Corrective Action Plans

Finding No. 2022-001 Significant Deficiency Personnel Responsible for Corrective Action: Jim Slattery, Chief Financial Officer Anticipated Completion Date: March 31, 2023 Corrective Action Plan: Management for the St. Louis Public library will review all processes associated with checking out equipment and make necessary revisions to processes and procedures to ensure all staff are properly trained to successfully execute all transactions.

C. Corrective Action Plan: ACED will use JDE?s actual fringe bene?t rates rather than the blended rate provided to the Department by the County?s Budget Of?ce each year. On August 22, 2023, ACED reached out to the Controller?s Of?ce Senior Analyst and the Assistant Manager of the J DE Service Center to request a ReportsNow report to help with this task. The report will provide ACED with JDE grand totals for a job for a given period as well as employee details from payroll to help the Department report more accurately on actuals for correct cross-charges.

Condition - Peak Vista determines the sliding fee discount charged to patients based on the patient's annual gross income and household size. We found two encounters where applications were not retained. Therefore, we could not determine if the sliding fee discount applied was in accordance with the guideline. We found two separate encounters where the patient did not meet the guidelines to receive a discount. We found one separate encounter where the patient was charged an incorrect co-pay. Recommendation - We recommend that Peak Vista's procedures be strengthened to ensure income is properly verified and adequately documented and retained. Peak Vista should strengthen processes surrounding monitoring of the program to ensure the Center's policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions - Management agrees with the finding. Peak Vista has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the enrollment and eligibility process, including our Enrollment, Reception, and Billing teams will be retrained on the process with emphasis on proper documentation. Peak Vista management plans to incorporate into our quality assurance audits the documentation for single service date discount applications and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion - In progress, estimated completion 12/31/2023. Action Taken - We have reviewed the recommendation and have a corrective procedure in place for addressing this issue. Will continue to monitor improvement. Person Responsible for Corrective Action Plan - Ryan Spillane, CFO

Condition: Monthly Claim for Reimbursement included second meal claims in excess of two percent of the number of first meals served to children for each meal type. Plan: Implement additional procedures to ensure the accuracy of meal counts prior to the submission of the monthly Claim for Reimbursement such as but not limited to training and conferences. Additionally, the District should contact the Illinois State Board of Education for further recommendation on this finding. Anticipated Date of Completion: 6/30/2023 Name of Contact Person: Thomas Akers, Superintendent Management's response: There is no disagreement with this finding and procedures will be implemented. The District will contact the Illinois State Board of Education for further recommendation.

Findings 2022-001 through 2022-007 During 2020 and 2021, the Organization had gone through a significant amount of turnover at the management level and in the Finance department. These changes have resulted in the identification of a significant lack of internal controls as well as a lack of resources. The Organization has gone through a process of hiring new Finance positions and engaging outside consultants as needed. With a change in leadership and an increase in resources, the Organization is in the process of implementing a system of internal controls that will focus on segregation of duties related to all significant transaction cycles (including monthly close procedures), increasing communication and transparency of transactions within the Organization, and a heightened sense of documentation to support all transactions, including grant funded activity. The goal of implementing this system of controls is to mitigate the risk of any wrongdoing, intentional or unintentional, at the Organization and to allow for proper compliance with restrictions set forth by government agencies. Responsible party: Scott Forbes; Executive Director; (978) 873-0916 Anticipated completion date: June 30, 2023

2022-001 ? ALN 14.871 ? Section 8 Housing Choice Vouchers Program - Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Tyronnda Bethune, Executive Director Projected Completion Date: September 30, 2023 2022-002 ? Significant Deficiencies in Internal Controls over Financial Reporting Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Tyronnda Bethune, Executive Director Projected Completion Date: September 30, 2023

2022-002: Lack of Documentation for Review of Tenant Files Name of contact person: Nancy Cashman, Executive Director Corrective Action: The Corporation created written policies and procedures for affordable housing program compliance and review of the applicable tenant files in fiscal year 2023 and is in the process of adopting these policies and procedures. Proposed completion date: The Organization plans to complete the plan by September 30, 2023.

MATERIAL WEAKNESS 2022-009 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Activities Allowed or Unallowed Condition Students were awarded HEERF aid in June 2022 based upon their outstanding account balance, and they were not given the option to take the disbursement as anything other than a credit to their account. Recommendation We recommend that the institution carefully review guidance regarding new funding sources in order to ensure that all applicable requirements are being met. Actions Taken As of April 1, 2023, the College has contacted the Department of Education in order to determine how best to remedy the situation and will take all actions recommended.

SIGNIFICANT DEFICIENCY 2022-007 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered that two students were over awarded subsidized direct loans. Recommendation We recommend that the institution implement controls to ensure that direct loan award amounts are reviewed for accuracy prior to making awards to students. Actions Taken As of March 23, 2023, the College has begun to implement a review of student awards that will include reviewing all aid and credits that the student is receiving and double checking NSLDS loan amount limits.

SIGNIFICANT DEFICIENCY 2022-005 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered one student was incorrectly awarded Pell, and two others did not receive Pell disbursements for both eligible semesters attended during the year. Recommendation We recommend that the institution implement controls to ensure that all scheduled disbursements are ultimately posted. In addition, when calculating Pell awards, the Payment and Disbursement Schedule that matches the student?s enrollment status should be carefully selected and applied. Actions Taken As of March 23, 2023, the scheduled Pell awards for the two noted students have been posted and disbursed. In addition, an additional review step has been implemented to take place before any aid disbursements are made.

FINDING NO. 2022-002: Section 202 Supportive Housing for the Elderly, CFDA 14.157 Recommendation: The Project should verify initial tenant income through the EIV system in a timely manner and ensure all required background checks are performed prior to a tenant moving in. Action Taken: Managers have been retrained on procedures for using the EIV system to verify tenant income and to perform background checks timely. Compliance will conduct periodic checks to see if reports are pulled and maintained in the tenant file, as required. If the Oversight Agency for Audit has questions regarding these plans, please call Christine Harris at 954-835-9200. Sincerely yours, Christine Harris Accounting Manager

Finding Number: 2022-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Robert Benson Todd McMurray Corrective Action Planned: Chisago County will implement additional procedures to provide reasonable assurance that all necessary documentation is properly inputted or updated in MAXIS. This will include internal staff training/updates at monthly unit meetings on the importance of accuracy in our case files. Our agency will also be implementing internal supervisory case reviews to ensure accuracy practices are being followed. Anticipated Completion Date: Our corrective action plan will be implemented immediately and ongoing.

2022-004 Community Health Centers Grant ? Assistance Listing No. 93.224/93.527 Recommendation: Management should refine and expand its internal audits of patient visits to identify instances where a patient was either assigned to the incorrect sliding fee category or billed the incorrect charges. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has instituted some measures and procedure to mitigate the risk of having patients being assigned to incorrect sliding fee category or billed the incorrect charges. These additional measures and procedures include but are not limited to providing training and more oversight of the front desk and billing staff. More oversight such as regular and ongoing internal audits of the front desk and billing staff will be contacted on a quarterly basis. The objective of the regular audit is to ensure that all policies and procedures are being followed and to ensure any instances of non-compliance are timely identified and corrected. Name(s) of the contact person(s) responsible for corrective action: Matthew White, Shannon Courson, Asante Muyungga Planned completion date for corrective action plan: August 7, 2023

2022-001 Eligibility ? Tenant Files Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 ? Housing Choice Vouchers 14.879 Mainstream Vouchers Material Weakness in Internal Control, Material Noncompliance Repeat finding of finding 2021-002 from the prior year September 30, 2021 Condition: Out of a total tenant population of approximately 573 tenants, 25 files were selected for testing. Exceptions were noted as follows: ? 1 file that did not contain a 214 affidavit for one member of the household, however they did have a birth certificate showing they were an eligible citizen. ? 2 files where the 214 affidavit was not checked for one member of the household certifying they were an eligible citizen, however they did have birth certificates to verify their citizenship. ? 5 files that did not contain a signed Form 9886 for at least one member of the household age 18 or over. ? 1 file where the tenant?s income was calculated correctly but had the wrong amount reported on the 50058, which would have decreased HAP rent by $11. ? 1 file where the prior year utility allowance schedule was used instead of the current year, however this had no effect on HAP rent. ? 1 file where there was no support that an inspection had been done for a new admission. ? 1 file that did not contain a tenancy addendum to support the contract rent and HAP rent for a tenant with a project-based voucher. ? 2 files where there was no support that an EIV report had been processed. In addition to the above, we noted the following during our new admissions testing ( new admissions tested): ? 3 files that did not contain a passed inspection completed prior to move-in. ? 1 file that did not contain a signed lease agreement or tenancy addendum. ? 1 file where the request for tenancy approval was not executed until the day after the voucher had expired. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: Errors were corrected in the tested files where corrections could be made. Meaning for example Form 9886 cannot be regenerated for this audit period but will be obtained during future annual recertification (also known as the personal declaration/application) periods. Adjustments will be made to the tenant accounts. Staff was informed to obtain Form 214 during all recertification re-examinations to ensure the required form is in the file. This way, if it was never obtained or if it was inadvertently purged, the file will always have a copy in the file for the review period. File Audit: A file audit (not a 100% audit) was completed for the Housing Choice Voucher Program. A procured third-party vendor performed this process. However, previous staff members did not make the file corrections. For months, there was only one staff member in the HCV Department. The department, at this time, is fully staffed. The current staff is making the file corrections as they come across various issues while moving the program/department forward. Of importance to note is the hire of a new Chief Operating Officer with over twenty (20) plus years of HCV experience who will oversee the Section 8 Department. We believe the new leadership, to include CEO and COO positions will provide the necessary oversight of the HCV program that will improve the overall performance of staff and the program. Quality Control Review: After completion of the file audit, the Housing Choice Voucher Program Manager and their supervisor will be responsible for documented monthly quality control reviews of 10% of files completed during the month. Effective Date: June 22, 2023 Contact Information Marcus Goodson, Interim Executive Director Sanford Housing Authority 1000 Carthage Street Sanford, North Carolina 27330 (919) 776-7655

Project Legal Name: Geneva Avenue Elderly Housing, Inc. HUD Project No.: 023-EE-110 Audit Firm: Cohnreznick LLP Period covered by the audit: 7/1/2021 ? 6/30/2022 Corrective Action Plan prepared by: Name: Amy Lawton Position: Regional Manager Telephone Number: 617-209-5266 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendation in the finding. b. Action(s) Taken or Planned on the Finding In order to verify that all EIV reports are being run in accordance with HUD regulations, an internal audit will be performed on a routine basis. This audit will be conducted by a Senior Manager, a Regional Manager, or by a member of the Compliance Department. This internal audit will be performed at the end of each fiscal quarter. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations N/A

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