Corrective Action Plans

Corrective Action: The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into departmental procedures. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated September 2026.

Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal control process should include a formal way to document the review and approval of Fire Safety salary costs charged to the grant to provide evidence that internal controls are effectively designed and implemented and functioning in a timely manner throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The City has authorized a full-time grants specialist position within the Finance Department to oversee the administration of grants separate from the programming department. The City will strengthen internal controls over grant compliance by implementing formal policies and procedures for allowable costs, documentation, and review. All grant expenditures will be reviewed and approved by Finance prior to submission, with supporting documentation maintained for eligibility determinations. Name(s) of the contact person(s) responsible for corrective action: Rebecca Holden Planned completion date for corrective action plan: 6/30/2026

Program Name: Emergency Housing Voucher (EHV) Program (Housing Voucher Cluster) 14.EHV During the audit of the financial statements for the year ended September 30, 2025, testing of Emergency Housing Voucher (EHV) program activity identified that approximately $90,317 of EHV funds were used for activities outside of the EHV program - specifically, within the Moving to Work (MTW) Demonstration Program - without a waiver or approval from HUD. EHV funds are restricted to activities allowable under the EHV program and are not subject to MTW funding fungibility; any application of MTW administrative flexibilities to EHV vouchers requires HUD approval before implementation. The Authority did not maintain adequate controls to ensure EHV funds were restricted to allowable EHV expenditures or to verify that appropriate HUD approval was obtained prior to using EHV funds for non-EHV activities. As a result, federal funds may have been expended for purposes not authorized under the EHV program, resulting in noncompliance with federal requirements and questioned costs of $90,317. This condition represents noncompliance and a significant deficiency in internal control over compliance. Questioned Costs: $90,317 The Authority concurs with the finding and questioned costs of $90,317. The Authority will strengthen controls over federal program expenditures to ensure EHV funds are used solely for allowable EHV activities; establish procedures to obtain and retain documentation of any HUD approvals or waivers before applying MTW flexibilities to EHV vouchers or using EHV funds outside of their intended purpose; work with HUD to resolve the questioned costs; and provide staff training on EHV program eligibility and allowable-cost requirements.Timeline for completion: 3 months

Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that supervisors will properly follow up with staff during casefile review and will retain documentation supporting that evaluation. Name of the contact person responsible for corrective action: Steven Jones Planned completion date for corrective action plan: December 31, 2026

Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will work with program managers to improve eligibility verification documentation. Name of the contact person responsible for corrective action: Heather Goodwin Planned completion date for corrective action plan: December 31, 2026

Management agrees with the recommendations. During 2025, DVCH’s front desk staff started to assume more responsibility for conducting the sliding fee categorization. This additional staff had training and is gaining experience. Management will ensure training, monitoring, auditing, and supervision is adequate to ensure registration properly documents the signed sliding fee attestation form. DVCH expects to adopt a software solution for sliding fee categorization in 2026. The software solution will make common errors less common by automating several manual processes. If the Health Resources and Services Administration has questions regarding this plan, please call Ryan Taylor, Chief Financial Officer, at taylorr@dvch or 267-240-2578.

Name of contact person: Melissa Labra, Income Maintenance Administrator II Caseworkers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Caseworkers will receive training on the work number (TWN) in NCFAST learning gateway. Workers will be retrained on NCFAST evidence for resources to ensure procedures are being followed for evidence on dashboard to match the supporting documentation used as verifications. Workers will be retrained on determining who to count in the needs unit and adequate case file documentation. Workers will be retrained on the proper use of Medicaid Forced Eligibility. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Proposed Completion Date: August 31, 2026

Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct income evidence into NCFAST. Caseworkers will receive training on determining the correct base period to use for income calculations Caseworkers will receive training on the work number (TWN) in NCFAST learning gateway. Caseworkers will receive training on income and budgeting policy (MA 3300). Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly, including income calculations Proposed Completion Date: August 31, 2026

Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on completing complete and thorough case documentation. Caseworkers will receive additional training on inputting the correct evidence into NCFAST, including income evidence. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 31, 2026

Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers will receive additional training on obtaining adequate verifications for income. Caseworkers will receive additional training on completing complete and thorough case documentation. Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 30, 2026

Program(s): Supplemental Nutrition Assistance Program (SNAP) 10.561 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following instance of noncompliance in the sample of sixty case files tested: • One MAXIS case file did not have a re-determination of eligibility performed within the 12-month period. • One MAXIS case file did not have documentation of income verification. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered and the information required by the contract is retained in the County’s records. Hennepin County Employee Responsible for the CAP: Jennifer Frey, Human Services Area Manager for SNAP Planned Completion Date for CAP: December 1st, 2026

Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP program period each year.

The Authority will establish controls to ensure all certifications are completed timely and in accordance with requirements.

Finding Reference Number: 2025-001 for U.S. Department of Housing and Urban Development: Assistance Listing 14.195 Project-Based Rental Assistance (PBRA) View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Contact Person Responsible: Flynann Skeen, President/Executive Director, Equality Community Housing Corporation Joshua Allen, President, J. Allen Management Co. Inc. Completion Date: Open

Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Taken and Planned 1. Resolution of the two identified cases. The Hospital reviewed and resolved the two patient accounts identified in the audit sample in which an incorrect sliding fee discount percentage was applied: • In the first case, the discount applied resulted in a charge to the patient below the amount that corresponded under the correct Federal Poverty Guidelines discount tier, and a lower amount was collected from the patient. Management evaluated the account and determined not to retroactively bill the patient for the remaining difference, consistent with the Hospital’s mission and its policy of not creating barriers to care for patients eligible under the Sliding Fee Discount Program. • In the second case, the Hospital billed and collected from the patient an amount higher than the amount that corresponded under the correct discount tier. This case was resolved and the amount collected in excess of the correctly discounted amount was returned to the patient by check no. 95274, issued on May 29, 2026. Documentation of the refund is retained in the patient’s account file. 2. Questioned cost. The known questioned cost of $245.97 has been repaid and offset by the Hospital. Supporting documentation of the resolution is available for review by the awarding agency. 3. Current Federal Poverty Guidelines implementation. The Sliding Fee Discount Schedule will be updated to the current Federal Poverty Guidelines (FPG) issued annually by HHS, and a standing procedure will be established requiring that the updated schedule be approved and incorporated into the Hospital’s billing system (eClinicalWorks) within thirty (30) days of the annual publication of the FPG. 4. Review of sliding fee determinations. The review process over sliding fee discount determinations, which had previously been performed by the Billing Department and was later delegated to the information management staff, has been returned to the Billing Department to ensure that discounts are properly applied to patients in accordance with the Sliding Fee Discount Program policies and the updated fee schedule. 5. Strengthened internal controls. A secondary review control will be implemented under which a quarterly sample of new and renewed SFDP eligibility determinations will be re-verified by the Billing Department against the current FPG schedule, income documentation, and household size, with the results documented in a monitoring log subject to review by the Chief Financial Officer. 6. Training. Formal training on the SFDP policy, the current FPG schedule, and the related documentation requirements will be provided to all registration, billing, and eligibility staff, with attendance documented. Refresher training will be provided annually upon each FPG update. Anticipated Completion Date Items 1 and 2 – Completed. Items 3 through 6 – October 31, 2026.

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF THE TREASURY, COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS (CSLFRF) – FEDERAL ALN 21.027 AND U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT, ECONOMIC DEVELOPMENT INITIATIVE, COMMUNITY PROJECT FUNDING, AND MISCELLANEOUS GRANTS – FEDERAL ALN 14.251 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires City of Farmington, Minnesota (the City) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the Economic Development Initiative and CSLFRF federal programs. During our audit, we noted the City did not have sufficient controls in place within these programs to ensure compliance with federal requirements related to assuring that the City was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The City performed the required suspension and debarment verifications; however, documentation was not retained for two of the three vendors tested. To strengthen internal controls going forward, the City has implemented an updated procedure requiring staff to consistently retain documentation of suspension/debarment checks at the time of procurement for all federally funded contracts. This includes either (1) a SAM.gov screen print; (2) a copy of the contractor’s certification; or (3) a retained record of the method used. The Finance Director has reinforced this requirement with the responsible staff to ensure consistent and complete documentation going forward. Official Responsible – Kim Sommerland, Finance Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The City agrees documentation was not retained for two vendors. Plan to Monitor – The Finance Director will oversee compliance with the updated procedures and will conduct periodic spot checks to ensure documentation is consistently retained for all federally funded procurements.

2025-006: STUDENT MEAL APPLICATIONS Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: E. Eligibility Condition: During our testing of eligibility determinations under the Child Nutrition Cluster, we selected 40 student meal applications for review. Of the 40 applications tested, two applications were incorrectly classified based on the information provided on the applications. Specifically, one application was approved as free when it should have been approved as reduced, and one application was approved as reduced when it should have been approved as paid based on applicable eligibility guidelines. Action planned in response to finding: The District will ensure nutrition applications are reviewed to determine they meet the appropriate classification criteria. In addition, applications will be reviewed and approved by someone other than the initial individual that is recording the classification type. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Edward Dickie, Business Manager.

June 25, 2026 Dear Cognizant or Oversight Agency for Audit: DePelchin Children’s Center (DePelchin) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed below from the Schedule of Findings and Questioned Costs (the schedule) for the year ended December 31, 2025 is numbered consistently with the number assigned in the schedule. Federal Award Finding 2025-001 Corrective Action Plan: DePelchin has implemented an internal review process whereby a grant specialist on the evaluation team conducts a monthly review of all enrollments to verify that eligibility requirements, including priority characteristics and service area criteria, have been met. Program staff, evaluation staff, and data team members have been provided additional training on the applicable eligibility requirements and documentation standards. Additionally, DePelchin has implemented an annual cross-functional review process involving program leadership, evaluation staff, and fiscal representatives to review eligibility requirements and key contract provisions prior to the start of each fiscal year. This review is intended to ensure that any changes in program requirements are identified, communicated, and incorporated into program operations in a timely manner. Based on these corrective actions and enhanced monitoring procedures, DePelchin believes the risk of similar eligibility documentation issues has been substantially mitigated. Contact Person Responsible for Corrective Action: Mr. Brian Pate, Senior VP and CFO Anticipated Completion Date: The corrective action plan is anticipated to be completed by October 31, 2026. Respectfully submitted, Mr. Brian Pate Senior VP and CFO

Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.

Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for review at the time of audit. Method of Implementation: The district will improve the filing and retention of payroll timesheets and resolutions authorizing payroll expenses for federal programs. All payroll documentation will be properly maintained and made readily available for review at the time of audit.

Agency: Colorado Coalition for the Homeless Audit Period: 2025 Audit Finding Number: 2025-001 Audit Finding Title Sliding Fee Health Center Cluster Department of Health and Human Services Assistance Listing Number 93.224 Behavioral Health Services, 93.527 Bridge Access Program Award Numbers: 4 H8NCS53841-01-02 and 5 H80CS00040-24-00 Award Years: January 1, 2023-December 31, 2025 Criteria or Specific Requirement: Special Tests and Provision: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition: The Organization has a policy that includes homelessness when applying the sliding fee discount in addition to income and household size. The Health Center Compliance Manual only identifies income and household size as determining factors for the sliding fee program. Documentation to support income or household size were not maintained adequately for some patients who received sliding fee discount adjustments. Cause: The Organization's sliding fee discount policy includes homelessness, which is not specifically listed as an applicable determining factor for the sliding fee discount. The Health Center Compliance Manual specifically identifies income and household size as determining factors for the sliding fee program. Additionally, the Organization's controls did not clearly document eligibility for all patients with the sliding fee discount policy. Effect or potential effect: Other adjustments were not distinct from sliding fee adjustments applied to patient charges and, therefore, all patients received a full discount for services. Questioned Costs: None Context: A sample of 25 patients out of a population of 13,454 patients were tested.  Four of the patients sampled lacked appropriate documentation of income and/or household size. Seven of the patients sampled between 100% and 200% of the FPL were adjusted to no patient responsibility under the sliding fee discount program based on their homelessness status as identified in the Organization’s policy. The sampling methodology used is not and is not intended to be statistically valid. Identification as a repeat finding: Not a repeat finding. Recommendation: The Organization should revise its sliding fee discount policy to focus only on income and household size and further eliminate homelessness as a factor. Furthermore, the Organization should implement a process to review sliding fee discount eligibility to ensure compliance with its revised policy. Other adjustments should also be captured separately from sliding fee adjustments within the Organization's billing system. Views of responsible officials and planned corrective actions: The Organization agrees with the finding. Specific steps to be taken to correct the situation (including a timetable for performance of the CAP) or reason why corrective action is not necessary (including disagreement with the finding) NextGen, the electronic health record and practice management system CCH utilizes for revenue cycle operations has been reconfigured to separate the sliding fee adjustments from other adjustments. This was identified and corrected before the audit was completed on April 21, 2026. CCH will revise and update the Sliding Fee Discount Program policy to clarify that the only two factors for application of the sliding fee discount are family size and income. The Sliding Fee Discount Policy will no longer include ‘homelessness’ as a factor for this particular discount. CCH will review the sliding fee discount process regularly to ensure compliance with the revised policy. Additionally, appropriate documentation of self-attestation of income and family size will be collected as required. CCH will also revise and update existing policies related to Billing and Collections and for Waiving or Reducing Fees Beyond the Sliding Fee Scale to define the other discounts CCH provides to clients including those who do not provide complete data for sliding fee discount eligibility determination Finally, appropriate staff will receive updated training on the updated policies. Anticipated completion date The billing system change occurred on April 21, 2026. The policy revisions will be completed and approved by the Board by October 31, 2026 Training on the updated policies will be implemented upon final approval by the Board and be completed by November 30, 2026. Name(s) and title(s) of contact person(s) responsible for corrective action Billing system changes: Rob Plimpton, Controller /Kathy Hatfield, Interim Revenue Cycle Director Policies and Training: Andrew RobGrimm, Chief Integrated Health Operations Officer

A 100% review of applications was completed on October 10, 2025. The Food Service Supervisor will run an original direct certification before school starts and import that into Linq system. A 100% verification is completed in the fall. Each month a new direct certification is ran to catch any changes.

Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.

Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: In September 2025, the Organization began its transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. This went live in December 2025. We included mandatory eligibility fields and document upload requirements before service can begin. We developed SOPs to include a standardized eligibility checklist to be completed for all new and returning participants. Staff were trained on Pantry Soft usage, eligibility requirements and document retention stands. The Executive Team performed spot checks on these records but will begin documenting this procedure.

View of Responsible Officials and Corrective Actions: We agree with the auditor's recommendation. Although the referenced invoices were reviewed by the CEO from the vendor for eligibility and reasonableness upon receipt of the automatic e-mailed invoice, there was no procedure to print and retain this documentation in the accounting files for Instacart invoices. Effective June 1, 2026, each month the Director of Finance will compare a checklist of all credit charges to the physical copies prior to filing and obtain any missing invoices as part of the monthly closing process.