Corrective Action Plans

Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financial aid grant to the student's oustanding account balance as a condition of receipt of or eligibility for an emergency financial aid grant funding. The recipient also acknowledges that adding preconditions to receiving a financial aid grant that thwart this requirement may be subjected to oversight and corrective action. In consideration for this award, Recipients agree that they hold these grant funds in trust for students and act in the nature of a fiduciary for students. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. Now that the FY23 audit is finalized, any such compliance issues with students will be taken care of during actual registration process. In the future, any such forms that will need student authorization will be handled during the registration process. Responsbile Person(s): Robin Jefferson, Director of Student Accounts rljefferson@vuu.edu 804 342-3976. Robert Merino, Executive Director of Financial Aid jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.

Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, services or “assistance”. The child must be less than 18 years old, or, if a full-time student in a secondary school (or the equivalent level of vocational or technical training), less than 19 years old. Freestore Foodbank Inc. and Affiliates require all individuals receiving food to complete an eligibility form prior to receiving food. Condition: We noted one instance (in a sample of 40 clients) in which an eligibility form was not obtained prior to client receiving food. Planned Corrective Action: Management will perform periodic audits of eligibility forms starting 10/15/2023 to ensure compliance. Management will retrain staff to ensure completeness of the intake process. Furthermore, by 9/30/2023, management will work with the developers of the database to see if controls can be implemented in the software, so food cannot be distributed before the signing of the required form.

Finding 2022-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.019 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements regarding Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program are in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2023.

2022-007 Tenant Eligibility Material Weakness Recommendation: In general, we continue to recommend a review of the re-certification process to determine areas of weakness. Specifically, we recommend the use of a standard checklist in the re-certification process. We further recommend that each re-certification clerk’s work be routinely audited. We also recommend more standardization in resident files organization of information, and procedures established to make sure all files are maintained adequately in order to be compliant. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

The District concurs with the finding. Because the District was not aware at the time the purchases were made, the District would be required to comply with uniform guidance procurement rules for the funds received, suspension and debarment verification procedures were not performed or documented for those transactions. To address this issue, the District will implement procedures requiring verification of vendor suspension and debarment status for applicable federally funded transactions, using an appropriate source such as SAM.gov. The District will also require documentation of the review performed and retention of that documentation in the applicable procurement or vendor file, along with supervisory review to help ensure the control is performed consistently.

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations

REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify that they meet the grant eligibility requirements. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745

It is recommended that the Budget Expenditure Report for Appropriations and Appropriation Reserves be reconciled with the General Ledger monthly.

In addition, the differences between Federal and State Program Bar and the Manually maintained worksheet be reconciled and adjusted.

Corrective Action and Explanation - The City of Newark will comply with the Auditor's recommendation. Implementation Date: Ongoing.

Corrective Action Plan Finding: Finding 2022-002-Low Rent Tenant File Deficiencies-Eligibility Condition: We reviewed 25 files, 7 of which were audit year move-ins, and 18 were annual re-examinations. We noted the following exceptions: (a)-We were unable to find any annual inspections for the 18 re-examinations. We did note them for 6 of the 7 move-ins. (b)-We were unable to find the required annual review of the utility allowances. The January 27, 2020 Minutes discuss utility allowances and approve new ones. However, the minutes do not reflect for which period the new allowances covered. In addition, there was no documented analysis of whether utility rates had increased beyond the level which required revision, and whether the allowances changed or instead were a holdover from the old rates. (c)-We were unable to view the waiting list, and thus could not review whether the 7 move-ins reached the top of the list. (d)-5 required Enterprise Income Verifications (EIV) were not present in the proper time frame for the 25 files reviewed. (e)-Of the 25 tenant files we reviewed, non were timely re-examined within the required one year period. (f)-We were unable to review documentation of the review of flat rents. Corrective Action Planned As noted previously, we were not the management during this audit period. Our initial Cooperative Agreement was executed November 14, 2023. We believe we have corrected the noted deficiencies. Person responsible for corrective action: Charles Unsell, Executive Director Telephone: (918) 367-5558 Housing Authority of Bristow, Oklahoma Fax: (918) 367-2341 1110 S. Chestnut Bristow, OK 74010 Anticipated Completion Date- June 30, 2026

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.

Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9 forms will be remediated where permissible. Management will retain evidence of completion and conduct periodic compliance reviews to ensure ongoing adherence. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by January 31, 2023.

Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the executive Director left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director, onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.

HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the Executive Director, left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.

Finding: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients included under this program are eligible. During the compliance testing of 44 sample items, there was two instances where the Organization applied a sliding fee discount to a patient who had not submitted any documents regarding their income level or family size and we could not determine whether the patient should have been included as a sliding fee patient, and one instance where the patient had properly submitted their forms, but the Organization applied the incorrect sliding fee rate. Currently, there is no known monetary impact, improper expenditure of funds or questioned costs identified. However, if the Organization does not strengthen the internal controls in regard to the eligibility determination process, there is a possible effect on the ability of the Organization to obtain additional funding under this program if ineligible patients are being treated with grant funding. Views of responsible officials and planned corrective actions: Management agrees with the recommendation to review policies, procedures and practices in place over the controls related to obtaining, retaining and reviewing proof of income support for patients. • Train relevant staff on the Sliding Fee eligibility process and supporting documentation requirements. Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO

Views of responsible officials: Before the approval of budget and the contract petition, the Chief Financial Officer will verify if the vendors are excluded as an authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the excluded list at least once a year. This verification process will ensure compliance with federal regulations and avoid engaging with vendors who may be suspended or debarred. Additionally, this procedure will be recommended to be included in the review process for quotes or bidding requirements, further enhancing the Company’s ability to comply with federal regulations and maintain responsible vendor relationships.

Management will enforce existing internal control procedures and train staff to maintain appropriate documentation.

The South Carolina Department of Employment and Workforce (SCDEW) immediately recognized the increased fraud risk presented by the federal pandemic programs. In an effort to deter this obvious fraud threat, SCDEW initially informed every applicant for federal pandemic benefits that they might be required to provide proof of their employment or self-employment at a future time. The USDOL, however, ordered SCDEW to remove this notification because, in the words of one USDOL representative, such a warning might deter a claimant from applying for federal pandemic benefits. USDOL subsequently issued guidance prohibiting states from requiring proof of employment or self-employment as an eligibility requirement to receive federal pandemic benefits. Therefore, all a fraudster had to do to receive federal benefits was simply tell a state they were unemployed as a result of the COVID-19 pandemic. SCDEW was prohibited from requiring that fraudster to prove that they were even employed, let alone that they were unemployed because of the pandemic. Many of the items identified as paid fraudulent claims were caused by SCDEW’s compliance with the USDOL guidelines. SCDEW complied with this guidance, even though it disagreed with USDOL’s highly technical parsing of federal law, and SCDEW advocated for Congress to amend the law to clearly establish commonsense fraud protections. While awaiting Congressional action, SCDEW implemented numerous fraud detection and prevention tools and strategies to minimize the potential fraud exacerbated by lax federal requirements. Unfortunately, Congress did not amend the law until late December 2020. As a result, eligibility determinations made by SCDEW prior to the law change followed the federal guidance for this pandemic funding; however, to meet federal and state expectations regarding the quick payment of federal pandemic benefits, the federal policies and procedures SCDEW was forced to adopt were not adequate to completely prevent fraudulent claims. SCDEW continues to review, monitor, and enhance eligibility processes and procedures to prevent and detect fraudulent claims. We also updated our internal controls to help mitigate future fraudulent claims. The COVID pandemic created unprecedented challenges for every state workforce agency due to the combination of historic claim volume, the availability of a staggering amount of federal money, and new programs with lax eligibility and verification requirements that had to be implemented quickly, despite often changing federal guidance. These factors created a perfect storm for sophisticated fraudsters to exploit. In response, SCDEW took numerous aggressive steps. In mid-2020, SCDEW required applicants to provide copies of their driver’s license or passport to prove their identity before receiving benefits. SCDEW also implemented identity verification questions through Lexis Nexis that every claimant had to pass before processing a claim. This was further enhanced in March 2021, when South Carolina was one of the first states to implement digital identity verification through ID.me. SCDEW also implemented reCAPTCHA to prevent against bot attacks, implemented new data sharing agreements, and increased the number of staff dedicated to investigating fraudulent claim activity to over fifty at the peak of the pandemic programs. SCDEW continuously reviews its fraud detection and prevention activities to stay ahead of emerging fraud schemes. Since the height of the pandemic, SCDEW has increased its data crossmatching, partnered with the State Law Enforcement Division to have a financial fraud investigator dedicated to unemployment insurance fraud, and made numerous enhancements to its computer systems to combat fraud and preserve the integrity of the unemployment insurance system. Per USDOL data, the agency had the twelfth lowest improper payment rate out of fifty-three programs during the year ending September 30, 2024. For more comprehensive explanation and response, please see August 26, 2024, letter attached from Paul Famolari, Assistant Executive Director of Unemployment Insurance. The Agency’s contact person responsible for the corrective action plan is Jacquelyn Carlen, CFO. The completion date of the corrective action plan was June 20, 2021, and is ongoing.

The Northeast Iowa Workforce Development Area acknowledges the finding. Since the period under review, a new Title I service provider has been implemented, and multiple corrective measures have been established to strengthen eligibility determination and documentation. Eligibility checklists and standardized enrollment packets are now required for each program. In addition, the new service provider has instituted a quality assurance process, with two directors conducting case file reviews across the local area. The NEIWDB has hired a compliance specialist to provide oversight, including ongoing, quarterly, and annual monitoring of eligibility and documentation. Title I staff utilize IowaWORKS reports and alerts to support compliance, and regular monthly technical assistance sessions, statewide trainings, and structured onboarding were provided to the new service provider. These measures were implemented beginning July 1, 2024 and are ongoing. The compliance specialist will report monitoring results to the NEIWDB to ensure accountability and corrective follow-up where needed. The Northeast Iowa Local Area believe these actions fully address the issue and will prevent recurrence in future program years.

Finding No.: 2022-045 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Allowable Costs/Cost Principles Questioned Costs: $99,924 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: The Hazard Mitigation Grant Program (HMGP) agrees with this finding. During the audit submission process, HMGP provided the support documents for the journal entries and reversals associated with the $99,923.27 to the auditor, as requested. However, it was only upon receiving this audit finding # 2022-049, that the discrepancy of a duplicate audit drawdown was called into question. HMGP’s ledger for this project as well as the Munis drawdown history does not indicate a remaining balance of $99,923.73 and the project related to this finding has already been closed out. To address this audit finding that HMGP received this last week on September 17th, HMGP reached out to the Department of Finance to provide related documents for the drawdowns. Based on the documents provided by DOF, the questioned cost was not a direct result of the duplicate drawdown but as a result of the reverse journal entries made by Tyler Munis staff in an effort to correct the duplicate drawdown. HMGP accurately completed all required steps to process and provided the necessary justification to process a total of $99,923.73 for professional services and submitted it to DOF. Based on the supporting documents, the $99,923.73 was comprised of: • $53,451.01- under Request for Payment Application #11, letter reference # GAR22-HM-005 received by DOF on 10/18/2021 and requested to be charged to M142352.62060. • $46,472.72- under Request for Payment Application #12, letter reference # GAR22-HM-031 received by DOF on 11/05/2021 and requested to be charged to M142352.62060. Both HMGP payment application requests show the project string was meant to be charged to 62060 which stands for Professional Services and was submitted to DOF for processing. Since the new Munis financial system portal was launch in the CNMI a month prior, HMGP personnel were not able to enter transactions directly, unlike the current process. However, when the transaction was processed on Munis, it was entered in by a Tyler Munis representative, as identified by the staff initials SMD, who was assigned to assist DOF employees with data input during the transition period and, according to the Munis transaction history, accidentally entered the debit for the $99,923.27 under the Construction project string instead of Professional Services on 12/2/2021. On 12/13/2021, SMD credited the $99,923.27 back to Construction and debited $99,923.27 to Professional Services with Journal entry # 2125. The Munis transaction history also shows various entries and reversals made under the project account that serve to correct the same journal error. HMGP personnel would not be able to review the transactions entered prior to posting, and based on the transaction logs, even after the transactions were posted, HMGP would see that those involved in processing the transactions corrected their errors. Additionally, the supporting documents associated with the drawdowns on Munis display a bank statement with a lumpsum total of various project accounts. Furthermore, most of the journal entries during the time in question either contained the same supporting documents or indicated “access denied” when selected by HMGP personnel with Munis access. The document provided to HMGP on 9/24/2025 indicated the final two transactions related to this expense was entered by Tyler Munis staff on August of 2022. In an effort to reverse the duplicate drawdowns that occurred in Professional Services, SMD reversed the $99,923.27 from professional services labeled as "REV JE 2125 DONE IN ERROR". Journal Entry (JE) 2125 refers to the debit they initially made on 12/13/2021. This credit effectively canceled out and corrected one of the two drawdowns that occurred within the Professional Services Project String. However, on the same day, SMD made a second journal entry reversal under the Construction project string with an identical PA journal comment ""REV JE 2125 DONE IN ERROR."" It is unclear as to why this transaction occurred given that original error under construction was made and corrected on December 2021. Since this incorrect journal entry was made as a debit to construction and the correct journal entry was made as a credit to professional services, the net draw would have been $0. Since $0 worth of funds were paid out and no check was cut as a result, this additional debit would not have been conspicuous to HMGP or the DOF staff. HMGP is prepared to provide the additional documentation upon request. Additionally, acknowledging that the second debit to construction in August of 2022 for $99,923.73 was recorded and was not corrected for this project, HMGP will work with DOF to correct the journal entry and return the funds to FEMA. To address the finding, a significant action step already taken is the transition that occurred in 2024 for agencies to initiate their own drawdowns. This drawdown process ensures HMGP’s direct oversight of all expenditures moving forward to reduce the risk of future duplications. HMGP created an internal drawdown tracker upon DOF’s transition to agency-initiated drawdown requests for 2024 expenses to present. HMGP will work with DOF to correct the journal entry on Munis in relation to the questioned cost and process the return of funds to FEMA. HMGP will create a tracker for all requested transactions made to DOF, such as reversals or corrections if needed as that function cannot be completed on Munis by HMGP. HMGP will review the tracker on a bi-weekly basis to ensure that all MUNIS journal entries and transfers related to HMGP to ensure expenditures are completed accurately and on a timely basis to avoid future misclassifications or duplications. HMGP will continue to ensure that all payments are correctly coded and submitted into Munis with the appropriate documentation and supporting details. HMGP will update the financial management portion of the HMGP standard operating procedures to reflect these action items. Proposed Completion Date: September 30, 2026

Finding No.: 2022-041 AL Program: 93.778 - Medical Assistance Program Area: Special Tests and Provisions - Provider Eligibility (Screening and Enrollment) Questioned Costs: $3,640,189 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: The CNMI Medicaid Office respectfully disagrees with the finding. While the office did perform OIG exclusion list validation, screenshots were not captured for each individual check. It is important to note that the OIG Exclusion List portal’s search function is limited to on-screen viewing and does not provide a built-in option to print or export search results. Additionally, the CMS access process for exclusion checks involves a rigorous background clearance, and only one personnel of three total successfully gained access. The CNMI Medicaid Office acknowledges that historically, limited personnel capacity has hindered full compliance with this requirement. However, efforts are currently underway to streamline and strengthen the exclusion verification process. The office is actively developing a fully functional Program Integrity Division that will be responsible for conducting and documenting OIG exclusion checks in a consistent and compliant manner moving forward. Proposed Completion Date: January 1, 2027