Corrective Action Plans

Condition: The University has not designated a Qualified Individual responsible for implementing and monitoring the University's information security program, nor does the University have a written information security program that addresses the six required minimum elements as required by the Gramm‐Leach Bliley Act (GLBA). Corrective Action: At the time that we replied to the question, our former Qualified Individual responsible for implementing and monitoring the Institution's information security program had left the organization a month previously. Upon reflecting on the significance of this position, I have elevated this role to a higher priority in the organization and named Darrin Burns, Director of ERP and IT, as Fielding’s Qualified Individual. In collaboration with Darrin and CIO Solutions, our MSP, we will draft the written information security program using the cybersecurity assessment results and recommendations as a starting point. In addition, we will ensure that the final document will include all six required minimum elements per Title IV regulations (16 CFR 314). Person Responsible For Corrective Action: Darrin Burns, Director of IT and ERP Anticipated Completion Date: December 31, 2024

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 ended August 31, 2024

Finding 2023-008 Inaccurate Information Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Finding 2023-004, 2023-005, 2023-006, 2023-007 also apply to State State Award Findings. Section IV - State Award Findings and Questioned Costs Darcey Wiggins, Supervisor FNS Supervisor will conduct a training to inform and train all staff on how to read a DSS 2435 (FNS recertification), DSS 8107's ( FNS application), and DSS 8194 ( Transmittal form) correctly. All staff will be trained on how to verify evidences documented on these forms to ensure all evidence is verified and documented, and the DSS 8650 is used to request all information correctly. IMC supervisor will review policies for income and expenses with all staff. IMC supervisor will ensure that all staff are following policy to document all telephonic signatures and guided interviews correctly. January 19, 2024 and ongoing.

Finding 2023-004 IV-D Cooperation with Child Support Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-005 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-006 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-007 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training will be held December 12, 2023. December 12, 2023 and ongoing. Linda Taylor, DSS Manager December 12, 2023 and ongoing. Electronic verifications discussed with all Medicaid Staff. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training will be held December 12, 2023. Linda Taylor, DSS Manager Section III - Federal Award Findings and Questioned Costs (continued) Linda Taylor, DSS Manager A training will be conducted at the end of the Continuous Coverage Unwinding per DHB-Admin. Letter 13-23. This policy is not required to be enforced at this time. We would like to reserve the rights to conduct this training at the is time to prevent confusing employees. Proposed training date to be held at the end of the Continous Coverage Undwinding period. Linda Taylor, DSS Manager Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training date December 12, 2023. December 12, 2023 and on going.

Finding 2023-004 IV-D Cooperation with Child Support Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-005 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-006 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-007 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training will be held December 12, 2023. December 12, 2023 and ongoing. Linda Taylor, DSS Manager December 12, 2023 and ongoing. Electronic verifications discussed with all Medicaid Staff. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training will be held December 12, 2023. Linda Taylor, DSS Manager Section III - Federal Award Findings and Questioned Costs (continued) Linda Taylor, DSS Manager A training will be conducted at the end of the Continuous Coverage Unwinding per DHB-Admin. Letter 13-23. This policy is not required to be enforced at this time. We would like to reserve the rights to conduct this training at the is time to prevent confusing employees. Proposed training date to be held at the end of the Continous Coverage Undwinding period. Linda Taylor, DSS Manager Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training date December 12, 2023. December 12, 2023 and on going.

Finding 2023-004 IV-D Cooperation with Child Support Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-005 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-006 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-007 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training will be held December 12, 2023. December 12, 2023 and ongoing. Linda Taylor, DSS Manager December 12, 2023 and ongoing. Electronic verifications discussed with all Medicaid Staff. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training will be held December 12, 2023. Linda Taylor, DSS Manager Section III - Federal Award Findings and Questioned Costs (continued) Linda Taylor, DSS Manager A training will be conducted at the end of the Continuous Coverage Unwinding per DHB-Admin. Letter 13-23. This policy is not required to be enforced at this time. We would like to reserve the rights to conduct this training at the is time to prevent confusing employees. Proposed training date to be held at the end of the Continous Coverage Undwinding period. Linda Taylor, DSS Manager Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training date December 12, 2023. December 12, 2023 and on going.

Finding 2023-004 IV-D Cooperation with Child Support Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-005 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-006 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2023-007 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training will be held December 12, 2023. December 12, 2023 and ongoing. Linda Taylor, DSS Manager December 12, 2023 and ongoing. Electronic verifications discussed with all Medicaid Staff. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training will be held December 12, 2023. Linda Taylor, DSS Manager Section III - Federal Award Findings and Questioned Costs (continued) Linda Taylor, DSS Manager A training will be conducted at the end of the Continuous Coverage Unwinding per DHB-Admin. Letter 13-23. This policy is not required to be enforced at this time. We would like to reserve the rights to conduct this training at the is time to prevent confusing employees. Proposed training date to be held at the end of the Continous Coverage Undwinding period. Linda Taylor, DSS Manager Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Training date December 12, 2023. December 12, 2023 and on going.

January 24, 2024 United States Department of Health and Human Services Community Health and Wellness Center of Greater Torrington, Inc. and Affiliate respectfully submits the following corrective action plan for the year ended September 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: September 30, 2023 The findings from the September 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 DEFICIENCIES Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), and Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 2023-001 Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Action Taken Education was provided to the staff who complete the applications, this included a quiz to measure the staff's knowledge of the process and mathematical calculations. Management developed a tool "How to Calculate Household Income for Processing Financial Assistance Applications" which includes step by step instructions for calculating household income. Prevention strategies have been implemented to prevent future occurrences of adverse events. Monthly audits of the calculation of annual income for a minimum of 10% of the total number of patients who have completed a financial assistance application are being performed. The manager of the population health department will report audit results quarterly at the continuous quality improvement (CQI) committee meeting. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Joanne Borduas, CEO at (860) 387-0425. Sincerely yours,

CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2023 HANAC, Inc. and Affiliates (HANAC) respectfully submits the following corrective action plan for the year ended June 30, 2023. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2023 The finding from the June 30, 2023 consolidated and combined schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None reported. FINDINGS – FEDERAL AWARD PROGRAMS AUDITS Material Weakness FINDING 2023-001 Eligibility U.S. Department of Housing and Urban Development 14.157 Supportive Housing for the Elderly Section 202 Loan Condition: In connection with the audit, it was noted that of the eight lease files tested four files did not have timely recertification of tenants and Enterprise Income Verification system documentation was performed later than the required recertification date. Additionally, one file did not contain the signed application or the background check. Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that tenant security deposits are correctly recorded, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: Management agrees with recommendation and has begun to implement the following: - A checklist form will be completed for every certification and signed off once file is approved. - An AR form will be created for the move in, transfer and move out process which is to be attached with proof of payment. Once completed it is to be sent to senior staff for review. Under this new management, we already have set in place policies and procedures under the governance of HUD and the tenant selection plan to ensure compliance and due diligence is taking place. Any new staff will be HUD trained. - The file setup format and recertification updates will be monitored on a monthly basis. - EIV are being run according to the frequency provisions related to the type of reports we are annually required to complete as per HUD. Annual inspections are being schedule as per Annual Recertifications are being processed. - Bi-weekly meetings will be in place to discuss the results collected with a tracking log on the progress of the project. - Trainings will be scheduled to keep on top of HUD updates/compliance procedures; Yardi software trainings; and in-house trainings covering compliance with the files and Yardi 50059 module. Expected completion date: January 2024 If any cognizant or oversight agency has questions regarding this plan, please call Lola Maroulis, Chief Financial Officer at 212-840-8005, extension 111. Sincerely yours, Lola Maroulis, Chief Financial Officer

SIGNIFICANT DEFICIANCY 2023-001 Condition: During our eligibility testing, one of 40 participant files reviewed showed that one ineligible participant received child care services for a period of time. Recommendation: We recommend the Organization enhance their training process with respect to documentation review to ensure an adequate review process is in place to prevent errors with respect to participant eligibilty. Views of responsible officals: CCCS has already alerted the DFD of the exception and requested a recoupment of funds. We will re-train our staff to ensure the existing procedures and documentation reviews are correctly followed. Name of the contact person for corrective action: Mary Jane DiPaolo, Executive Director Planned completion date for corrective action plan: September 30, 2024

Condition: The District did not select and verify the required sample of approved free and reduced price applications by the required deadline. Plan: The district will have a calendar reminder to begin auditing applications on Oct. 1 and complete the process with submission to ISBE by December 15. Anticipated Date of Completion: 12/31/2024 Name of Contact Person Yasmine Dada, Business Manager ________________________________________________

Finding 2023-001 Eligibility – Noncompliance and Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: Registration staff is requesting beneficiary identification at the time of registration for all patients that do not have it in their EHR. Project is ongoing. Monthly audits of the elements of registration, including documentation of beneficiary status will be conducted to ensure continual compliance. Additionally, Maniilaq will work with our local tribes to get enrollment information to assist in verifying beneficiary status. Individual(s) Responsible for Corrective Action Plan Kandy Barlow VP of Health Services 907-442-7385 Anticipated Completion Date: March 31,2024

Perquimans County Department of Social Services unit will continue to 2nd party cases monthly, randomly review workers calculations and procedures of the countable resources. IMS will implement a training with question and answer session to demonstrate the proper calculations to be used.

Perquimans County Department of Social Services unit will continue to 2nd party cases monthly, randomly review workers online data and continue to train on the important of pulling current and accurate information from the online data system. IMS will implement a Power point presentation to illustrate the importance of the information the County utilizes from the online and work number systems.

Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management’s Response: The Medicaid Program Manager reviewed the verification process and the requirement to upload all information into NCFAST with the Medicaid staff. The formal case file review process will continue to monitor this and other areas. Additional training will be offered if the case file reviews reveal deficiencies in this area. Proposed Completion Date: Immediately and ongoing.

Management’s Corrective Action Plan Soka University acknowledges the finding and the recommendation regarding improving procedures. Finding 2023-001 - Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance After addressing the identified deficiency in our enrollment reporting process, a thorough evaluation was conducted to rectify the issue and prevent its recurrence. We recognized that alterations in students' academic plans, prompted by the COVID-19 pandemic, led to delays in fulfilling mandatory graduation requirements such as study abroad requirements, resulting in delays in posting study abroad grades to the Soka transcript. Consequently, during end-of-term degree audits by the Office of the Registrar, students with pending study abroad grades or incomplete grades in their final term were inadvertently not updated to a withdrawn status, thereby failing to trigger updates to the National Student Clearinghouse and subsequently National Student Loan Data System (NSLDS). In collaboration with the Office of the Registrar, robust internal controls have been implemented to mitigate this issue going forward. Following the conclusion of each term, the Registrar will generate a comprehensive report listing all students who have applied for degree completion. This report will be annotated to identify students who have fulfilled all degree requirements, enabling their degrees to be conferred promptly. Additionally, students with incomplete grades will be flagged, and their status will be promptly changed to withdrawn. In both scenarios, enrollment status updates will be transmitted to the clearinghouse and subsequently NSLDS. The Registrar will inform the Office of Financial Aid of graduates and students with updated statuses for NSLDS reporting, and Financial Aid will request an ad hoc enrollment request on NSLDS. To ensure accuracy, a manual spot-checking process will be conducted in NSLDS on 20% of the updated student records in NSLDS. Upon notification of completed incomplete grades, the Registrar will promptly update transcripts, review degree requirements, and confer degrees where applicable. Following this update, the Registrar will manually update the clearinghouse and ask the Office of Financial Aid to request an Ad hoc enrollment report on NSLDS, ensuring timely and accurate reporting. This manual request will be verified on NSLDS after the ad hoc report has been run. Students failing to meet degree requirements due to failed coursework and are enrolled to return in subsequent terms will not be updated to withdrawn status unless they fail to return as scheduled. These measures aim to enhance the integrity and accuracy of our enrollment reporting process, ensuring compliance with regulatory requirements and minimizing the risk of future deficiencies. Anticipated Completion Date: February 2024 Scott Brandos Director of Financial Aid Soka University of America 949-480-4048

United States Department of Housing and Urban Development Gilbert Straub Plaza, Inc., respectfully submits the following corrective action plan for the year ended August 31, 2023. Name and address of independent public accounting firm: Maher Duessel, CPA's 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: September 1, 2022 - August 31, 2023 The finding from the August 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT See Below FINDINGS— FEDERAL AWARD PROGRAMS AUDITS Finding 2023-001 Department of Housing and Urban Development Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects - Section 223(f)/207 ALN 14.155. Recommendation: The Property should have internal controls in place to review Form HUD-50059 to ensure all documentation used to calculate the tenant rent and assistance payment is supported and properly calculated. Action taken: The property management company has revisited the internal controls with the on-site manager. The manager certifies that they will do diligence in the future to ensure that they follow these controls in calculating tenant rent and assistance payments. If the Department of Housing and Urban Development has questions regarding this plan, please call Dan Barbusio at 412-646-5193.

FINDING 2023-002 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Findings: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. The free and reduced-price applications were completed online by the applicants, and the information was automatically uploaded into the School Corporation's nutrition program software system. The software system then calculated the student's eligibility for free and reduced-price meals based on the parameters in the system. There was no documented oversight, review, or approval process to ensure the parameters in the system were correct and that the eligibility determination made complied with the requirements of the programs. The lack of internal controls was a systematic issue throughout the audit period. Contact Person Responsible for Corrective Action: Julie Dudley Contact Phone Number and Email Address: 812.537.7205 jdudley@lburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director and Business Manager have added the verification of every 30th Free/Reduce application that is submitted during the school year to their monthly checklists. Beginning with the 2024-25 school year, the Food Service Director will enter the eligibility parameters into the school nutrition software. Once entered the Food Service Director will provide a copy of the prices entered into the system to be reviewed and approved by the Business Manager or Superintendent. Anticipated Completion Date: January 2024/July 2024

2023-003 – 10.558 – Child and Adult Care Food Program – Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Eligibility Condition Four providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Comments on the Finding Given the Organization’s limited size, it is not always feasible to fully segregate the duties surrounding the meal claims processes. However, in order to mitigate errors, steps have been taken to implement checks within those processes. Action Taken Whenever possible, an employee other than the Director will prepare the claims. The Director of the Organization will later review the claims for accuracy and compare the claim numbers in both the Excel Spreadsheet and the Little Organizer Program to ensure their correctness.

Corrective Action Plan 2023-004: The College concurs with the finding and has reviewed and where appropriate made updates to the processes used to package loans when there is an annual or aggregate loan limit reached. Completion Date: August 2023 Contact Person: Haley Wesley, Vice President of Enrollment Management & Marketing

Re: 2023-01 Audit Finding/Plan of Action The Lexington Housing Authority (LHA) proposes this corrective plan of action to address the late recertifications (13) and annual recertification (1) from the audit conducted by Rector, Reeder & Lofton PC, onsite at LHA September 25-29, 2023. ADDRESSING STAFFING Securing qualified candidates to fill Housing Management Specialist (HMS) positions throughout 2020, 2021 and 2022 was challenging for LHA. In some instances, positions were vacant for up to 12 months before they were filled. LHA will do the following to address staffing: • Seek to fill HMS positions within forty-five (45) days of the position going vacant. • Advertise to hire two full-time HMS positions for the two management teams with the most units in their management portfolio. • Continue to advertise open positions online, on social media and in the local newspaper. • Offer incentive bonus up to $1,500 to newly hired HMS, paying $750 to new hires after six month of employment and an additional $750 after 12 months of employment. • Over-time will be allowed on an as-needed basis to complete and process certifications. CERTIFICATION PROCEDURES Further, LHA housing management staff will adhere to the following procedures to facilitate timely completion of annual certifications. - HMS staff will continue utilize in-person interviews and mail (via USPS and email) to complete needed documentation for annual certifications. - All housing management staff may utilize electronic signature to attain required signatures when necessary. - The first day of each month housing managers will run the certification audit report to be shared with the Chief Operating Officer to monitor the status of in-progress and upcoming certifications. - July 1, 2023, LHA implemented quality control (QC) of public housing files to be conducted by a newly created compliance position. LHA' s compliance coordinator will complete 229 (25%) QC reviews of public housing files during FY2024 (July 1, 2023 - June 30, 2024). - At least once monthly on a rotating basis housing management staff from all offices will convene at a selected housing management office to complete and process certifications. This schedule will continue until all offices are up to date on certifications. LHA staff will apply these procedures as outlined to mitigate this finding to ensure compliance and proper documentation of future certifications. Contact Person: Andrea Wilson, Chief Operating Officer Anticipated Completion Date: June 30, 2024

FINDING 2023-002 Finding Subject: Child Nutrition Cluster - Verification of Free and Reduced Price Lunch Applications Summary of Finding: Management had not developed or implemented a system of internal control that would have ensured compliance with requirements related to the grant agreement and Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) compliance requirements. The failure to establish an effective internal control system placed the School Corporation at risk of noncompliance with the grant agreement and Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) compliance requirements. A lack of segregation of duties within an internal control system could also allow noncompliance with compliance requirements and allow the misuse and mismanagement of federal funds and assets by not having proper oversight, reviews, and approvals over the activities of the program. We recommended that the School Corporation's management establish a system of internal controls, including segregation of duties, related to the grant agreement and Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) compliance requirements. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director or Assistant will review the applications, the other will do a second review. The Food Service Director and Assistant sign each application that is verified to ensure all information is accurate and the eligibility status is correct in Skyward. If additional verification information is provided, it will be documented and recorded in the binder with the applications. Anticipated Completion Date: August 2024

FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation's management had not developed a system of internal controls that would have ensured compliance with the Eligibility compliance requirements. The failure to establish an effective internal control system places the School Corporation at risk of noncompliance with the grant agreement and the Eligibility compliance requirements. A lack of segregation of duties within an internal control system could also allow noncompliance with compliance requirements and allow the misuse and mismanagement of federal funds and assets by not having proper oversight, reviews, and approvals over the activities of the program. We recommended that the School Corporation's management establish a system of internal controls, including segregation of duties, related to the grant agreement and the Eligibility compliance requirements listed above. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director or Assistant will enter online and paper applications, the other will review the entries compared to the applications, and both will sign off the applications. An additional selection will be added in Skyward to document which type of classification. A legend for the codes will be kept in the front of the binder where the applications are kept for reference. Anticipated Completion Date: August 2024

Finding 2023-001 Special Tests and Provisions - Sliding Fee Scale Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated, and patients receive the correct sliding fee discount. Action Taken: We implemented a new EHR system AthenaOne and it includes a sliding fee scale calculation tool. By March 18, 2024 we will have completed doing all of the testing and training of all current Patient Services/Front Desk staff. Effective April 1 2024, we will implement the following changes to ensure clients are appropriately charged according to the sliding fee scale: • Update recurring sliding fee scale employee training sessions to quarterly. • Update training process documentation and reference materials for sliding fee scale. • Implement monthly review and spot check procedures to ensure compliance with the sliding fee scale requirements and guidelines. Based on the results of the reviews and spot checks, individualized training will be provided staff. • Onboarding new Patient Services/Front Desk staff will be based on the updated training and reference materials. Should you need additional information or have questions, you can reach me at ekintu@kphc.org or (808) 791-6315. Emmuel Kintu, D. Mgt, MBA Chief Executive Office & Executive Director

The Section 8 Program will improve its internal controls and monitoring procedures to assure the correction of income included in the 50058-Family Report. Implementation Date: During the fiscal year 2023-2024 Responsible Persons: Mr. Job Bonilla Federal Program Director