Corrective Action Plans

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.

2022-001 - U.S. Department of Health and Human Services - Nebraska Department of Labor ? Temporary Assistance for Needy Families ? 93.558 Criteria or Specific Requirement ? Management is responsible for implementing and effectively operating internal controls over compliance to mitigate the risk of misuse of the Organization?s federal funds and ensure participating students are eligible based on financial need. The Temporary Assistance for Needy Families (TANF) funds may be used for expenses related to Job?s for America?s Graduates (JAG) Program, which helps low-income students with additional resources in middle and/or high school to help the students graduate. To be eligible for the JAG Program, which is funded by the TANF funds, the students must be low-income, evidenced by qualification for free or reduced lunch. Planned Corrective Actions (Management's Response) - United Way of the Midlands (UWM) has reviewed and updated its policies, procedures and training within the JAG Program to improve retention of eligibility documentation and, in the event such documentation is no longer available, document the validation of eligibility requirements used to support Management?s decision on the applicant?s eligibility. This is fully documented in our Quality Assurance SOP (Standard Operating Procedures). UWM also implemented an additional detective internal control in our JAG Nebraska Invoicing SOP that requires a UWM Finance member independent of the eligibility onboarding process to audit monthly a small sampling of students for proper documentation and eligibility related to TANF invoicing. Management will monitor this regularly throughout the year to ensure procedures are being followed as documented. All changes have been implemented. Anticipated Completion Date - October 15th, 2022

The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings ? Federal Award Program Audit Finding 2022-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs Federal Catalog Numbers: 14.871 and 14.879 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 5,068 units. Of a sample size of fifty-nine (59) tenant files, the following was noted: - HUD 9887 Form was missing in 4 files - Annual HUD 50058 recertification form and verification of income and assets was missing in 1 file - Lead based paint disclosure form was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: $59,947 Cause: There is a significant deficiency in compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly maintained tenant files in compliance with program requirements following the expiration of HUD waivers as a result of insufficient staffing. Effect: The Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs are in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement a corrective action plan 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. Following the expiration of the COVID-19 HUD regulatory waivers, the Authority experienced a large backlog of reexaminations along with higher than usual rates of staff turnover and other staff capacity challenges related to the pandemic. Authority management has developed and implemented a plan to rapidly work through the backlog, bringing the program into compliance. Current HUD SEMAP data reflects that 96% of reexaminations have been completed in a timely manner, which is high enough to provide full points for this SEMAP indicator. Authority management will continue to monitor and strive towards 100% timely recertifications by the end of this fiscal year. Aaron Pomeroy, Finance Director, will be responsible to implement this corrective action by June 30, 2023.

Finding Reference 2022-009 Contact Person: Gerald Moench, Interim CFO (or Emily Buckley, VP of Advancement) Views of Responsible Officials and Planned Corrective Action: In including the questioned indirect cost as a HEERF expense, management only considered the per unit cost threshold, rather than both the per unit cost and the expected life of the items. The audit clarified the regulations and Donnelly promptly notified our program officer, posted a corrected quarterly report and refunded the funds to the Department of Education. Anticipated Completion Date: October 2022

Finding Reference 2022-007 Contact Person: Stephani Berry Views of Responsible Officials and Planned Corrective Action: These Pell recipients are from the 2nd Chance Pell Grant Experiment and guidance has been inconsistent in the awarding process, resulting from staffing issues and high turnover. Student credit hours are now determined using the correct Pell Grant Payment Schedule and awarded accordingly. Verification process includes reviewing student's maximum lifetime Pell award percentage of 600%. Anticipated Completion Date: July 1, 2022

FINDING 2022-002 As a result of the 2022 Single Audit, the Department of Housing (DOH) received an audit finding with respect to potential unallowable rental assistance payments made because of an internal control failure in the case management workflow that did not adequately segregate reviewer and approver duties. As a corrective action, DOH terminated its contractual agreement with its program administrator effective May 12, 2023. To disburse the remaining emergency rental assistance dollars, DOH has entered into a contractual agreement with the Illinois Housing Development Authority to be its new program administrator effective June 30, 2023. DOH is actively investigating questionable cases to quantify the total population and dollar amount of ineligible payments made. In addition, DOH is reviewing its case management workflow procedures to ensure clear segregation of duties in any future rental assistance program. Daniel Kay Hertz, DOH Director of Policy, will be responsible for ensuring that this corrective action plan is fully implemented by January 1, 2024.

Finding 2022-002 - Management will continue to accumulate proper supporting documentation to support their compliance with the eligibility compliance requirement and to provide such documentation, when legally possible.

Finding No. 2022-004 Criteria: The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 1 and Period 2 reporting required an organization to illustrate how PRF funds received were used. An organization was allowed to include eligible expenditures from January 1, 2020 through December 31, 2021 depending on the period reporting. Condition: During the process of identifying expenses that were incurred to prevent, prepare for, or respond to the coronavirus pandemic, management included expenses incurred in January 2020 and February 2020 which were not supported by management in relation to prepare, prevent, or respond to coronavirus as these were incurred prior to when the Hospital began to prepare for coronavirus. Planned Corrective Action: Management will continue to refine processes to review reporting requirements and the accumulation of eligible expenditures per the terms and conditions of the PRF and reporting guidance provided by HRSA. However, the Hospital also incurred and reported sufficient unreimbursed expenditures attributable to coronavirus in the PRF reporting portal that if the noted item were not to be reported, the Hospital would have satisfactorily incurred eligible expenses in excess of PRF funds received, including interest earned on such funds. Planned Completion Date: Ongoing Person Responsible: Crystal Wyatt, CFO

September 14, 2023 Corrective Action Notice Community Action Resource & Development, Inc. FISCAL YEAR END DATE: 12/31/22 The audit citation of a staff incident wherein net rather than gross income was utilized is most regrettable and an obvious error. Appropriately, the staff person was notified and the error was corrected. Retraining and relevant corrective action was taken. All persons who figure income eligibility received training and notifications regarding this failure to follow instructions. I and my staff feel certain that no further incidences of this outcome will happen in the future. Measures have also been placed on persons reviewing files and entering data for reporting purposes will double check the income eligibility to ensure correctness. Please know that our good intentions and continued efforts to accomplish clean and reliable audits is paramount.

ALN No. 97.036, Disaster Grants ? Public Assistance (Presidentially Declared Disasters); Award Number: 033-UECF5-00; Award Year: January 1, 2020 to July 1, 2022; Pass-Through Entity: State of Washington Military Department Emergency Medicine Division; Award Number: D20-368 Finding: Activities Allowed or Unallowed ? The controls were not sufficient to ensure that purchase orders issued for capital purchases were fully fulfilled and paid prior to submission for program reimbursement. Status: Corrective action in progress. Corrective Action: Internal controls will be strengthened in future periods to ensure that costs are incurred prior to submission for program reimbursement. Instead of tracking purchase orders issued we will utilize general ledger details ensuring only purchase orders with receipts and subsequent invoices are included in reimbursement requests. The accounting team will pull invoice and payment support which will be reviewed by the Director of Finance prior to submission to ensure all expenditures have been paid prior to submitting a request for reimbursement. Person(s) Responsible for Implementing: Jenna Bevilacqua, Director of Finance and Lindsey Soboloski, Controller Implementation Date: March 20, 2023

ALN No. 93.498, Provider Relief Fund; Award Year: Periods 2 and 3: July 1, 2020 to June 30, 2021 Finding: Activities Allowed or Unallowed ? The controls were not sufficient to ensure that depreciation expense for capital purchases were excluded when the capital expense was also submitted for program reimbursement. Status: Corrective action in progress. Corrective Action: Internal controls will be strengthened in future periods to ensure that ledger details are appropriately filtered to exclude depreciation expense for costs already considered during the review of capital expenditures. The Director of Finance will review ledger details prior to submission to ensure only appropriate ledger accounts are included in requests for reimbursement. Person(s) Responsible for Implementing: Jenna Bevilacqua, Director of Finance and Lindsey Soboloski, Controller Implementation Date: March 20, 2023