2024

2023-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their processes for eligibility determination and documentation to ensure all information is properly documented and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Northwest Oregon Housing Authority has reviewed eligibility determination and documentation processes. Staff have received updated training regarding proper data entry of assets and application of COLA. NOHA continues to conduct on-going quality control file reviews to monitor file quality; year to date, approximately 6.5% of transactions have been reviewed. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 1/31/2024

To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2023. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2023 The findings from the April 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Awards Findings: Finding 2023.001 - Sliding Fee Scale Discount 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 • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2024. Any findings through the audit process will be reported to the COO. At least five patien.t charts will be audited monthly. o In addition, the billing manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper set up of sliding fee discounts. o Health Center Practice Administrator will review and implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and billing manager. If there are any question regarding this plan, please e-mail Regina Oxford at roxford@heartlandhealth.org. Sincerely,

Name of Contact Person: Matt Lacy, Chief Financial Officer; Recommendation: We recommend the District verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000; Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000.

Finding 2023-001 Response Type of Finding: Material weakness in internal control over compliance and noncompliance. Criteria: In accordance with DH, Incorporated’s regulatory agreement with HUD for its HUD Section 223(f) Insured Mortgage and HUD Section 8 Housing Assistance Payments contract, DH, Incorporated is required to annually recertify its tenants. It is the responsibility of management to design and implement internal controls to ensure the tenants are recertified within the applicable timeframe required by HUD. Additionally, HUD requires minimum security deposits of $50 to be collected for all tenants. Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action: a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare b. Amanda Smith, Property Development Manager/ShelterCare 2. The corrective action planned: a. Pinehurst Management was overseeing property through 4/30/2023. ShelterCare was assigned as new managing agent 5/1/2023. b. ShelterCare is working to ensure that the onsite manager will be trained in HUD compliance. Training started in October 2023. c. We are currently prioritizing recertifications by oldest first so we are able to catch them up and get the property certifications back on track. d. Monthly review of Tenant Rental Assistance Certification System (TRACS) reports to ensure recertifications are being completed in a timely manner. 3. The anticipated completion date: a. New training was started in October 2023 and to be completed by 12/31/2023. Monthly review of TRACS reports was implemented 10/1/2023.

Auditor Description of Condition and Effect. Instead of earning additional aid due to the Return of Title IV calculation error, one of the twenty one students who were affected saw a reduction due to a transposition/rounding error that was missed in the original calculation. As a result of this condition, input errors for the Return of Title IV calculations can make it through the process without being discovered. It is our understanding that on July 26, 2023, the College corrected the transposition/rounding error that impacted the students Return of Title IV calculation. Auditor Recommendation. Management has already taken appropriate corrective action by updating the returns for the student impacted by the input error. However, we recommend that the College implement a review process to ensure that the R2T4 calculation is being reviewed by a second individual. Corrective Action. The College has performed the necessary steps to correct the error and will amend the calculation process to ensure that a second individual is reviewing the work performed. Responsible Person. Katie Malone, Director of Student Aid Anticipated Completion Date. June 30, 2024

Auditor Description of Condition and Effect. For the Winter 2023 semester, a break of 5 days (excluding weekends) was being subtracted instead of 9 days (including weekends) from the total days in the term, which resulted in the calculation being incorrect for all students who had returns in the Winter 2023 semester. As a result of this condition, Return of Title IV calculations were incorrect for 21 students for the Winter 2023 semester, resulting in $4,265 in excess funds returned to the U.S. Department of Education. It is our understanding that on July 26, 2023, the College repaid the 21 students affected by this calculation error. Auditor Recommendation. Management has already taken appropriate corrective action by updating the returns for the 21 students impacted by the calculation error in the Winter 2023 Semester. However, we recommend that the College implement a review process to ensure that the R2T4 calculation is being reviewed by a second individual. Corrective Action. The College has performed the necessary steps to correct the error and will amend the calculation process to ensure that a second individual is reviewing the work performed. Responsible Person. Katie Malone, Director of Student Aid Anticipated Completion Date. June 30, 2024

Child Nutrition Cluster: National School Lunch Program (Assistance Listing # 10.555) School Breakfast Program (Assistance Listing # 10.553) Summer Food Service Program for Children (Assistance Listing # 10.559) Compliance Requirement: Eligibility Criteria Children from households with incomes at or below 130 percent of the Federal poverty level are eligible to receive meals or milk free under the School Nutrition Programs. Children from households with incomes above 130 percent but at or below 185 percent of the Federal poverty level are eligible to receive reduced price meals. Persons from households with incomes exceeding 185 percent of the poverty level pay the full price (7 CFR sections 245.2, 245.3, and 245.6; section 9(b)(1) of the NSLA (42 USC 1758 (b)(1)); sections 3(a)(6) and 4(e) of the CNA (42 USC 1772(a)(6) and 1773(e))). Condition A sample of 40 students receiving benefits were selected to be tested under the Child Nutrition Cluster program. Two students received free lunch benefits who should have received reduced lunch benefits. In this instance, income was incorrectly calculated when determining eligibility, causing an incorrect certification. Additionally, one student was denied lunch benefits but should have received free lunch benefits. Known and likely questioned costs were determined not to be material or exceed $25,000. The sampling methodology used was not statistically valid. Cause Adequate oversight of the eligibility determination process was not in place in order to identify mistakes in determining eligibility. Effect Without demonstrable, documented controls supporting compliance with Child Nutrition compliance standards, compliance with the requirements may not be assured. Recommendation The School District institute additional procedures to ensure that eligibility determinations are made correctly. The School District should ensure that the household number and income be compared to the National Income Eligibility Guidelines to calculate whether the student qualifies for free or reduced lunch. Corrective Action Plan The School District became Community Eligible in 2023-2024 and all students are now eligible to receive free meals without the requirement to submit an eligibility application. However, students may qualify for other benefits based on their eligibility for free or reduced priced meals. Beginning in 2023-2024, Hyde Park CSD is utilizing the service of the Capital Region BOCES Food Service Management Program which includes review and oversight of the eligibility applications to ensure compliance. Responsible School District Official Director of Food Services Completion Date June 30, 2024 Linda Steinberg, Assistant Superintendent for Finance and Operations

Child Nutrition Cluster: National School Lunch Program (Assistance Listing # 10.555) School Breakfast Program (Assistance Listing # 10.553) Summer Food Service Program for Children (Assistance Listing # 10.559) Compliance Requirement: Eligibility Criteria Children from households with incomes at or below 130 percent of the Federal poverty level are eligible to receive meals or milk free under the School Nutrition Program. Children from households with incomes above 130 percent but at or below 185 percent of the Federal poverty level are eligible to receive reduced price meals. Persons from households with incomes exceeding 185 percent of the poverty level pay the full price (7 CFR sections 245.2, 245.3, and 245.6; section 9(b)(1) of the NSLA (42 USC 1758 (b)(1)); sections 3(a)(6) and 4(e) of the CNA (42 USC 1772(a)(6) and 1773(e))). The School District must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). (b) Comply with the U.S. Constitution, Federal statutes, regulations, and the terms and conditions of the Federal awards. (c) Evaluate and monitor the non-Federal entity's compliance with statutes, regulations and the terms and conditions of Federal awards. (d) Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings (e) Take reasonable measures to safeguard protected personally identifiable information and other information the Federal awarding agency or pass-through entity designates as sensitive or the non Federal entity considers sensitive consistent with applicable Federal, State, local, and tribal laws regarding privacy and responsibility over confidentiality. Condition/Context A sample of 40 students receiving benefits were selected to be tested under the Child Nutrition Cluster. Applications were viewed determining eligibility that are to be reviewed and signed by the Director of Food Services to ensure the eligibility status was deemed correct for each application. 24 applications were not documented as having been reviewed. Known and likely questioned costs were determined not to exceed $25,000. The sampling methodology used was not statistically valid. Cause Adequate oversight of the eligibility determination process was not in place in order to identify mistakes in determining eligibility. Effect Without demonstrable, documented controls supporting compliance with Child Nutrition compliance standards, compliance with the requirements may not be assured. Recommendation The School District should institute additional procedures to ensure that eligibility determinations are reviewed and accurate. Corrective Action Plan The School District is utilizing the service of the Capital Region BOCES Food Service Management Program. The service includes review and oversight of the eligibility applications to ensure compliance. Responsible School District Official Director of Food Services Completion Date June 30, 2024 Linda Steinberg, Assistant Superintendent for Finance and Operations

Finding 2023-004- Eligibility- Reimbursements Request Auditor Description of Condition: The School District's support for the number of meals served did not agree to the meals requested on the reimbursement requests. The District should request reimbursement for the actual number of meals served and should maintain support for the number of meals served for each reimbursement request. The School District maintained records from a point-of-sale system, but those meals served could not be reconciled or agreed to the reimbursement requests for our sample of 3 claims. The lack of reconciliation or other records to explain the differences could have resulted in the School District over or under requesting reimbursement from Michigan Department of Education. Corrective Action Plan: The Business Office will work with the Food Service Director to implement procedures to ensure meals service data is retained and communicated to the entity requesting reimbursement for meals served. Responsible Person: Director of Finance and Director of Food Service. Anticipated Completion Date: June 30, 2024

Views of the Responsible Officials and Planned Corrective Actions: The Business Administrator will work closely with the new Food Service Director to verify and record any company/vendor that is paid with Federal money.

The District will monitor vendors to ensure they are able to accept federal monies. By Ashley Simmons, Accounts Payable clerk by 6/30/2024.

November 27, 2023 United States Department of Health and Human Services Wood River Health Services, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: 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. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2023.001 – Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly documented. Action Taken Wood River Health Services is committed to documenting the sliding fee discounts being applied. Actions we are taking: Re-education of the Sliding Fee Discount Schedule (SFDS) documentation process to all personnel in the Community Resources Area Create review cheat sheets for SFDS including the documentation needed for decision making Review of Community Resource approvals If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please contact Alison Croke acroke@wrhsri.org. Sincerely yours, Alison Croke, MHA President and Chief Executive Officer

Material Weakness, Internal Control over Compliance Personnel Responsible for Corrective Action: Julie Whitmore, Director of Nutrition Services and Leon Hanhardt, Superintendent of Schools Anticipated Completion Date: June 30, 2024 Corrective Action Plan: The District will document the review of a sampling of eligibility determinations for program participants.

Recommendation: The electronic file case management should require a sign off for both the staff and the supervisor related to the eligibility and recertification of SSVF program participants. Corrective Action: In order to ensure that eligibility and recertifications of SSVF program participants were correctly being reviewed by a Supervisor, Frontline Service implemented new case management steps to add sign off steps for both the staff and the supervisor to provide an audit trail. Person Responsible for Corrective Action: Ken Webster, CFO Completion Date for Corrective Action: The corrective action was implemented in February 2023 in response to the recommendations provided by the Review Report on November 30, 2022 by The Department of Veterans Affairs (VA) which recommendations mirrored the recommendations from Bober Markey Fedorovich.

2023-005 – Student Financial Aid Cluster – (a) Federal Supplemental Educational Opportunity Grant (b) Federal Work Study Grant (c) Federal Perkins Loan Program (d) Federal Pell Grant Program (e) Federal Direct Loan Program, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 - Year Ended June 30, 2023 Condition Found The College did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 2 of the 40 students in the sample (5%). We consider this condition to be an instance of noncompliance in internal control over compliance relating to the Eligibility compliance requirement. Corrective Action Plan We have updated our process for reporting actual loan disbursement dates and validated that our future loan disbursement dates are accurate. Responsible Person for Corrective Action Plan Jeremy Hurse – Director of Student Financial Services Deborah Beck – Associate Director of Student Financial Services Implementation Date of Corrective Action Plan 7/1/2023

2023-004 – Student Financial Aid Cluster – (a) Federal Supplemental Educational Opportunity Grant (b) Federal Work Study Grant (c) Federal Perkins Loan Program (d) Federal Pell Grant Program (e) Federal Direct Loan Program, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 - Year Ended June 30, 2023 Condition Found For 2 of the 40 student files (5%) we examined, we noted the students were not properly awarded Direct loans. We consider this condition to be an instance of noncompliance relating to the Eligibility compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2022-003. Corrective Action Plan We have updated our process to initially evaluate all loans at the beginning of each semester, then again mid-semester, and finally a third time at the end of each semester for the academic year. Responsible Person for Corrective Action Plan Jeremy Hurse – Director of Student Financial Services Deborah Beck – Associate Director of Student Financial Services Implementation Date of Corrective Action Plan 10/11/2023

2023-002 - Child Nutrition Cluster - Special Tests and Provisions - Verification Condition Of the six households selected for testing of verification compliance, two were found to have been incorrectly calculated as being eligible for reduced price meals. Recommendation We recommend that the District review its controls related to verification in order to ensure that only eligible households receive free or reduced price meals. Comment on the Finding Recommendation The District is aware of the errors and has taken extra care with the verifications completed for the ongoing school year. Action Taken Kristy Alvord and Cindy Clark attended training in the Fall of 2023 that was conducted by the Kansas State Department of Education, regarding verification compliance. In addition, all verification calculations will be double-checked by a staff member who did not perform the initial calculation.

Finding #2023-001 – Significant Deficiency and Other Noncompliance. Recommendation: Provide additional training to personnel responsible for determining eligibility for monitoring the annual reassessment and changing the funder until the reassessment can be performed. Planned corrective action: Interfaith Ministries will provide the recommended additional training to all staff responsible for assessment and billing activities to ensure that existing control policies and procedures are consistently followed. Interfaith Ministries will also strengthen the existing processes by adding additional ongoing management reviews to identify any errors in assessment or billing data. Responsible officer: Ali Al Sudani, Chief Programs Officer. Estimated completion date: October 2023.

Contact: Reginald Gregory Title: Executive Director/Controller Phone Number: 202-772-4300 Estimated completion date: June 30, 2024 Corrective Action: The Executive Director of Family, Parish and Community Outreach department and Senior Program Manager will create and implement the following for FPCO awardees: a required document checklist for each of the EFSP jurisdictions; develop and provide a training for all staff assigned to Emergency Food and Shelter Program case work, to be given out with each new award and periodically as needed; and monitor use of funds throughout the implementation of the funding period. All required eligibility support documents will be stored in a secured Caseworthy case management database system.

Responsible Official’s Plan: District will a establish a policy and implement internal control procedures regarding the review of all grant award letters to ensure that the District is aware of all requirements that are imposed on the District with accepting the funds • Timeline for completion of corrective action plan: December 2023 • Employee position(s) responsible for meeting the timeline: Mr. Felix Garcia, Federal Programs Director and Patricia Cordova, Federal Programs Clerk

Internal Controls over distribution of USDA Foods to recipients (Material Weakness) Response and Corrective Action Plan: In addition to strides made in FY23 towards correcting the documentation of recipients in Link2Feed, Brown Bag has continued to address it in FY24 by performing the following- 1) Build communication and relationships with the remaining sites still not documenting (16 of our current 77) 2) Issued emails and phone calls asking sites to update their records. 3) Making appointments and visiting all sites still not in compliance to make an in-person plea to comply. 4) As of November 1, issue written communications warning any remaining sites that food deliveries will cease at the end of the year for any remaining sites not in compliance. No exceptions. Participants will be invited to go to the closest open MBBP site in their area. 5) Management is actively trying to close the loop on the remaining MOU’s, including SAHA, which remains unsigned. Deliveries will cease to any sites not covered with an MOU at the end of calendar year. No exceptions. Responsible Person: Janice Roberts, Program Director, under the oversight of the Mercy Executive Director. Estimated Completion Date: July 1, 2023

Finding: 2023-002 Name of Contact Person: Angela Karchmer, Social Services Director Criteria: In accordance with 45 CFR 1356 and the Child Welfare Funding Manual, documentation must be maintained to support eligibility determinations under the requirements of IV-E and the Development Disabilities Assistance and Bill of Rights Act of 2000. Recommendation: Caseworkers should verify all documents are completed and retained in the applicant’s casefile. Corrective Action/Management’s Response: Management concurs with this finding and will adhere to the Corrective Action Plan in this audit report. The County has implemented the following process: • Supervisors will review 5120 forms for appropriate signatures and eligibility, after, forms will be sent through QA for a second level review. • Training on how to appropriately complete DSS form 5120 will be completed for every employee in CFS annually. • CFS QA will conduct annual audits of form 5120 to ensure compliance with required signatures. • Internal Audits will be reviewed with DSS management every six months to ensure appropriate internal controls are in place for the completion of DSS form 5120. Any Gaps in the system will be addressed immediately through an internal corrective action plan. Proposed Completion Date: Management and the Board will implement the above procedures immediately.