Corrective Action Plans

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to a lack of verification of whether the patient had active eligibility or not. Steps have already been taken to begin addressing the issue. Additional training and communication will be provided to the Financial Services team to reinforce understanding of eligibility and documentation requirements. Also, the Data Analyst in the Financial Services team will generate a bi-weekly report in Pioneer to identify all medications being billed to Ryan White and current status of eligibility. Implementation of this planned corrective action is the responsibility of Financial Services-IAT reporting.

Recommendation: Management should continue to minitor month-end and year-end closing procedures to ensure controls in place are sufficient to ensure the financial statements are prepared in accordance with GAAP. Management Views: Management agrees with the finding noted during the 2024 fiscal year audit. Action Planned: The error has been corrected in the current audit for the years ended June 30, 2024 and 2023 and will be fixed in the Organization's general ledger going forward. Anticipated Completion Date: Complete Responsible Party: Catina Downey, CPA with oversight of Heidi Hooker, Executive Director

Management acknowledges that the City’s audit package and Data Collection Form were not submitted timely to the Federal Audit Clearinghouse within the required timeframe in accordance with Uniform Guidance (2 CFR 200.512). We understand the importance of timely submission in maintaining compliance with federal grant requirements and ensuring continued eligibility for federal funding. The delay was due to new ERP system conversion and staffing shortages. We will re-evaluate our current processes and ensure that all deadlines associated with the Single Audit process are clearly documented and monitored. We will conduct internal reviews after each year-end closing to ensure audit-related deadlines are met and updates will be provided to senior leadership as needed. We will strengthen internal controls and improve communication with our auditors to avoid future delays in submission to the Federal Audit Clearinghouse. Anticipated Completion Date: 7/31/2025 Person Responsible: Diana Gomez, Finance Director

2024-002 - Internal Control over Eligibility Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan Staff has undergone extensive training on eligibility determination since mid-June. All forms and applications have been updated with specific language related to needed documentation, and a portable scanner has been purchased so documents can be scanned wherever clients are engaged. After application review, there will be additional communication regarding appointment confirmation as well as a reminder of documentation required when clients arrive. Person(s) Responsible: Monica Pettengill, Development Director Timing for Implementation: July 1, 2025 LeeAnn Horowitz, Chief Financial Officer" Corrective Action Plan for Current Year Findings 2024-001- Internal Control over Payroll Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan DONNA M. KELLEY, LCSW President & CEO Waldo CAP was finally able to hire an additional Human Resources staff member in May of 2025, who will complement our current payroll review process by adding a second layer to ensure not only the accuracy of the Wage Change of Status form (among other enhanced review duties) but to also ensure the completeness of the form including required signatures. Person(s) Responsible: Katie Bagley, Human Resources Director Timing for Implementation: August 1, 2025 2024-002 - Internal Control over Eligibility Major Program: AL#93.569 - Community Service Block Grant Corrective Action Plan Staff has undergone extensive training on eligibility determination since mid-June. All forms and applications have been updated with specific language related to needed documentation, and a portable scanner has been purchased so documents can be scanned wherever clients are engaged. After application review, there will be additional communication regarding appointment confirmation as well as a reminder of documentation required when clients arrive. Person(s) Responsible: Monica Pettengill, Development Director Timing for Implementation: July 1, 2025 LeeAnn Horowitz, Chief Financial Officer P.O. Box 130, 9 Field Street, Belfast, ME 04915 I Phone: (207) 338-6809 I Fax: (207) 338-6812 I www.waldocap.org

U. S. Department of Housing and Urban Development. Heritage Grove, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024. The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs - Federal Award Programs Audit: Department of Housing and Urban Development: Supportive Housing for Persons with Disabilities Program (Section 811), Assistance Listing # 14.181: 2024 - 004 Recommendation: Management agent and sponsor will continue to recertify and update the tenant files to make sure it includes current required documentation. If the Department of Housing and Urban Development has questions regarding this plan, please call Mary Garrison, Heritage Grove, Inc. at (217) 362-6262.

Finding: Allowable Activities & Allowable Costs and Eligibility (Reference Number: 2024-001) Criteria or Specific Requirement: Funds may be expended for foster care maintenance payments on behalf of eligible children, in accordance with the Title IV-E agency’s foster care maintenance payment rate schedule and in accordance with 45 CFR section 1356.21, to individuals serving as foster family homes, to childcare institutions, or public/private child-placement or child-care agencies. In accordance with Code of Colorado Regulations (CCR) section 7.302.2, for each child, Jefferson County Human Services (JCHS) must have an agreement with the provider which details the daily maintenance payments. JCHS agreement to purchase services must be signed by the provider and JCHS. Additionally, in accordance with CCR section 7.301.3, the Family Services Plan shall be reviewed in conference with the caseworker and supervisor every 90 calendar days. Condition: • Two instances out of 40 where there was no signed agreement in place to support revised maintenance payments following a child’s 9th birthday. The correct maintenance amount was paid to the provider in accordance with the State of Colorado rates published in IM-CW–2024-0028 and IM-CW-2023-0021. • One instance out of 40 where the required 90-day review was not completed on time. The review was conducted 15 days late. Cause: The state's Foster Care system did not automatically generate a notice that a new agreement to purchase services was needed based on the child's birthday. Additionally, JCHS lacks an effective control mechanism to proactively identify when a 90-day review is approaching or overdue. Corrective Action Plan: We agree with the finding. The Integrated Case Management System (ICM) is designed to generate an email notification to Collaborative Foster Care Program (CFCP) staff when a child turns 9 or 14 years of age while in foster care. This email notification instructs CFCP staff to generate a new Child Specific Addendum (SS23-B) due to the increase of the child maintenance rate. This email instructs and standard procedure requires CFCP staff to verify the child maintenance rate in Trails after an SS23-B is generated. The IT Systems Support Team responsible for the maintenance of ICM determined that ICM has failed to notify CFCP staff when a child turned 9 or 14 years of age while in foster care: • The IT Systems Support Team responsible for the maintenance of ICM has been asked to ensure that ICM is generating an email notification when a child turns 9 or 14 years of age while in foster care. • While this issue is being addressed in ICM, the CFCP requested a report that included the birthdays for all children in foster care. CFCP staff have generated new Child Specific Addendums (SS23-B) for children that have turned 9 or 14 years old while in foster care. CFCP staff will utilize this report to generate new Child Specific Addendums for future birthdays. • After a new Child Specific Addendum is generated, staff will verify the child maintenance rate in Trails. • The CFCP has determined that it can no longer rely on ICM and has decided to migrate its functionality over to the ancillary system supported by Jefferson County known as the Caseworker Application Timesaver (CAT). With this migration, the email notifications will resume so that CFCP staff are properly notified of the need to generate the new SS23-B and verify the child maintenance rate. • Migration is scheduled to occur on Friday, June 20, 2025. • On Monday, June 23, 2025, the CFCP will meet with the Jefferson County Application Program Analyst to ensure the migration was successful. • Additionally, the CFCP and the Jefferson County Application Program Analyst have scheduled a second meeting for July 9, 2025, to ensure the successful migration from ICM to CAT. • To ensure 90-Day Reviews are completed timely, the Division of Children, Youth, Families, and Adult Protection (CYFAP) will continue to utilize the 90-Day Review compliance feature of CAT. Additionally, CYFAP leadership will emphasize this requirement with supervisors and casework staff and ensure their compliance. Person(s) Responsible for Implementation: Barb Weinstein, Director, Division of Children, Youth, Families and Adult Protection Implementation Date: July 1, 2025

2024-005 – Over Award of Federal Pell Grant Program Funds (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Criteria: In accordance with 34 CFR 668.32, a student is eligible to receive Title IV, HEA program assistance if the student meets all of the requirements in 34 CFR 668.32 paragraphs (a) through (m). 34 CFR 668.32(a)(1)(i) requires the student to be a regular student enrolled, or accepted for enrollment, in an eligible program at an eligible institution. Condition: Of 26 students tested for eligibility, one student received Title IV, HEA program assistance for a semester that the student was not enrolled in. Cause: Controls are not functioning properly. Effect: Title IV program funds were awarded to a student who was not eligible to receive such funds. Recommendation: We recommend the University review and update its procedures to ensure that Title IV funds are awarded properly. Management Response: The University acknowledges the over-award of Title IV funds due to disbursement for a student who was not enrolled during the term in question. In response, the University has strengthened its internal controls to ensure that federal aid is awarded and disbursed only to students who meet all eligibility criteria as outlined in 34 CFR 668.32. Corrective actions taken include: 1) System Validation Enhancements: The student information system has been updated to include enhanced enrollment validation checks before the release of Title IV funds. Title IV disbursements are now restricted to students with confirmed active enrollment in eligible programs for the applicable term. This is enforced through automated disbursement blocks that are triggered when enrollment data is missing or inconsistent. 2) Pre-Disbursement Review Process: A pre-disbursement verification step has been implemented, requiring financial aid staff to confirm active enrollment statuses before releasing funds. 3) Staff Training: Targeted training has been provided to financial aid staff on Title IV enrollment eligibility requirements. Responsible Party and contact information: Triniti Lee – Financial Aid Processor, Leetk2@webber.edu. Expected Date of Correction: 8/1/2025

2024-004 –Satisfactory Academic Progress Policy (Significant Deficiency) Department of Education, SFA Cluster, Eligibility Criteria: In accordance with 34 CFR 668.34(a), an institution must establish a reasonable satisfactory academic progress policy for determining whether an otherwise eligible student is making satisfactory academic progress in his or her educational program and may receive assistance under Title IV, HEA programs. A student placed on academic probation may receive Title IV, HEA program funds for one payment period. At the end of one payment period on financial aid probation, the student must meet the institution's satisfactory academic progress standards or meet the requirements of the academic plan developed by the institution and the student to qualify for further Title IV, HEA program funds. Condition: Our review of 26 student files disclosed that one student was placed on academic probation after fall 2023 semester and received Pell for spring 2024 semester. The student did not meet satisfactory academic progress standards at the end of spring 2024 semester, however, the student received Pell for summer semester 2024. Cause: Controls are not functioning properly. Effect: Title IV program funds were awarded to a student who was not eligible to receive such funds. Recommendation: We recommend the University review and update its policies to ensure that the University’s Satisfactory Academic Progress policy is enforced. Management Response: The University acknowledges the oversight in the enforcement of its Satisfactory Academic Progress (SAP) policy and has taken corrective action to address the deficiency. Specifically, the Financial Aid Office has conducted a comprehensive review of SAP monitoring procedures to ensure full compliance with federal regulations under 34 CFR 668.34. Corrective steps taken include: 1) Policy Clarification and Staff Training: The SAP policy has been reviewed and clarified to emphasize the requirement that a student failing to meet SAP after one payment period on financial aid probation is no longer eligible for Title IV funds unless they meet the conditions of an approved academic plan. Targeted training was delivered to financial aid counselors and compliance staff to reinforce correct application of SAP policies and documentation protocols. 2) Automated SAP Compliance Flag: An automated flag has been integrated into the student information system to alert staff when a student has reached the end of a probation period. This flag prevents Title IV disbursement until a manual review confirms eligibility based on SAP or academic plan compliance. 3)Ongoing Monitoring and Quality Assurance: At the conclusion of each academic term, the University runs comprehensive SAP reports to identify all students who have either regained eligibility, remained on SAP, or have newly been placed on SAP status. The student information system is configured to automatically flag these students and restrict Title IV disbursements through system-based controls in the auto-packaging process, thereby preventing ineligible aid disbursements and ensuring compliance with federal regulations. Responsible Party and contact information: Pamela Denton - Financial Aid Counselor, dentonpe@webber.edu, Trinity Lee – Financial Aid Processor, Leetk2@webber.edu. Expected Date of Correction: 8/1/2025

Corrective Action Plan Year Ended December 31, 2024 Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2024-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the State of New Jersey, Department of Law and Public Safety Program Titles and Assistance Listing Numbers (ALN): Disaster Grants – Public Assistance (Presidentially Declared Disasters) – ALN 97.036 Federal Grant Numbers: State of New Jersey pass-through number: UH1WX, Project #2365 – Award Year 2024 (Application 696220) Contact Person: Donna Wilser, Deputy Executive Director, 732-750-5300 Corrective Action: Management agrees with the finding. Beginning in December 2024, as a commitment to strengthen our processes and ensure that all physical timesheets related to FEMA-declared disaster events are properly maintained and readily accessible, management put a process in place to enhance procedures and controls for timesheets going forward to ensure full compliance with the Uniform Guidance requirements. This process was successfully implemented as of this date and for prospective periods. However, this process does not remedy the issue noted in the finding which relates to time worked from 2020-2022, which is before the process was in place. Therefore, the finding is repeated from the prior year. Anticipated Completion Date: Completed

Finding: 2024-3 Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2025

N9) Satisfactory Academic Progress The College will seek to work through the SAP committee to ensure that all the standards are met for satisfactory academic progress including stating when evaluating will be done and notifying students of disbursements through the Committee by then end of 2025. This will be over seen by the Vice president for administrative services Sean Welsh and the Director of Financial Aid Keri Whitehead

Description:Significant deficiency in FFATA reporting threshold. Planned Corrective Action: CGS will familiarize itself with all FFATA reporting requirements to ensure that the $30,000.00 threshold for first-tier subawards will be reported to FSRS with all reporting deadlines observed by building this requirement into the grants management calendaring system. Completion Date: October 1, 2025 Responsible Person: Keith Peregonov, VP for Finance, Human Resources and Operations

Implemented beneficiary eligibility review process has been reenforced to reduce the chance of the same happenings.

Contact Person Amy Baldwin, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2025

Program: Medical Assistance Program. Assistance Listing Number 93.778 Type of Finding: Material Weakness in Internal Control over Compliance Condition: During our testing, we noted the following instance of noncompliance in the sample of sixty case files tested: • One MAXIS case file did not have a renewal application on file. In addition, the County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the two eligibility determination systems, MAXIS and METS. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered, and the information required by the contact is retained in the County’s records. Hennepin County Employee Responsible for the CAP: Vickie Goulette Planned Completion Date for CAP: December 31, 2025

Program(s): Supplemental Nutrition Assistance Program (SNAP). Assistance Listing Number 10.561 Type of Finding: Material Weakness in Internal Control over Compliance Condition: During our testing, we noted the following three instances of noncompliance in the sample of forty case files tested: • One MAXIS case files did not have a renewal application on file. • One MAXIS case file did not have a signed application on file. • One MAXIS case file did not have documentation matching the income on file. In addition, the County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the eligibility determination system, MAXIS. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered, and the information required by the contract will be retained in the County’s records Hennepin County Employee Responsible for the CAP: Jennifer Frey Planned Completion Date for CAP: December 31, 2025

Brockwood Community Association 801 W. Washington Street Greenville, South Carolina 29601 CORRECTIVE ACTION PLAN April 14, 2025 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Brockwood Community Association respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The finding from the year ended December 31, 2024 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - Federal Award Program Audit Finding 2024-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Projects (Section 223(f)/207) Recommendation: We recommend that the management ensure the required household members sign the HUD-50059 prior to submitting to HUD. Action Taken: We agree with Finding 2024-001 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will ensure that all required signatures are obtained on all Form HUD-50059's prior to submitting to HUD going forward. If HUD has questions regarding this corrective action plan, please call (704) 771-1696. Sincerely yours, Claudia A Keene, CPA Controller Multifamily Select, Inc. Managing Agent

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that the Authority review the controls in place to ensure that the inspections team can complete the reinspections in a timely manner and are knowledgeable of all internal procedures in place over inspections. We also recommend that the Authority review rules and internal controls in place around record retention for completed inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HCV will complete a comprehensive redesign of its inspection scheduling process in 2025 and provide training to the Inspections Coordinators. Additional reports have been developed to identify past due inspections, and, in addition to the Inspections Manager, the Compliance Team will closely monitor them in addition to ensure any outstanding inspections are cured.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Continuous. Preventive actions will be ongoing as part of the regular compliance and quality management process. The Management Team has been required to clear all work backlogs by the end of FY2025

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that the Authority review the controls in place to ensure that all required recertification documents are completed, signed, and in the tenant's file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA has adopted the updated HUD-9886-A in addition to its own Release of Information. The updated release form does not expire and provides more indefinite Release of Information coverage. An additional data field has been created to track households that opt out of their release.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Preventive actions to identify households that opt out of the adopted indefinite Release of Information will be ongoing as part of the regular compliance and quality management process.

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review the controls in place to ensure that no tenants are overlooked, even when the original case manager is no longer an employee of the Authority. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HCV has developed new software process workflows that automatically incorporate completion of certification checklists. Work backlogs created by staff turnover are being addressed. The Management Team has a created a plan of action with a timeline to clear all backlogs by the end of 2026. The team meets on a weekly basis to discuss progress. Additional oversight of termination processes will be provided by Compliance Team review of payment holds and $0 HAP reports.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Continuous. Preventive actions will be ongoing as part of the regular compliance and quality management process. The Management Team has been required to clear all work backlogs by the end of FY2025.

Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information has been obtained in accordance with TCA’s policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA Health has addressed the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff were trained in the approved sliding fee scale policy and its requirements. Worked with third-party billing company, and Athena to roll back the EMR update which contributed to ineffective application of the sliding fee in November 2023. TCA hired a full-time Patient Services Manager in 2024 to support ongoing staff training, quality assurance monitoring, and implementation of the updated EMR and registration workflows. Staff have become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. Additionally, TCA began to undergo internal audits of records ensuring that proper documentation is maintained and a patient service manager, utilizing testing template provided by the organization’s auditor. Name(s) of the contact person(s) responsible for corrective action: Samantha Oliver Mitchell, Chief Operating Officer Planned completion date for corrective action plan: June 2025

Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has conducted appropriate training for all staff to ensure compliance moving forward. Planned Completion Date for CAP December 31, 2025

The Organization will implement additional procedures to ensure that documentation to support the eligibility of all program participants. These procedures will be implemented by the end of fiscal year ending June 30, 2025.

Views of responsible officials and planned corrective actions – Management has begun staff training and will meet with the billing team regarding the sliding fee policy and process, including scanning of application into the patient's file. Management will ensure HFBG continues to apply and audit the application of sliding fee discounts on the patient accounts consistent with policy.

Condition: During our testing of 40 Foster Care IV-E benefit transactions, we noted one sample out of forty total samples where the individual receiving payment under Foster Care IV-E was not eligible as the individual did not meet the eligibility requirement of living with a parent or specified relative during the required timeframe. Recommendation: We recommend the County collaborate with the Colorado Department of Human Services to ensure that reimbursements under Foster Care IV-E only occur for individuals that are eligible under the Foster Care IV-E Program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Adams County Human Services (ADHS) finance staff will implement a monthly review comparing the IV-E status report in the ADHS Mango application to the monthly Discoverer payments report from the State of Colorado system. This monthly process should show IV-E payments made for clients who were flagged non-IV eligible. If errors are found, ADHS will send a list of the clients and payments in question to the state for their review and correction. ADHS finance staff will also verify that we have correctly entered the client eligibility determination in the state system. Name of the contact person responsible for corrective action: Maurice Stenberg Planned completion date for corrective action plan: December 31, 2025