Corrective Action Plans

Finding 2022-007 Inaccurate Resources Entry Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022 discussing manual MA-2230 and MA-3320 with all Medicaid staff. A documentation template was created for applications and recerts to include a resource checklist reminder. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Agency will send a monthly email reminder to address trending errors. Proposed Completion Date: December 7, 2022 and ongoing

Finding 2022-006 Inaccurate Information Entry Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022. A documentation template was created to remind workers of TWN and other informational resources available. Agency will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address accuracy. Agency will send a monthly email reminder to address trending errors. Proposed Completion Date: December 7, 2022 and ongoing

Finding 2022-005 IV-D Cooperation with Child Support Name of contact person: Theressa Smith, Deputy Social Services Director Corrective Action: Training was completed on December 7, 2022. Will continue to complete second party reviews to monitor compliance with Medicaid policy. Agency will conduct quarterly trainings to address IV-D child support cooperation. Agency will send a monthly email reminder to address trending errors. Proposed Completion Date: December 7, 2022 and ongoing

CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 U. S. Department of Housing and Urban Development Timber Hills Housing of Alcorn County, Inc. (the "Project") respectfully submits the following corrective action plan for the year ended September 30, 2022. Audit Firm: Harper, Rains, Knight & Company, P.A. 1052 Highland Colony Parkway, Suite 100 Ridgeland, MS 39157 Audit Period: Year Ended September 30, 2022 Audit Finding Reference: 2022-002 Planned Corrective Action: Management will ensure that the Project has all required forms for each tenant. Name of Contact Person: If the U. S. Department of Housing and Urban Development for audit has questions regarding this plan, please call Scott Russell at 601-856-2362. Sincerely, Timber Hills Housing of Alcorn County, Inc.

Management is cognizant of the District?s internal control structure and continues to evaluate cost effective opportunities to further improve segregation of duties. The District has strengthened the internal control structure in recent years by revising the roles and responsibilities of multiple positions within the accounting department. The District continues to identify and implement effective mitigating controls when possible. Current District procedures in both the accounts payable and payroll functions include one position that is primarily responsible for transaction processing and require that a second individual review and approve transactions. As a result of these procedures, the Finance Manager has less responsibility with daily functions which enables the position to provide additional secondary review and oversight both in the financial areas of accounts payable, accounts receivable, and in the payroll/HR areas. Name of responsible official: Michelle Lillibridge, Business Services Director Expected Completion Date: Ongoing, no formal expected completion date

Management Views ? Management agrees with the finding and the recommendation. Corrective Action Planned ? Management has implemented procedures to ensure that the free and reduced price applications and the verifications are kept on file and scanned. The appropriate employees will be trained and be made aware of the requirements for these documents. Anticipated Completion Date ? This procedure has been implemented for the 2022-2023 school year and all of the appropriate employees are aware of the importance of keeping these documents.

Finding 2022-005 Responsible Party Name: Ju Chinnery Position: Property Accountant Telephone Number: (816) 246-9220 Federal Agency Department of Housing and Urban Development Federal Program Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Sec 207/223(F)) Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee?s Comment on Finding We agree with the auditor?s finding. Corrective Action We will follow procedures to ensure applicant and tenant eligibility and recertification is being maintained properly and management will review the accuracy / completeness of the documentation being processed in the tenant files on a quarterly basis. Anticipated Completion Date June 30, 2023

Finding 2022-004 Responsible Party Name: Ju Chinnery Position: Property Accountant Telephone Number: (816) 246-9220 Federal Agency Department of Housing and Urban Development Federal Program Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Sec 207/223(F)) Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee?s Comment on Finding We agree with the auditor?s finding. Corrective Action We will follow procedures to ensure tenant eligibility and establish and maintain security deposits for move outs and management will review the accuracy / completeness of the documentation being processed in the tenant files on a quarterly basis. Anticipated Completion Date June 30, 2023

Finding 2022-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Catalog Numbers: 14.871 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility. Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 1,805 units. Of a sample size of thirty-one (31) tenant files, the following was noted: ? Annual inspection report was missing in 1 file ? HUD 50058 Form was missing in 1 file ? Verification of income and assets was missing in 1 file. Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The affected files relate to clients that have been on the program for decades and as files get large, archiving takes place. To correct this finding, a directive will be issued to staff that will ensure that when files are archived the original application must be placed in the current working file going forward. Allison Landrum, Chief Executive Officer, is responsible for implementing this corrective action by September 30, 2023.

Galindez LLC Urb. Perez Morris, 19 Ponce St. San Juan, PR 00917 Dear CPA Marcos Claudio: In connection with the Schedule of Findings and Questioned Cost of Administracion de Servicios Medicos de Puerto Rico (ASEM) for the year ended June 30, 2022, below please find our comments, and planned corrective actions for Finding identified. Finding No. 2022-001 Eligible Uses Providing Premium Pay to Eligible Workers As more fully explained to your representative during the audit, the Administrator of this Premium Pay Program was the Health Department of Puerto Rico (HD) who was in charge of developing the program to all Public Hospital in Puerto Rico, among them, the Administracion de Servicios Medicos de Puerto Rico (ASEM). At all times, ASEM followed the instructions provided by the HD. Furthermore, we provided the HD with the list of possible eligible employees, including the information of the requirements established by them. The salary $40,000.00's limit was not a requirement to be considered. After the review done by HD, they provided ASEM with the authorized list of employees eligible for the benefit which ASEM used for the payment. Accordingly, it was never the intention of ASEM to pay this benefit to not eligible beneficiaries, it was only a matter of not providing ASEM with the actual requirements from the Program's Administrator. Should you have any question, please call at your convenience. Paul Barreras Diaz, CPA Finance & Budget Director

Compliance activities were temporarily suspended during the COVID-19 pandemic; however, the eligibility requirements resumed during the year ending June 30, 2022. The Organization did not resume eligibility verification when the requirements were reinstated. A risk assessment spreadsheet is maintained and submitted to the funder annually, which details if sub-recipients meet the required eligibility criteria. However, the Organization does not have controls in place to review these eligibility determinations to verify that they are complete and correct. The corrective action plan by the Organization is as follows: 1. Training on 2 CFR section 200.303 and related federal statutes for all staff involved in the management and implementation of the program. Estimated date of completion 04/03/2023 2. Improve controls through the implementation of a new annual verification process with each sub-recipient participating in the program (this is in addition to regularly scheduled check-ins required by WSDA and annual risk assessment). Estimated date of completion 04/28/2023 Responsible Individual: Samantha Franklin, CFO SamanthaF@foodlifeline.org - 206.432.3601

2022-002 Eligibility Recommendation: The College implement procedures in order to strictly comply with the requirements of 34 CFR 668.173 as it relates to the return of Title IV funds. Corrective Action Taken: The College's Financial Aid Office has implemented new procedures. When final high school transcripts come in during a semester, the Office will add a step to review the actual graduation date to make sure that the College is not paying a student for an ineligible semester. Anticipated Completion Date: Fall semester 2022.

Description of Finding: Errors in the sliding fee category - 4 patients were improperly billed for as compared to the sliding fee level they were properly approved for based on support provided with their application. Corrective Action: The Center has made it mandatory that two staff members verify the income levels of all eligible patients and apply the correct sliding fee discount by entering the right data into our billing system to make sure that the eligible patients are billed for the correct slide category. The Center will implement an internal audit on a quarterly basis of 5 random applications to ensure that the patient has been entered into the correct sliding fee discount level and is billed correctly. Name of Responsible Person: Taneia Gatchell, Controller Projected Completion Date: Completed at time of report.

In 2023, management will be utilizing the local programming TIC in Yardi so tenants will recertify annually to ensure that they meet the 50% AMI restriction.

Name of Auditee: Walnut Grove Non-Profit Housing FHA Auditee Identification Number: 126-EE045 Period Covered by the Audit: Year ended December 31, 2022 CAP provided by: Name: Andrea Bean Position: Director of Property Management Telephone Number: 360-694-2501 Finding 2022-001: 1. Statement of Condition: One of the tenant files selected for review did not perform the annual recertification for 2022. 2. Cause: No annual recertification was done for one tenant file in 2022 due to staff turnover. 3. Actions Taken on the Finding: Site staff are currently working with the resident to complete missing AR and will make any necessary adjustments to the resident ledger. Management?s corrective action plan includes processing monthly outstanding AR reporting from our Management software by our Compliance Specialist. These monthly reports will be provided to our Housing Portfolio Managers and reviewed with site staff to ensure that AR?s are completed timely and provide additional monitoring to prevent AR?s being missed in the future.

June 21, 2023 Corrective Action Plan Finding Number: 2022-001 Condition: The Organization charged costs to the grant which were associated with individuals who were subsequently discovered to have insurance. In addition, the Organization did not timely refund private pay patients for payments that were paid by HRSA funding. Planned Corrective Action: Management has allocated for staff to review and process credit balances. Additionally, Management has contracted with an outside vendor to expedite these reviews and processing of credit balances in a timely manner. Contact person responsible for corrective action: Dudley Harrington, VP of Patient Financial Services Anticipated Completion Date: 7/31/2023

Views of Responsible Officials and Planned Corrective Actions: The testing reveals a singular instance of an 1 item missing from 1 file. We do not believe this is to be broad evidence of the Birmingham Urban League not following its' internal controls but rather an instance of a "missed placed document". We will review internal control procedures with all employees who were parties in the chain of command related to this file and provide ongoing training with respective staff.

Reporting views of responsible officials and planned corrective actions Management will put in place procedures to ensure verification of tenant assets is done during recertification.

b. Finding 2022-002. Tenant Files Move-ins: 1. In one (1) instance out of seven (7) tenant files tested, Form HUD-50059 was not signed by the tenant. 2. In one (1) instance out of seven (7) tenant files tested, Form HUD-50059 was not signed by management. 3. In one (1) instance out of seven (7) tenant files tested, the ?Notice and Consent for the Release of Information? (Form 9887), was not maintained in the tenant?s file. 4. In one (1) instance out of seven (7) tenant files tested, the ?Applicant?s/Tenant?s Consent for the Release of Information (Form 9887-A), was not maintained in the tenant?s file. Recertification: 1. In one (1) instance out of nineteen (19) tenant files tested, the Pension benefit per the Form HUD-50059 was $486 per month; however, the supporting documentation was for $493 per month. 2. In one (1) instance out of nineteen (19) tenant files tested, there was no supporting documentation, to support the Federal wage income of $9,360. 3. In five (5) instances out of nineteen (19) tenant files tested, the Lease Amendment form was not signed by management. 4. In one (1) instance out of nineteen (19) tenant files tested, the ?Initial Notice ? Section 202/8 or Section 202 PACs?, was not signed by the tenant. 5. In one (1) instance out of nineteen (19) tenant files tested, the ?Initial Notice ? Section 202/8 or Section 202 PACs?, did not have a witness signature. Move-out: 1. In one (1) instance out of four (4) tenant files tested, the security deposit was not refunded within the 30 day timeframe. (1) Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor?s recommendation that Alpha Tower process applicants and tenants, including recertification of tenants in accordance with guidelines established by the Department of Housing and Urban Development prior to the tenant occupying the unit. In addition, security deposits should be refunded with interest, within 30-day after the effective move-out date. (2) Actions Taken on the Finding. Corrected going forward.

Provider files will be reviewed to ensure that files are complete and enrollment forms should be obtained for those not located.

We concur with the recommendation: FHC Hired Nelrod to train, correct PIC errors and complete recertification?s, Also Public Housing staff is helping with recertification?s.

We concur with the recommendation: The Director of Asset Management is reviewing files for accuracy and completeness.

2022-001 ? Student Financial Aid Cluster ? (a) Federal Supplemental Educational Opportunity Grants (b) Federal Work Study Program (c) Federal Perkins Loan Program ? Federal Capital Contributions (d) Federal Pell Grant Program (e) Federal Direct Student Loans (f) Teacher Education Assistance for College and Higher Education (TEACH), Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 (f) 84.379 ? Year Ended June 30, 2022 Condition: In three of the 40 student files tested (7.5%), Subsidized and Unsubsidized Direct loans were not properly awarded. The University under awarded one student $1,000 in Subsidized loans and over awarded the student by $1,000 in Subsidized loans. A second student was under awarded $2,560 in Subsidized loans and over awarded $2,560 in Unsubsidized loans. The third student was under awarded $862 in Unsubsidized loans. Management Response: All of the errors identified by the auditors were a direct result of manual miscalculation of loan eligibility. In two of the instances cited, the students had previous additional unsubsidized loans issued as a result of parent PLUS loan denials. When we received ISIR data these students were flagged with a reject due to aggregate loan limits. In order to calculate each student?s loan eligibility, a manual review of loan information via the U.S. Department of Education?s Common Origination and Disbursement (COD) portal is necessary. The additional unsubsidized loans disbursed as a result of PLUS denial, were manually removed from each student?s loan total to determine current year eligibility. In both instances, the total loan eligibility was correct, however the manual calculation of the subsidized versus unsubsidized split of the loan funds were miscalculated. In the last instance a student was under awarded $862 in unsubsidized loans, the miscalculation occurred due to receipt of an outside scholarship. In the Fall term the scholarship check was received with documentation indicating the disbursement was to be applied to the Fall term in it?s entirety and the Spring disbursement would follow. The outside scholarship caused the student to be over awarded and the student loans were adjusted to remain within cost of attendance limits. Subsequently the Spring term disbursement of the scholarship was received for $862 less than the Fall disbursement. At that time, the student should have been offered the additional $862 in unsubsidized loan funds to bring their total aid back up to cost of attendance. The staff person entering the scholarship payment on the student?s account failed to notify the loan coordinator an adjustment was warranted. Corrective Action Plan: The loan coordinator who made the errors has been in the position for just over a year. In order to prevent future issues in calculating a student?s loan limits and eligibility, the employee attended a loan regulation and processing overview course produced by the National Association of Financial Aid Administrators (NASFAA). Further, a form was developed to help calculate aggregate limits when an ISIR reject occurs in order to avoid missed steps in the calculation process. 2022-001 ? Student Financial Aid Cluster ? (a) Federal Supplemental Educational Opportunity Grants (b) Federal Work Study Program (c) Federal Perkins Loan Program ? Federal Capital Contributions (d) Federal Pell Grant Program (e) Federal Direct Student Loans (f) Teacher Education Assistance for College and Higher Education (TEACH), Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 (f) 84.379 ? Year Ended June 30, 2022 (Continued) As a result of the outside scholarship error, our procedures for entering an scholarship payment have been adjusted to include a final review of all outside scholarship disbursements entered by the loan coordinator. Responsible Person: Lynette Lambert, Assistant Director/Loan Coordinator Implementation Date: August 1, 2022

Management?s Response/Planned Corrective Action: To address the volume of files that must be rapidly reviewed, we restructured the program, effective November 1, 2022. We have divided the staff into Housing Specialist I (HIS) and Housing Specialist II (HSII) positions. HS I does the initial review of the file then sends it to the HSII for final review and approval. This new structure allowed us to increase the number of staff conducting these final reviews resulting in lower caseloads and more time to thoroughly review. The Coordinator now monitors for overall program compliance. Heather Kimmel, Assistant Executive Director is responsible for the corrective action plan. Implementation began on November 1, 2022.

Department of the Treasury ? CDFI Fund Grant Vantage West Credit Union respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Doeren Mayhew 305 West Big Beaver Rd., Ste. 200 Troy, MI 48084 Audit period: January 1, 2022 ? December 31, 2022 The finding from the December 31, 2022 schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF TREASURY CDFI Program ? CFDA No. 21.024 Significant Deficiency: See Finding 2022-001. Recommendation: Complete established procedures to identify and track eligible loans deployed during the RRP grant performance period and reconcile the totals to the underlying loan data. Action Taken: Vantage west will enhance its reporting to our third party CDFI reporting consultant to clarify and fully define borrower data points, in support of improving the accuracy of financial products reported annually on the Performance Reports to the CDFI Fund.