Corrective Action Plans

Mamage1nent will enhance their review controls over the documentation in the files for individuals serving on the program, to ensure compliance with all documentation requirements that support the National Service Criminal History Checks. Program Management will require staff to obtain a file review and a signature from the Program Director before any volunteer can be placed verifying that no incorrect spelling/typos of names were submitted for background checks and all verification documentation is included in the file. This procedure will be incorporated within the volunteer recruitment and onboarding guide and training on this for all program staff will be required. Name of contact person: Emily Marble, Director of Community Programs, 203-752-3059, extension 2906, emarble@aoascc.org. Projected Completion Date: Volunteer recruitment and onboarding procedural guide will be updated and reviewed with program staff by March 30, 2023. Director's confirmations of background checks will be an on-going process. If the Office of Management and Budget has questions regarding this plan, please call Emily Marble at 203-752-3059, extension 2906.

2022-001 Finding: Missing eligibility forms for Title X Patients Planned Parenthood of Greater Texas (PPGT) was awarded a five-year Title X grant in March 2022. At that time, it was necessary to write new policies, develop forms, trainings, and provide staff education on Title X expectations. The 2023 financial audit was the first audit of Title X since PPGT regained the program a year earlier. The audit identified gaps in understanding of front-line staff and PPGT policy. Corrective Action Plan Annual Title X training will be provided to staff Title X centers in mid-June 2023. The training will include expanded direction and provide clarity for the staff regarding the expectations around eligibility forms. In April 2023, the Sr. Grants Project Manager began performing monthly chart audits across all Title X sites to assess compliance with the 340b program. The audits review ten charts from each Title X center, chosen at random. The criteria include looking for evidence demonstrating compliance with the requirement that an eligibility Form is completed with income information and signed by the patient. Following an audit, a report is provided to the 340b committee and further corrective action will be taken as needed.

The City of Corpus Christi?s Responsible Official(s) will work with HUD to determine the nature of demolition costs and ensure all demolition costs are being appropriately expended under the grant agreement and ensure costs reported through the Consolidated Annual Performance Evaluation Report have the correct IDIS numbers. Person Responsible: Leticia Kanmore, Grant Monitoring Manager, Neighborhood Services Anticipated Completion Date: May 31, 2023

Finding 2022-001- Eligibility Condition During our audit, for 1 out of 40 individuals selected for testing, the Organization did not maintain eligibility or self-certification documentation. Corrective Action Plan Corrective Action Planned: The Organization agrees with the finding. In the future, the Organization will no longer be accepting paper applications for this program due to the efficiency of tracking online applications. Name(s) of Contact Person(s) Responsible for Corrective Action: Robert Nicolella, Executive Director and Susan Mazza, Finance Administrator Anticipated Completion Date: November 2022

"""Condition: HUD guidelines regarding the EIV system were not followed and the EIV system reports were not utilized timely during 2022. Planned Corrective Action: Management has implemented guidelines and trainings surrounding the use of the EIV system. Management will continue to monitor the appropriate use of the EIV system. Contact person responsible for corrective action: Julie Reed, Housing Accounting Manager Anticipated Completion Date: December 31, 2023 "" "

CORRECTIVE ACTION PLAN March 27, 2023 Health Resources and Services Administration St. Thomas East End Medical Center Corporation and Affiliate respectfully submits the following corrective action plan for the year ended February 28, 2022. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: February 28, 2022 The findings from the February 28, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS ? FINANCIAL STATEMENT AUDIT Finding 2022-001 ? Pension MATERIAL WEAKNESS Recommendation We recommend that the Center implement policies and procedures that allow for the timely payments of the pension plan payments. Action Taken & Completion Date The Center is working hard to make sure that all pension payments are made on time by strengthening our controls to ensure that the pension payments process is monitored properly. Completion Date October 1, 2023 Finding 2022-002 ? Account Analyses MATERIAL WEAKNESS Recommendation We recommend that the Center ensure that all accounting records are analyzed and reconciled on a monthly basis. Action Taken & Completion Date Management is working with staff to ensure that all accounting records are reviewed, analyzed and reconciled on a monthly basis. A new Chief Financial Officer started working at the Center on April 3, 2023. We are in the process of working together to create tighter protocols within the financial department. COMPLETEION DATE: October 1, 2023 FINDINGS ? FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance Listing Number 93.224/93.527) Finding 2022-003 ? Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee scale is calculated properly. Action Taken St. Thomas East End Medical Center has already provided some training to staff regarding the Sliding Fee Discount Program and is in the process of developing a training area within the Business Office to ensure the staff is appropriately trained regarding the scale. We are also creating new processes for quality improvement and compliance. Completion Date October 1, 2023 Finding 2022-004 ? Reporting MATERIAL WEAKNESS Recommendation We recommend that the Center establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the financial statement audit is submitted on a timely basis to the federal government. Action Taken & Completion Date St. Thomas East End Medical Center is currently onboarding new leadership. As a part of this change, we are working diligently to ensure that the Business Office is restructured, to include development of quality controls, appropriate processes and procedures surrounding analysis and reconciliation of accounts. We are also working with team to ensure that all reporting is done on time. Completion October 1, 2023 If the Health Resources and Services Administration has questions regarding this plan, please call Tess G. Richards, M.D. Interim Executive Director at 340-775-3700, ext. 3023. Sincerely yours,

Finding: 2022-002 Name of Contact Person: Nicole Alston Corrective Action/Management?s Response: The WIC Director, Clerical Supervisor or designee will randomly audit a minimum of 10 Crossroads records at least quarterly for quality assurance. WIC has revised the audit tool to include additional eligibility criteria (attached for review). Proposed Completion Date: Immediately and Ongoing

BRIGHAM YOUNG UNIVERSITY-HAWAII Management's View and Corrective Action Plan Finding 2022-001- Non-Compliance with Timely and Accurate Student Enrollment Change Submissions to the National student Loan Data System (significant Deficiency) Grantor: U.S. Department of Education Program : Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant program Award Years: 7/2021 - 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan Corrective Action Plan: Due to the NSLDS outage as announced by the U.S. Department of Education Federal Student Aid's (FSA) office, we were unable to submit enrollment rosters for the period of July 19,2022 through February 28, 2023. Therefore, we are continuing to implement the following corrective action plan to address both the prior year and current year issues as discussed below. The current year finding is the result of three separate reporting issues. The first issue is a repeat finding from the 2021 fiscal year audit (2021-001) related to inaccurately reporting the status of graduated students. When graduation files were sent to the National Student Clearinghouse (NSC), many could not be processed due to the "G" status not being applied when students were reported as graduated. Because of this, the NSC was not sending graduation information for some students to the National Student Loan Data System (NSLDS). Therefore, to appropriately resolve this issue, Daryl Whitford, Registrar, will regularly access the NSC dashboard, prior to submitting of monthly enrollment report, to promptly identify and resolve any reporting issues to ensure NSLDS has the correct information for students. The second issue is a repeat finding from the 2021 fiscal year audit (2021-001) and is the result of inappropriate configuration of each semester's credit load determinations (i.e., how many credits constitute full time, three quarter time, half time, etc.) into PeopleSoft. As a result of the inappropriate configuration, certain student statuses were reported incorrectly given the number of credit hours the student was attending. To ensure accuracy of each semester's credit load determinations, at the beginning of each semester, Daryl Whitford, Registrar, will review and approve the credit load determinations prior to them being pushed into PeopleSoft. This will ensure that PeopleSoft is configured to communicate the appropriate statuses to the NSLDS. The third issue referenced the reporting of the correct program begin dates. When a student returns from a leave of absence or an internship, PeopleSoft updates the students program begin date for the students return date rather than the original program begin date. Daryl Whitford, Registrar, will perform a review of program begin dates for students returning from a leave of absence to ensure the proper program begin date is reported. In addition, we will review if any PeopleSoft enhancements can be made to provide additional comfort that the program begin dates are accurate in these circumstances. Daryl Whitford, Registrar, who is responsible for enrollment reporting at Brigham Young University- Hawaii will continue to provide training to staff who participate in enrollment reporting to ensure that they are aware of the campus and program enrollment changes to be reported, the details to be reported for each change, and the importance of submitting changes timely. Also, Daryl Whitford, Registrar, will oversee the implementation of a control wherein the University will sample students from each roster submission and trace the information from the batch file back to the supporting documentation to ensure that the information included in the batch roster file is accurate. Timing: Daryl Whitford, Registrar, will be responsible to oversee that the items as noted in the Corrective Action Plan section above will be implemented by July 1, 2023. Signed and Acknowledged Daryl Whitford Registrar

2022-2 Condition: Deficiencies Noted in Examination of New Construction Section 8 Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents. Management has implemented procedures in order to clear this finding in FY 2023. Timeframe: By FYE December 31, 2023 Individual responsible for correction: Ms. Zena Zahran, Executive Director

Finding Number: 2022-004 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant policies for assets and child support non-coop with Eligibility workers on the Family Team to provide additional support and guidance for processing of these cases. Anticipated Completion Date: 8/31/2023

Finding Number: 2022-003 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant policies for assets and child support non-coop with Eligibility workers on the Family Team to provide additional support and guidance for processing of these cases. Anticipated Completion Date: 8/31/2023

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan The prior year corrective action plans were successful in addressing the issues identified in previous audits in enrollment reporting. These additional steps will be taken to address the new issues found during the 2022 audit within enrollment reporting, which resulted in a repeat finding of 2021-001. Grayson Layton, Registrar, will review the College?s policies and procedures surrounding student enrollment and enrollment reporting, starting in May 2023 specifically as it relates to students that have withdrawn that are expected to return in the subsequent semester but fail to reenroll. Any changes in the College?s policies and procedures will be appropriately documented and communicated to the individuals involved in updating student enrollment information in the system. Additionally, Enrollment Services will work with a PeopleSoft consultant and technical staff to customize our Student Information System to allow for the correct reporting of student status to the National Student Clearinghouse (NSC). Technical staff and a consultant will be engaged to perform an evaluation of all systems and practices related to enrollment reporting. The Enrollment Services and Financial Aid and Scholarships Offices will use various NSC and National Student Loan Data System (NSLDS) error reports to ensure student enrollment information, including program level information, is reported in an accurate and timely manner. Timing Grayson Layton, Registrar, will work with consultants and technical staff starting in May 2023 to begin making necessary adjustments to the Student Information System to allow for accurate reporting of student enrollment information and to evaluate systems and practices related to enrollment reporting. They will meet monthly throughout the year to monitor their progress with an expected completion in December 2023. Grayson and Riley Niemand, Manager of Financial Aid, will coordinate the use of NSC and NSLDS error reports to identify students with reporting errors. This process will be complete in June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

CORRECTIVE ACTION PLAN May 30, 2023 United States Department of Health and Human Services Richland Medical Center, Inc. d/b/a Central Ozarks Medical Center respectfully submits the following corrective action plan for the year ended November 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: November 30,2022 The findings from the November 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCIES Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), and Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 2022-001 Recommendation The Center should ensure that internal controls are in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken In May 2022 COMC hired a Sliding Fee Coordinator. This position reviews all new slide fee applications to ensure all required documentation is present and that the correct slide scale has been applied. This position also reviews current slide applications for patients that are sacheduled for upcoming appointments to ensure paperwork is current or if paperwork is outdated a new application is received. This position also monitors and trains staff on the slide fee process. The finding from this year was prior to the position being filled in 2022. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sabrina McAfee, CFO at (573) 836-7079. Sincerely yours, Sabrina McAfee Chief Financial Officer

2022-002 Ineligible Expenditures Federal Program: Housing Choice Voucher Program, CFDA No. 14.871 Criteria: All payments must be eligible items under federal guidelines. Condition: During the fiscal year ending June 30, 2022 CARES Act funds were used to provide funds to the board members. Each board member was provided a check in the amount of $2,500. Two of the board members returned their check prior to cashing them once they found out it was not allowed. Questioned costs: $5,000. Effect: Payments were made that are not allowable under HUD of federal guidelines. Cause: PHA was not aware of the limitations in place for payments made to board members. Repeat Finding: This finding was reported in the prior audit as item 2021-002. Recommendation: Reimbursement for the payments should be made to the Housing Authority. Views of responsible officials and planned corrective actions: We have begun the process of reimbursing the amounts paid to the board members and will refrain from making these payments in the future.

Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID 19 HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund Management agrees with this finding and performed a review of claims submitted to the HRSA COVID 19 Uninsured Program identifying payments for ineligible services and refunded the entire overpayment amount. In March 2022, HRSA announced the discontinuance of the HRSA COVID 19 Uninsured Program, and therefore, remediation of internal controls is no longer applicable. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.

Processes are being implemented.

2022-003 – Eligibility Rent Calculations – ALN#14.850 – Public & Indian Housing The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Federal Public Housing program compliance, including an update to the Admissions and Continued Occupancy Policy (ACOP), retraining for all Public Housing staff and implementation of initial and recertification checklists as well as regular QC audits. Planned Implementation Date of Corrective Action Reminders to Staff regarding appropriate verification of all income: Completed Updates to Section 8 Administrative Plan and ACOP: 12/31/23 Retraining of staff, checklists and QC audit procedures: 6/30/24 Person(s) Responsible for Corrective Actions: Paul Dettman, PHA Consultant Tracy Pero, Section 8 Staff Leased Housing Program Manager Senior Public Housing Manager

2022-001 – Eligibility Rent Calculations –ALN#14.871 – Housing Voucher Cluster The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Section 8 program compliance, including an update to the Section 8 Administrative Plan, retraining for all Section 8 staff and implementation of initial and recertification checklists as well as regular QC audits. Planned Implementation Date of Corrective Action Reminders to Staff regarding appropriate verification of all income: Completed Updates to Section 8 Administrative Plan and ACOP: 12/31/23 Retraining of staff, checklists and QC audit procedures: 6/30/24 Person(s) Responsible for Corrective Actions: Paul Dettman, PHA Consultant Tracy Pero, Section 8 Staff Leased Housing Program Manager Senior Public Housing Manager

Corrective Action Plan: Management concurs with the finding and a reconciliation of costs charged to the SVOG award was provided to the auditors after requested. Management will implement procedures to ensure that a timely reconciliation of costs is maintained for costs charged to any future Federal awards. Name of Responsible Person: Mike Stone, COO Anticipated Completion Date: January 31, 2024

Compliance: Finding 2022-002 – U.S. Department of State - Citizen Exchanges – CFDA No. 19.415 See finding 2022-001 for action taken.

COVID-19 Educational Stabilization Fund: HEERF Institutional Portion – Assistance Listing No. 84.425F Recommendation: We recommend the University review internal control reports and implement review controls for work performed by third party servicers. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. The University is utilizing Visual Compliance to assess all vendors for suspension and debarment but will obtain and document the review of the SOC 2 report for Visual Compliance annually. Name(s) of the contact person(s) responsible for corrective action: Scott Schlotthauer, Chief Procurement Officer at Oklahoma State University. Planned completion date for corrective action plan: December 2023

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University review internal control reports and implement review controls for work performed by third party servicers. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. The University is already utilizing Visual Compliance to assess all vendors for suspension and debarment but will obtain and document the review of the SOC 2 report for Visual Compliance annually. Name(s) of the contact person(s) responsible for corrective action: Scott Schlotthauer, Chief Procurement Officer at Oklahoma State University. Planned completion date for corrective action plan: December 2023

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate its procedures around disbursements of loans and ensure that notifications of disbursements are sent and contain all of the required elements outlined in the FSA handbook. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. Loan disbursement procedures and processes are being updated to ensure notifications are sent as outlined in the FSA Handbook. The University will develop policies and procedures to ensure compliance with the FSA Handbook. Name(s) of the contact person(s) responsible for corrective action: Sheila McGill Executive Director, Financial Aid & Scholarships, Langston University. Planned completion date for corrective action plan: January 2024

Recommendation: Established procedures to either identify and track eligible loans deployed during the RRP grant performance period or establish a method in which to validate the analysis and data provided by Inclusiv. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will ensure we are able to identify eligible loans deployed in the TM in the future.

The third-party service provider has provided SOC1 reports that appear to have resolved the internal controls. The service provider will continue to provide SOC 1 reports through Fiscal Year 2024. The IDES will review to ensure that appropriate controls remain in place.