Corrective Action Plans

2023-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions Proposed Completion Date: December 31, 2023

Finding 2023-004 - Tenant File Review Auditee's Response and Planned Corrective Action The Authority will establish a checklist covering all compliance requirements for tenants for the Tenant Housing Representatives to use during the recertification process which will be signed by the Tenant Housing Representative and maintained in the tenant's file. Planned Implementation Date of Corrective Action: December 31, 2023 Person Responsible for Corrective Action: Mike Cruz, Executive Director Long Beach Housing Authority

2023-002 Condition: Questionable Use of Federal Funds Steps to Resolve: We concur with this finding and the Auditor's recommendation. We will establish internal financial control procedures over the budget process to ensure that each program operates within its means and in accordance with HUD regulations. We have already taken steps to reduce expenses in the COCC and will generate revenue from grants and other business activity to offset the COCC expenses. Management will take corrective action to close this finding in connection with the FY 2024 audit report. Timeframe: By the fiscal year end for March 31, 2024 Individual responsible for correction: Mr. Ahmad Taylor, Executive Director

Management Views and Corrective Action Plans 2023-001 – Inaccurate Submission of Student Enrollment Change Submissions to the National Student Loan Data System (NSLDS) Point of Contact – Jennifer Spiegel Goldberg, University Registrar, (646-592-6275) Management agrees with the current year finding and the recommendations. The Office of the Registrar has recently been reorganized to create a dedicated, Records unit to assure that limited personnel will be responsible for leaves and withdrawals and who will use internal reports available to quality control data input before external reporting. All staff have been retrained to watch for the condition that led to this error when handling requests, including reminder of University policies and procedures. This retraining took place on September 6, 2023. The NSC Roster and NSLDS will be updated by December 29, 2023. We believe this finding will be remediated in fiscal 2024.

CKHA will implement an internal quality control function which will review the income calculations for one hundred (100) percent of all move-ins and ten (10) percent of monthly recertifications by site to determine that incomes are correctly included int he Family Reports in accordance with the ACOP and 24 CFR 960.259. Moving forward, Tammy Edelman, Director of Housing Management, will be responsible for assuring this function is completed in an accurate and timely manner. Anticipated Completion Date: This new function with be implemented January 1, 2024, and this will be an on-going function.

Finding 2023-004: Quarterly Reporting of Emergency Financial Aid Grants to Students and Annual Reporting for COVID-19 Education Stabilization Fund Contact person responsible for correction action – Mitzi Suhler, Vice President of Enrollment Services Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding of not meeting the posting deadline for the quarterly reports for March 31, 2023, and June 30, 2023. The reports were posted within the required month but did not meet the ten-day limit for posting. Sterling College recognizes the importance of meeting reporting requirements for all federal programs and if any additional programs were to arise that are similar in nature, we will review the compliance requirements, and prior findings, to ensure proper processes are in place to ensure compliance in reporting are met.

Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding of the under award and over award of federal aid for two students. During the 2022-2023 year we hired new financial aid staff that required significant training in the regulations of financial aid. Although checks and balances were in place these two instances were overlooked. Continued training, along with improved checks and balances through our updated software system, will enable the financial aid office to avoid issues with under and over-awarding federal student aid. The office will perform periodic reviews of awarding through reports from the system that will flag students who have potentially been under or over awarded federal aid.

Finding 2023-001 – Housing Choice Voucher Tenant Files – Eligibility – Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster – ALNs 14.871 and 14.879 Corrective Action Plan: Finding: Somerville Housing Authority (SHA) received the authority’s Single Audit for the year ended March 31, 2023, indicating that SHA received a finding of Significant Deficiencies identified not considered to be material weaknesses. Auditors noted three files missing documentation of the action, as well as four missing income verification or outdated income verification. Auditors recommend that SHA conduct a file audit to determine the extent of deficiencies. They also recommend that SHA implement a quality control review to monitor the maintenance of tenant files. PHA Response: The SHA has implemented a corrective action plan to address noted deficiencies. The SHA has had significant staffing turnover in the last year. As a result, until all vacant positions are filled, the SHA has contracted with Nan McKay Associates (NMA) to complete all Annual Recertifications. NMA has assigned four full-time staff to complete all recertifications and has assigned one additional full-time staff person to conduct a monthly Qualify Control Review of all recertifications completed by NMA. During NMA’s contract, SHA has focused on refilling positions and training new staff. SHA has hired a new Director of Leased Housing, a new Leased Housing Supervisor, and one Leasing Coordinator. Two additional Leasing Coordinator positions are still vacant, and interviews are ongoing. SHA plans to hire two more staffers for that role. The Director and Supervisor have been providing one-on-one training and support to all new staff in addition to enrollment in training opportunities provided by outside vendors. At weekly staff meetings, the Director reviews Administrative Plan policies, and corrections needed for any quality control issues found before they become systemic. Besides the Nan McKay monthly quality control review, the SHA has begun conducting internal quality control audits every month for SEMAP. Additionally, SHA has implemented an electronic file storage system, utilizing PHA Web’s online system to better organize, track, and maintain client files. PHA Goal: Based on the SHA’s monthly quality control sample of tenant files: (A) The SHA obtains third party verification of reported family annual income, the value of assets totaling more than $5,000, expenses related to deductions from annual income, and other factors that affect the determination of adjusted income, and uses the verified information in determining adjusted income, and/or documents tenant files to show why third party verification was not available; (B) The SHA properly attributes and calculates allowances for any medical, child care, and/or disability assistance expenses; and (C) The SHA uses the appropriate utility allowances to determine gross rent for the unit leased, (D) The SHA applies the appropriate payment standard in accordance with 24 CFR 982.505. PHA Strategies: Target completion date 1) The SHA will review its current quality control tracking system to record the results of random sampling of files as required in 985.2. The SHA will revise this system on an ongoing basis if necessary. 12/31/2023 2) Confirm that 90% or more files sampled contain proper third party written verification (or equivalent) of income and assets, proper calculation of appropriate deductions and allowances and that appropriate utility allowance were used in the calculation of tenant rent. 80% 12/31/2023 Person Responsible: Matt Lincoln, Director of Leased Housing David Hospedales, Leased Housing Supervisor Anticipated Completion Date: The SHA anticipates completing all hiring and training of new Leased Housing staff no later than 04/01/2024.

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: e. New onsite HUD compliance training was started in October 2023 and to be completed by 12/31/2023. Monthly review of TRACS reports was implemented 10/1/2023.

Corrective Action Plan Finding 2023-002 – Documentation of Controls Auditee’s Response and Planned Corrective Action The Authority will use a checklist for each recertification to ensure all compliance requirements are met and maintain a copy in the tenant’s file. Planned Implementation Date of Corrective Action: December 2023 Person Responsible for Corrective Action: Betty Mermelstein, Executive Director Village of New Square Housing Authority

Corrective Action Plan Village of Hempstead Housing Authority 2023 Audit Finding 2023-001 – Documentation of Controls Auditee’s Response and Planned Corrective Action AUDITEE’S RESPONSE HHA will establish and utilize a check list to be used by the Tenant Housing Representative to use during the recertification process. The checklist will be initialed and signed by the housing representative and maintained in each tenant’s file. Having this control in place will help ensure that HHA is compliant with reporting. Planned Implementation Date of Corrective Action: December 20, 2023 Person Responsible for Corrective Action: Shereen Goodson, Executive Director Village of Hempstead Housing Authority Shereen Goodson, Executive Director

Recommendation: The District should put into place internal controls to ensure all steps of verification are completed by program management, including secondary review of the free and reduced rosters after the verification process has been completed. Action to be taken: The District concurs with the finding and will implement a review process to ensure students selected for the verification process are changed to the proper status. Additionally, the District will retain the proper documentation to support the verification process.

Recommendation: The District should put into place internal controls that ensure there is a process to verify the free and reduced students submit applications or be switched to full pay status in their software. Action to be taken: The District concurs with the finding and will put procedures in place to verify that free and reduced students all have applications on file and properly qualify for that status.

U.S. Department of Housing and Urban Development Pond Street Housing Development Fund Company, Inc. (Bishop Harrison Apartments), HUD Project No. 014-11248 respectfully submits the following corrective action plan for the year ended March 31, 2023. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 North Franklin Street #60 Syracuse, New York 13204 Audit period: April 1, 2022 – March 31, 2023 The findings from the 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDIT Finding 2023-001: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 Recommendation: Our auditors recommended that we review resident files to ensure income was properly calculated and documented and obtain signatures on the revised HUD-50059. Procedures for verifying income documents and building tenant files should be reviewed. Action Taken: Bishop Harrison Apartments replaced the apartment manager subsequent to year-end and has reviewed all files to ensure appropriate documentation and calculations. Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO, (315) 424-1821. Completion Date: July 2023

Views of responsible officials and planned corrective actions: The Authority is working with Yardi, the software company that supports the Authority’s client management software, to provide standardized reports that can be used by managers to flag exceptions to requirements such as regular inspections, and re-inspections within 30 days for units that fail due to non-life-threatening conditions. There are current limitations within the software that do not allow for a fully automated work flow, which then necessitates a highly manual process and more likelihood of human error. The Authority will also implement more internal controls at the management level; specifically with units that fail inspection. All failed inspections will be independently tracked to ensure that a re-inspection takes place within 30 days, and management will review reports of all failed inspections, at least weekly. Finally, the Inspections Supervisor will receive more training on the Authority’s abatement policies, so that units that fail and are not corrected within the corrective period are abated according to the Authority’s HCV Administrative Plan.

Corrective Action Plan for FYE June 30, 2023 Finding 2023-001 Corrective Action Plan: Due to a series of circumstances such as high turnover at CNY Works in the youth department, including the departure of the Director of Youth Services at the end of the summer of 2022 and later the successor in the middle of the Summer Youth Employment Program of 2023, youth department operating with one full-time employee and having a vacuum on direct leadership in the department where factors in which unfortunately led to this finding. CNY Work youth staff along with the Executive Director, Deputy Director and Director of Youth Services will review current policies and procedures to ensure these are operating effectively reflecting allowable activities and allowable costs (including hours worked by youth in the program) are allocated and charged accurately to the federal program. Underlining the importance of internal controls to ensure documents are signed by designated individuals to comply with requirements. The Director of Youth Services and Deputy Director will review timesheets, eligibility forms, and signatures, along with other requirements of the program to ensure internal control procedures are adequate and operating as intended. Finally, management will develop a method for monitoring the operational effectiveness of the applied internal controls on compliance and document any mitigating controls that are developed and implemented. Contact Person Responsible for Corrective Action Plan: Rosemary Avila-Ticio Executive Director, CNY Works Phone Number: 315-477-6901 Email: ravila@cnyworks.com Anticipated Completion Date of Corrective Action Plan: March 30, 2024

In conjunction with the Office of Research and Sponsored Projects (ORSP), Office of Sponsored Programs (OSP) will require program staff to review and verify eligibility on all student applications prior to their admission to the program before placement on official rosters to receive services.

The University filed four quarterly HEERF reports for the year that accurately reflected the spending and accounting of federal funds. The report in question is the annual report, which, by its design (it cannot be saved prior to submission, and the only way to print it is to print a screen shot of each of the 48 pages) makes review before submission extremely difficult. There were literally hundreds of entries in this report, and there were three errors, each of which reflected information that was reported accurately in the quarterly reports posted on the University’s website. Despite the unfortunate design constraints, the University will endeavor to identify a practical way to conduct a review of the annual report before submission next spring. Anticipated Completion Date: Continuing Responsible Contact Person: Eugene L. Munin

A. The specific findings and plans of action are as follows: Huntington Junior College is committed to addressing the findings of our administration of Title IV programs. We concur with the findings and recommendations of the audit team. B. Actions Taken or Planned. Finding 2023-002 Failure to Meet the Standards for Safeguarding Customer Information. The security of all customer information is very important to Huntington Junior College. We have engaged a new IT firm to establish and maintain proper GLBA requirements. All faculty and staff will be retrained on information security policies and procedures.

Finding 2023-004 Eligibility Administration for Children and Families FFAL 93.566 Refugee and Entrant Assistance – State Administered Programs Finding Summary: a. Four participant case files were not reviewed through the Organization’s peer review process and two participant case files were not reviewed in a timely manner through the Organization’s peer review process. b. Four instances in which the family’s first month’s prorated cash assistance payment was not properly calculated based upon the date the Cooperative Agreement and Rights and Responsibilities Form was signed by the client. c. One instance in which a family was underpaid based upon their family size and eligibility for the month. d. One instance in which a family was moved from the Refugee Cash Assistance program to another program and the expenses remained to be charged under the Refugee Cash Assistance program. Responsible Individuals: Nathan Beyer, Sheri Ekdom, Tim Jurgens Corrective Action Plan: a. The procedures for case file review will be reviewed to ensure the process can be followed, even when there is turnover in staff. b. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate the arrival date for proration of the first month of payments. c. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate family size and eligibility. d. The procedures will be reviewed with staff for removing a client from the program, and notifying staff to void checks. The checks in question were voided and credited back to the grant for $481.48 and $878.00 in September 2023 which is within the grant’s budget period. LSS is also implementing a new software program to help the review process be more efficient, and less reliant on manual processes. Checks and balances will be integrated into the software, allowing for electronic review of files. The software will also help automate some of the ongoing documentation requirements. Anticipated Completion Date: December 31, 2023

Method of Implementation - The School District shall obtain and provide necessary training to personnel regarding A.S.S.A. reporting guidelines and low income eligibility guidelines; the School District shall ensure student lunch statuses are documented appropriately throughout the District's online databases {PowerSchool, PaySchools, IEP Direct, etc.). Responsible for Implementation - Food Service Director, School Accountant & School Business Administrator. Implementation Date - Immediate

Planned Corrective Action Plan: Upon initial notification of the verification findings, the District Food Services department immediately began corrective action to ensure the success of the SY 23-24 Verification. Specifically, three Food Services Office staff members were actively involved in the Verification training offered by the governing State agency, as well as, the software provider. All questions throughout the verification process were immediately asked of the State agency and/or software provider as appropriate. All supporting documents were reviewed by two staff members at the time of submission. Once verification was completed on November 15, 2023, a report was pulled to show change in status. The change in status for families that did and did not respond was reviewed by two staff members to ensure accuracy. Anticipated Completion: 11/16/2023 Responsible Contact Person: Jaleena Davis, Director - School Food Services

Finding 2023-001 – U.S. Department of Education (USDE), Title IV Student Financial Aid Programs We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: 1. Two (2) out of 16 students tested did not have timely or accurate enrollment reporting to the National Student Loan Data System (NSLDS). 2. One (1) out of 16 students tested did not have a post withdrawal disbursement within the allotted days of the school’s withdrawal date determination. 3. One (1) out of 16 students tested did not have Title IV funds returned within the allotted days of the school’s withdrawal date determination. 4. One (1) out of 16 students received Title IV funding and was not charged for courses taken. The questioned cost is $124. The funds were subsequently returned to the USDE. 5. One (1) out of 16 students received a Pell grant greater than the amount for which the student was eligible. The questioned cost is $862. The funds were subsequently returned to the USDE. 6. Five (5) out of 16 students were selected for refund canceled check testing. There was no documentation provided to test signatures for two (2) of the students selected. All requested documents were subsequently provided. 7. One (1) out of 16 students tested was eligible for a Federal Direct Subsidized loan and was not awarded. 8. One (1) out of 16 students tested had an award letter that stated subsequent Title IV disbursements were available to the student and the subsequent disbursements were not awarded." The University should implement corrective actions to ensure that the above findings are resolved and do not recur in future periods. Corrective Actions – 1. NSLDS reporting is actively reconciled monthly with our third-party financial aid servicer and, as of November 16, 2023, the University confirmed 97.34% reported. The University will continue to actively monitor this reporting to ensure accuracy and timeliness. 2. Student Information System integration with third-party financial aid servicer’s system will allow the University to improve timing of drop notifications to ensure the third-party financial aid servicer is notified timely. The University will continue to monitor and review the process of withdrawal disbursement more thoroughly with the third-party financial aid processor to ensure that they are processed timely. 3. The University will monitor and review the process of returning Title IV funds to ensure that returns are processed timely. 4. The University has implemented a process that cross-checks enrollment with financial aid funding to identify and address situations in which students are inappropriately awarded Title IV funding. 5. The University is working with its third-party financial aid servicer to ensure Pell grants are awarded appropriately and within the amounts eligible. The University will ensure timely enrollment changes are sent to third-party financial aid servicer for any adjustments to aid eligibility. 6. The University has robust controls related to student refunds, and will continue to enforce these controls and retain the necessary documentation. 7. The University is working with its third-party financial aid servicer to ensure Federal Direct Subsidized Loans are awarded in all cases where appropriate. This is a unique situation where the FA software failed to recognize NSLDS information. The third-party financial aid servicer will monitor students closer until the system issue is resolved. 8. The Universiy is working with its third-party financial aid servicer to ensure Title IV disbursements, as outlined in award letters, are ultimately awarded.

Finding 2023-001: Special Education Cluster Suspension and Debarment Procedures Recommendation: The School District should follow its suspension and debarment procedures for verifying the eligibility of its contractors and vendors prior to entering into business contracts or transactions that equal or exceed $25,000 in value. In addition, the School District should retain supporting documentation of these verifications performed, such as the printing of vendor search results from the SAM.gov website. Action Taken: At the start of each fiscal year, the School District will generate a list of vendors that were paid amounts in excess of $25,000 in the previous fiscal year. Vendor searches will be completed and documented on all these vendors using the SAM.gov website. All purchase requisitions made exceeding $10,000 will reference the MAISD Debarment list to ensure the suspension and debarment procedures were completed. Vendor searches will be performed and added to the MAISD Debarment list if vendor is not already on list. Requisitions will be denied if vendor is ineligible for participation in federal assistance programs or activities. Responsible Person and Anticipated Completion Date: Director of Financial Services, October 2023. If the Michigan Department of Education has questions regarding this plan, please call Jesse Rickard at (231) 767-7209.

SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2023-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should verify initial tenant income through the EIV system in a timely manner and perform annual unit inspections and maintain all required documentation in the tenant files. Action Taken: Managers have been trained that EIV Income Reports must be pulled timely, reviewed, and action taken, if needed. They have also been instructed to maintain a checklist to ensure unit inspections are done annually. Alerts have been turned on in One Site to remind managers to pull EIV 90-day reports. If the Oversight Agency for Audit has questions regarding these plans, please call Christine Harris at 954- 835-9200. Sincerely yours, Christine Harris Accounting Manager