Corrective Action Plans

Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with all Medicaid workers, including NC Fast Learning Gateway Training “Supplemental Security Income (SSI) Course”. Proposed Completion Date: June 30, 2026. Certain controls are currently being created and reviewed. Management will continue to monitor the progress of this issues and modify the controls as needed.

Finding 2025-001 Eligibility - Noncompliance and Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: Historical documentation on patient eligibility for IHS beneficiary status residing in paper financial files (in use at the time of roll and scroll registration) will be scanned in the BMW registration system making them a permanent part of the patients’ electronic health record. 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. Individual(s) Responsible for Corrective Action Plan Kandy Barlow VP of Health Services 907-442-7385 Anticipated Completion Date: March 31, 2026

We agree with this comment. Starting with fiscal year 2026, we will ensure that eligibility forms include signature or initials of the preparer, and documentation of review by the supervisor, regardless of whether or not the state form has a second line for the supervisor approval.

The Center 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. Repeat Finding No Action Taken Management has implemented enhanced internal controls to ensure sliding fee discounts are accurately calculated and fully supported. The Center standardized income verification procedures, reinforced documentation requirements for family size and income, and updated its sliding fee eligibility checklist to ensure consistency. Supervisory review protocols were established to verify proper calculation and supporting documentation prior to approval. Additionally, staff received refresher training on sliding fee policy requirements to promote ongoing compliance. Management will conduct periodic internal audits to monitor adherence and ensure continued effectiveness of these controls. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sean Murphy, CFO at 860-610-6387.

2025-007: Medication assistance was provided to a patient who was not eligible to receive assistance on the date of service due to active insurance coverage for the prescription. The Organization’s eligibility procedures were not supported by a formal policy or consistently followed as written. Additionally, the Procedure for Medication Financial Assistance provides Community Health Workers and other staff significant discretion in making eligibility determinations. This flexibility and subjective process, while intended to reduce barriers to patients obtaining opioid use disorder treatments, increases the risk for inconsistent and inappropriate eligibility determinations. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: May 2026 Views of responsible officials and planned corrective actions: Issues identified during the audit were indicative of an overall lack of controls and processes by grant directors and Finance Department staff. The Organization has reviewed the processes and has developed a formalized policy for medication assistance eligibility determinations, clearly identifying grant requirements for eligibility. Additionally, the procedure associated with the policy identifies the need for secondary review of eligibility determinations and clear communication to the Finance Department along with adequate record keeping. The Organization’s CEO, a former CFO of the organization, will continue to provide oversight for the Finance Department to ensure controls and processes are implemented.

Management’s Response: The University has undertaken several initiatives to enhance compliance and accuracy: Management acknowledges the material weakness related to the awarding and disbursement of TEACH Grants and recognizes the importance of ensuring that grant eligibility is verified in accordance with federal regulations prior to disbursement. During fiscal year 2025, an eligibility determination error was identified for one student. Subsequent to year-end, the University returned the related TEACH Grant funds to the U.S. Department of Education through the G5 system. Management has taken corrective actions to strengthen eligibility verification and prevent recurrence. Corrective actions implemented include: • Strengthened Leadership and Oversight: A new Financial Aid Director was hired in March 2025 and has prioritized the development and enforcement of appropriate controls over TEACH Grant awarding and disbursement. • Revised Policies and Procedures: TEACH Grant awarding and disbursement procedures were reviewed and updated to ensure alignment with federal eligibility requirements. • Improved Eligibility Documentation: The TEACH Grant application was enhanced to clearly document all required eligibility criteria and support consistent eligibility determinations. • Secondary Review Controls: A secondary review and approval process has been implemented to ensure that TEACH Grant eligibility is independently verified prior to awarding and disbursement. • Enhanced Tracking and Monitoring: Additional tracking mechanisms were implemented to confirm that eligibility requirements are met and documented before funds are applied to student accounts. • Ongoing Compliance Monitoring: The Financial Aid Office continues to monitor TEACH Grant activity to ensure continued compliance with program requirements. Management believes these actions have significantly strengthened internal controls over TEACH Grant awarding and disbursement. Continued application of these procedures is expected to prevent recurrence and support full compliance in future audit periods. These initiatives demonstrate the University’s commitment to maintaining accurate student enrollment records and ensuring compliance with federal regulations, thereby safeguarding the interests of its students and the institution.

While the District maintained the requisite supporting documentation, limitations arising from the internal record retention policies in place at the time, coupled with the retirement of key personnel, resulted in certain enrollment records not being readily locatable. The District acknowledges that these factors limited the availability of prior-year supporting data. This issue has since been addressed through updated retention practices to ensure that this does not occur going forward. Beginning with the next fiscal year cycle, the District has implemented a documented procedure that specifies the data sources, query parameters, and data pull dates; requires that all supporting extracts and calculations be retained in a centralized, version-controlled folder; and establishes a formal review and approval process to verify that enrollment and low-income counts reconcile to source documentation before submission to ADE. Staff in Federal Programs and Finance have been trained on the new procedure, and an annual internal review has been established to confirm compliance. The Director of Finance and the Director of Federal Programs are responsible for implementing and monitoring this corrective action, which will be completed prior to the next Title I eligibility submission.

Condition There were two missing inspection reports for tenants that had moved in during the year. Recommendation We recommend that the Foundation complete and maintain inspection reports in tenant files. Comments on the Finding The Foundation is aware of the oversight and has implemented procedures to prevent this in the future. Action Taken As of the date of this notice, the Foundation has implemented an additional review of all tenant files to ensure all inspection reports are completed and maintained.

2025-002 Eligibility- WIOA intake applications were not signed properly U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Condition: During our testing of WIOA participants, it was noted that for one of the six youth participants selected for testing the WIOA intake application was not signed by the case manager. Recommendation: We recommend that the Board thoroughly review all applications for Youth Activities to ensure that all required eligibility documentation is completed and properly approved. Region 3 Action:ln direct response to this finding, the Board developed and implemented a comprehensive Youth Eligibility Policy, effective February 25, 2025. This policy establishes clear and enforceable procedures to ensure that all youth participants are properly vetted prior to receiving WIDA-funded services.Specifically, the policy includes a dedicated "Eligibility Verification" and "Documents for Verifying WIOA Eligibility" section which requires that service providers confirm each individual meets all applicable WIOA eligibility requirements including age, selective service registration and citizenship status at the time of registration. The policy further requires that each participant file contain a completed application along with supporting documentation confirming general WIOA eligibility and all applicable Youth eligibility data elements. Additionally, all questions on the intake form must be fully answered and both the applicant and the intake staff member are required to sign the intake forms prior to the delivery of services. Primary Eligibility Review is the Local Board's program staff's responsibility to ensure all registration paperwork is complete and accurate before WIOA enrollment.The Board is confident that these policy requirements provide the necessary framework and controls to ensure consistent, documented eligibility verification across all service providers administering youth activities under WIOA. The Board will continue to monitor compliance with this policy through its oversight activities to ensure the controls remain effective on an ongoing basis.

Finding 2025-002: Student Financial Aid Cluster – Allowable Costs and Allowable Activities and Eligibility Federal Agency: U.S. Department of Education Program: Student Financial Assistance Cluster Criteria: The College is required to have controls in place to ensure students receive the proper amount of student financial assistance they are entitled to based on financial need. Condition: Our financial aid sample of 40 items tested yielded 31 students who received Direct Loan Funding. Of the 31 students who received Direct loan funding, we noted 1 instance where the student received the incorrect amount of Unsubsidized funding. Based on the students Student Aid Index, the student should have received $1,750 in Unsubsidized funding; however, they received $2,227 in Unsubsidized Direct Loan funding, resulting in an overpayment of Direct Loan funding of $477. Cause: The controls in place did not detect that the student had incorrectly been awarded assistance based on more than 30 credits when they actually had 25 credits. The additional 5 credits needed for the amount of the award were not earned until the following semester. Effect: Internal controls related to student financial assistance were not operating properly. Repeat Finding: This is not a repeat finding. Questioned costs: $477 Recommendation: We recommend Thaddeus develop systems that would detect credits posted but not earned to ensure proper student assistance is awarded. View of Responsible Officials and Planned Corrective Action: Management agrees. See separate Corrective Action Plan. Corrective Action Plan: There is no disagreement with the audit finding. After reviewing the policy for Grade-Level Advancement for Direct Loan Consideration, it was determined that the student referenced in the funding did not meet the qualifications needed to be considered a sophomore level student for the Fall 2024 semester. The student became eligible for the increased loan amount in the Spring 2025 semester. The $500 that was incorrectly awarded to the student for the Fall 2024 semester has been corrected and reallocated to Spring 2025. The Office of Financial Aid has created a procedure to check student loan amounts during fall and spring semester to ensure accuracy. Additionally, an Assistant Director of Financial Aid was hired in February 2025 to strengthen financial aid administration within the department. Name(s) of the contact person(s) responsible for corrective action: Melissa Wisniewski, Dean of Enrollment Services at 717-391-7234. Planned completion date for corrective action plan: January 2026. If the Department of Education has questions regarding this plan, please call the Vice President of Finance and Administration, George Longridge at 717-391-6947.

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER – FEDERAL ALN 84.027 AND 84.173 2025-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 requires Independent School District No. 728 (the District) to establish and maintain effective internal control over compliance with requirements applicable to its federal program expenditures, including suspension and debarment requirements. Our testing indicated the District did not have sufficient controls in place within its special education cluster federal programs to assure it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds, prior to purchasing over $25,000 of goods or services from the vendor. Corrective Action Plan Actions Planned – The District will review policies and procedures relating to suspension and debarment for special education cluster federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding prior to expending federal funds with such vendors. Official Responsible – The District’s Director of Finance, Joseph Primus. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Director of Finance will monitor the implementation of these corrective actions to ensure appropriate controls are in place to verify that any vendor with which the District contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website prior to expending federal funds with such vendors.

Condition: A student added an additional course after the summer term census date, however, the Financial Aid Office did not adjust the student’s corresponding Pell Grant eligibility. As a result, the Pell Grant award was not recalculated to include the additional course. Criteria: The University’s monitoring controls for post-census date enrollment changes were not consistently applied. Although the University’s normal process includes reviewing and adjusting aid when students add/drop classes after the census date, this case was not identified due to human oversight for post-census date schedule changes. Cause: Per 34 CFR 690.80(b)(2)(ii), the University must adjust Federal Pell Grant awards if a student’s enrollment status changes and the change occurs within the University’s established recalculation (census) policies. Additionally, internal University policy states that Pell Grant awards will be adjusted when students add/drop courses after the census date if those courses are applicable toward the student’s degree or certificate requirements and occur within the eligible recalculation period. Effect: Because the student’s enrollment increase was not identified and processed, the student did not receive the full amount of Pell Grant awards they were entitled to. This resulted in a $924 underpayment to the student. Context: This issue was identified during audit testing of Pell Grant awards for the 2024–2025 year. The University reviewed the case and agreed that the student should have received an additional $924. The University believes the error to be an isolated incident rather than a systemic process failure; however, it indicates that post-census monitoring controls may not be fully effective in all cases. Recommendation: The University should establish a formal process to monitor when students add/drop courses after the term census date to ensure financial aid is accurately adjusted and reflected in a timely manner. This process should include periodic reviews or automated reports that identify enrollment changes impacting grant eligibility and additional procedures to verify that corresponding adjustments are made to student accounts. Strengthening this process will help ensure compliance with federal regulations and prevent underpayments or overpayments of student aid. View of Responsible Officials and Planned Corrective Action: The University has recognized the failure to adjust the student's enrollment status and recalculate the Pell Grant award in a timely manner that resulted in an underpayment of $924. To prevent similar issues in the future, the Financial Aid Office will implement a formal process to monitor students who add/drop courses after the census date, including generating reports to flag enrollment changes that impact Pell Grant eligibility and reviewing these cases to ensure adjustments are made promptly.

Condition: There was an incorrect cost of attendance amount used to calculate a parent PLUS loan for 1 out 40 students tested. Criteria: According to the U.S. Department of Education, an institution must use cost of attendance minus other financial aid received to calculate the amount of PLUS loans that students are eligible to receive. Cause: The University utilizes a paper worksheet to manually calculate a student’s eligibility for PLUS loans. Due to a manual entry error, the cost of attendance was recorded as $1,000 less than the correct amount. As a result, the student was eligible to borrow more funds than initially indicated. Effect: As a result of the manual calculation error on the loan worksheet, the student was informed of a lower borrowing limit than they were actually eligible for. This discrepancy contributed to the student receiving less financial aid than anticipated. Additionally, the error highlights a risk in the manual calculation process, which could result in similar miscalculations for other students if not addressed. Context: The University determines PLUS loan eligibility using a manually prepared worksheet rather than an automated system calculation. Financial aid staff record the cost of attendance and other aid amounts on this form to compute the eligible PLUS loan amount. During audit testing, it was noted that an error occurred in recording the cost of attendance, resulting in an incorrect calculation of the student’s PLUS loan eligibility. Recommendation: The University should implement controls to prevent, or detect and correct, manual calculation errors in determining PLUS loan eligibility. This may include transitioning to an automated system-based calculation, improving the secondary review process for all manually prepared worksheets, or incorporating validation checks for key data. Implementing these controls will help ensure accuracy in loan determinations and compliance with federal awarding requirements. View of Responsible Officials and Planned Corrective Action: Thank you for the opportunity to report on enhancements the University has made to resource our students and maintain the highest standards of accounting. While we are pleased that the audit indicated significant progress, the following are additional steps we are taking to ensure even greater accuracy and compliance: 1. An improved review process for all manually calculated loan worksheets to verify the accuracy of key inputs, including the cost of attendance and other aid amounts and 2. The University is also exploring options to automate the loan calculation process within its financial aid management system to reduce the risk of manual errors.

Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063 Recommendation: We recommend that the College review its procedures to ensure their internal system pulls the correct SAI amounts directly from the student's ISIR when calculating a student’s Pell award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To ensure compliance, the College will implement the following corrective actions: 1. System Configuration Review: The Financial Aid Office, in coordination with Powerfaids (College Board), will conduct a comprehensive review of system configuration settings to confirm that SAI values are pulled directly and accurately from the student’s valid ISIR transaction when calculating Pell eligibility when PARM ROLL is run each year. 2. Validation and Testing: The College will perform test file reviews comparing ISIR SAI values to system-calculated Pell awards to confirm accuracy. Any discrepancies identified will be corrected through system reconfiguration or vendor-supported adjustments (as per College Board.) 3. Quality Control Review: A secondary-level review, (i.e., the counselors designated to their individual alphabet cohort) will be implemented during each awarding cycle to confirm that Pell awards align with the student’s valid SAI and enrollment intensity. These corrective actions strengthen internal controls over Pell awarding, ensure SAI data integrity, and mitigate the risk of future calculation discrepancies. Name(s) of the contact person(s) responsible for corrective action: Stephanie Schroeder, Director of Financial Aid Planned completion date for corrective action plan: Immediate action will take place, with the goal of implementing these changes effectively before the start of the new academic year

Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for review at the time of audit. Method of Implementation: The district will improve the filing and retention of payroll timesheets and resolutions authorizing payroll expenses for federal programs. All payroll documentation will be properly maintained and made readily available for review at the time of audit.

Finding 2025-002: Eligibility Student Financial Assistance Cluster U.S. Department of Education Award Period: July 1, 2024 – June 30, 2025 Responsible Person: Wilbert Casaine, Executive Director of Student Financial Aid, 609-771-2211 Corrective Action Plan: During the compliance audit for the fiscal year ending June 30, 2025, the College had one student out of a sample of 40 who was selected for the eligibility compliance and control testing that had an incorrect Pell grant award for the Spring 2025 semester. The student was identified as having received the incorrect amount of Pell based on changes in enrollment intensity during the College’s Add/Drop period. The result of this error was that the student was under-awarded the Pell grant. Once the error was discovered, the student’s Pell grant was increased to the correct amount and reported to COD. The College recognizes the importance of reviewing student enrollment intensity changes throughout the disbursement process to ensure it does not result in errors in the calculation and disbursement of aid in accordance with 34 CFR 668.42, 34 CFR 673.5, 34 CFR 673.6, and 34 CFR 685.301. The College has a robust process for confirming enrollment intensity, which includes automated system reviews of student records, as well as manual/in-person award confirmations. In this student’s case, there were multiple course changes in a short span of time during the Spring semester’s Add/Drop period, which required multiple reviews and revisions to the student’s financial aid package. During one of the reviews, a staff member did not accurately increase the student’s Pell grant award when it was flagged by the system as being incorrect. As part of our corrective action, we have implemented additional reporting enhancements to review and confirm accurate awards. The reports are listed below: • The Office of Records and Registration will provide a comprehensive roster of student registration actions immediately following the Add/Drop period, and continuing weekly, until mid-semester, for review. • The Senior Business Analyst in the Financial Aid Office created an enhanced part-time user edit report of Pell students only who are not full-time at the end of the Add/Drop period for review. • The Analyst in the Financial Aid office developed a report to compare student enrollment intensity changes weekly, after the Add/Drop period is over, to identify and correct discrepancies in real time. The aforementioned corrective actions in the Financial Aid Office were fully operational for the Fall 2025 semester. Internal control reviews confirmed that no award errors occurred during the Fall 2025 term, validating the effectiveness of the new reporting and review structure. The College implemented the corrective action on 08/26/2025. Anticipated Completion Date: Completed in August 2025

The City concurs with the finding. The City will update Continuum of Care procedures related to subrecipient monitoring, in-kind contribution documentation, match tracking and reporting, and grant closeout review to strengthen compliance and oversight. Additionally, the City will provide additional grants training and a list of subject matter experts within each department that can work with auditors during the single audit.

Condition: The District had one missing application and two instances of students being claimed in the incorrect eligibility category. Plan: The District will improve their review processes to ensure applications are all retained and eligibility information is correctly applied. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Andrea Havlovitz, Business Administrator Management Response: The District agrees with the finding and will correct this in future years.

Loras College Corrective Action Plan For the year ended June 30, 2025 February 19, 2026 Finding 2025-001: Significant Deficiency – Incentive Compensation Assistance Listing Number: Various Federal Agency: U.S. Department of Education Condition: One out of five employees selected for testing had a promotion letter that included a salary increase if performance metrics for enrollments were met, with goal numbers for yearover- year increases in applications, admissions, new transfer enrollment and graduate enrollment. This is not in compliance with applicable requirements regarding incentive compensation. Recommendation: The College should establish a policy where employee contracts and compensation are reviewed and approved to ensure compliance with applicable requirements regarding incentive compensation per the regulations at 34 CFR 668.14(b)(22). Corrective Action: Management has reviewed internal processes and procedures and a process has been established whereby all employee contracts and compensation are first reviewed by the Associate VP for Finance/Treasurer and President before they are sent to Human Resources for processing. The Associate VP for Finance/Treasurer has a CPA background. In addition, the President and the HR Director are now well versed in applicable requirements regarding employee compensation. Management believes this process will eliminate a reoccurrence. Renate A. Root Treasurer 1450 Alta Vista St. Dubuque, IA 52001 563-588-7775

None reported Finding 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Findings 2025-001 also apply to State requirements and State Awards. Margaret Pierce - Burke County Finance Director, Korey Fisher-Wellman - Department of Social Services Director, Amanda Grady - Assistant Department of Social Services Director, and Tammy Wright - Medicaid Program Manager For all findings identified, Medicaid staff are required to attend training sessions to address the issues, and sign-in sheets will be required. During training, appropriate policies will be reviewed. The root causes of the errors were determined to be staff oversight and procedural lapses, compounded by policy changes, staff turnover, and the inexperience of some workers. Medicaid Supervisors will continue conducting 2nd Party Reviews. As cases are reviewed, supervisors will provide additional training as needed, either individually or in group settings. Training materials will be kept current and shared with the lead worker to ensure proper delivery. Workers will be required to complete refresher training when errors are found and collaborate with lead workers or supervisors for more detailed instruction or training. Group training will be scheduled if multiple workers demonstrate similar issues based on 2nd Party Review results. Supervisors conducting 2nd Party Reviews will examine two random cases per worker each month for timeliness and accuracy. In addition, two extra cases per worker will be spot-checked monthly to verify accurate resource entry. The Program Manager and Supervisors will monitor reports to ensure timeliness and require staff to document any cases that have gone overdue. These processes will help determine whether improvements have been made in resource accuracy. New employees will have notices and other correspondence reviewed before they are sent out to ensure accuracy. All new employees will continue to have 100% of their cases reviewed until supervisors determine they can process cases independently and correctly. Results from 2nd Party Reviews will be shared with the Program Manager, Assistant Director, and DSS Director. Corrections have been made to cases in error, and supporting documentation has been updated in NCFAST. Section IV - State Award Findings and Question Costs Supervisors will conduct training in response to the identified errors, with completion targeted by the end of January. Success will be measured through the results of ongoing 2nd Party Reviews. The agency will continue to monitor outcomes, provide group or individual training as needed, and address persistent issues through the disciplinary process when necessary. Additional training requirements and expanded, targeted spot-checks of cases will be implemented on an ongoing basis, based on continued findings, to further strengthen accuracy and compliance. Burke County, North Carolina Section III - Federal Award Findings and Question Costs Corrective Action Plan For the Year Ended June 30, 2025 Section II - Financial Statement Findings 139

2025-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Daphne Chan, Interim Head of Finance Corrective Action: Management implemented staff training and periodic internal reviews in response to the prior year finding related to the Sliding Fee Discount Program. While these actions improved awareness of requirements, management identified the need for additional controls to ensure consistent application and documentation going forward. To address the remaining gaps, management will implement the following actions: - Strengthen intake and documentation controls by reinforcing procedures to ensure proof of income documentation is obtained and retained. - Train site staff to ensure consistency in applying sliding fee discount. - Routine spot checks with timely escalation to Site Directors and Operations leadership when issues or variances are identified. - Refine internal monitoring activities to focus on higher risk transactions, such as new patient registrations, income re-certifications, etc. for final eligibility determination. Management will continue to monitor the effectiveness of these controls and make adjustments as needed to ensure ongoing compliance with Health Center Program requirements. Estimated Completion Date: June 30, 2026 Signed by Daphne Chan Interim Head of Finance

Views from Responsible Officials and Corrective Action Plan BCFS Health and Human Services For the Year Ended August 31, 2025 Finding Number: 2025‑001 and 2025-002Federal Program: Crime Victim Assistance – AL 16.575 (Common Thread – Texas) Pass‑Through Entity: Texas Office of the Governor Award Number: 3853406 Questioned Costs: $853,982 Responsible Person: Rosa Baez, President BCFS Health and Human Services Views of Responsible Officials: Management concurs with the finding. BCFS Health and Human Services’ (BCFS HHS) in-kind match plan includes the use of exempt personnel performing after-hours "on-call" volunteer duties, such as answering phones or undertaking responsibilities outside their standard work roles. BCFS HHS did not meet the in-kind match requirements, as the former Program Executive Director deviated from the in-kind match plan, as approved by the funder. The former Program Executive Director did so by hiring full-time personnel to perform the same duties as the on-call volunteers and including them as part of the in-kind match. In 2022, during the COVID pandemic, the funder waived match requirements; during this period, the prior Program Executive Director hired full-time overnight on-call personnel, in response to increased call volume driven by restrictions on face-to-face services due to concerns of exposure. The match waiver was discontinued with the grant awarded for October 2024 through September 2025, and BCFS HHS was required to meet their match obligations. The former Program Executive Director failed to reassign the On-Call workers resulting in a significant deviation from the approved match plan and contributed to the noncompliance of in-kind match requirements. Immediately upon the issuance of the monitoring report regarding match requirements, BCFS HHS’ President has been actively working with Office of the Governor (OOG) to rectify the match requirements per the grant. Management has recorded an accrual for the estimated adjustment and has implemented the corrective action plan outlined below. Page 2 of 3 Corrective Action Plan Upon receiving the preliminary monitoring report from the OOG, management promptly initiated an internal review with the OOG and began collaborating with OOG to address and resolve the findings identified. Effective immediately, BCFS HHS has established new protocols to ensure compliance with match requirements for the Common Thread Texas program. BCFS HHS will undertake the following corrective actions: 1. Revised In-Kind Volunteer Hotline Process A protocol has been implemented to manage the volunteer hotline for the Common Thread Program during after-hour operations. The hotline provides callers with program information, resources, referrals, and transfers calls as appropriate, including crisis response or intake services. The volunteer hotline is managed by volunteers that include exempt employees (working outside their regular duties), interns, and other approved community volunteers. Volunteers must complete training prior to being scheduled. The protocol guidelines include: •A designated volunteer timesheet. •A signed attestation certifying that hours listed are an accurate record ofvolunteer service. •Confirmation that the volunteer work is not required by their employment andis different and separate from their regular job duties. These measures provide robust supporting documentation and ensure that match activities are voluntary, allowable, and compliant. The Volunteer Hotline Protocol was reviewed and approved by the Office of the Governor (Public Safety Office and Office of Compliance and Monitoring). Target completion: Completed January 2026 2. Strengthen Match Documentation Processes Volunteer Attestation and Timesheet- Volunteers are required to sign a timesheet and an attestation affirming that the recorded hours accurately reflect their service with the Common Thread Volunteer Hotline. Additionally, if applicable, volunteers must confirm that this service is not mandated by their employment and is distinct from their regular job responsibilities. Monthly Match Meetings: These meetings will review the reported match activities against the approved match plan. Additionally, the meetings provide an opportunity to evaluate current needs and trends, and to ensure match obligations are met. Page 3 of 3 Target completion: Completed January 2026. 3. Correct and Reclassify Previously Reported Match BCFS HHS excluded the disallowed match activities and included permissible methods such as unrecovered indirect costs, reductions in billed expenditures, including personnel and training—and additional adjustments approved by OOG. All necessary changes are incorporated in the final Financial Status Report (FSR) submitted on January 29, 2026. Target completion: Completed. 4. Staff Training and Ongoing Compliance Monitoring BCFS HHS will provide Common Thread leadership training on uniform guidance match requirements, OOG-specific guidance, and the Volunteer Hotline Protocols. Weekly Audits- The BCFS HHS Director of Support Services, or designee, will conduct weekly audits to ensure protocol adherence. This will encompass a review of the hotline volunteers’ timesheets, and schedules. Results will be discussed in the monthly match meetings. Use of U.S. Bureau of Labor Statistics wage data- All volunteer and intern hours are valued using OOG‑approved labor categories. Target completion: Training will be completed by February 28, 2026; monitoring process will be implemented February 1, 2026. Sincerely, Rosa Baez, President BCFS Health and Human Services

Condition: During review of 40 eligibility determinations and redeterminations, we identified two exceptions: one case lacked documentation of IEVS reports required to verify income and eligibility information, and another case had a redetermination completed more than 12 months prior to the active eligibility date, which does not comply with the annual redetermination requirement under 42 CFR 435.916. Recommendation: CLA recommends that the County strengthen monitoring procedures to ensure that Income and Eligibility Verification System (IEVS) reports are obtained and retained for all eligibility determinations, implement controls to verify that redeterminations are completed within the required 12-month timeframe prior to the active eligibility date, and provide staff training on compliance requirements and proper documentation standards to reinforce adherence to established policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: All eligibility units will review the updated CP 25- 01 “EFAS IEVS Process” by 2/27/26 and annually thereafter. Supervisors will monitor CalSAWS reports/tasks for assigned staff to ensure compliance with processing standards. Supervisors will also monitor CalSAWS Monthly Productivity reports for their units to ensure that Redeterminations are completed timely and include Medi-Cal redeterminations in the case review process for new and journey-level staff. Eligibility Specialists will review the memo MC 25-016 “Updated Medi-Cal Annual and Change in Circumstance RE Guidance” by 2/27/2026. To avoid late redeterminations, staff will be offered overtime opportunities to ensure compliance until such time as the units have enough staff to meet the workload. The Department will complete minimally two eligibility induction training classes and two journey level refresher trainings per year. Name(s) of the contact person(s) responsible for corrective action: Rachel Ebel-Elliott, Social Services Deputy Director Planned completion date for corrective action plan: 6/30/2026

Incorrect Loan Disbursement Amount Corrective Action Plan: The Financial Aid Services office, in collaboration with IT, has implemented an exception report. This report is received daily, and designed to identify any students whose subsidized and unsubsidized loan awards may not align with their enrollment status, need, and annual loan limit. The goal is to proactivety identify and correct any discrepancies before disbursement to ensure accuracy. Responsible Person for Correction Action Plan: Marlon Jones Jr., Director of Financial Aid Services Implementation Date of Corrective Action Plan: 9/18/2025

Incorrect Pell Disbursement Corrective Action Plan: The Financial Aid Services office, in collaboration with IT, has implemented an exception report. This report is received, daily, and designed to identify any students whose Pell Grant awards may not align with their enrollment status or need. The goal is to proactively identify and correct discrepancies before disbursement to ensure accuracy. Responsible Person for Corrective Action Plan: Erika Guzman, Associate Di rector of Financial Aid Services Implementation Date of Corrective Action Plan: 6/23/2025