Corrective Action Plans

Finding Number: 2022-002 Title and Program Name: HUD Title 24 Part 982 - Section 8 Housing Choice Vouchers Program -CFDA No. 14.871 Category and Award No.: Internal Controls-Eligibility Form HUD-92006, Supplement to Application for Federally Assisted Housing. Section 8 - Award # RQ006 Management Response and/or Corrective Action: The Municipality of San Juan concurs with the finding. As part of the corrective action plan, the Housing Department incorporated the Form HUD-92006 into the system so that it could be included as part of the recertification documents kit. The forms can be filed on the participants case on paper and in a digital form.. Assigned Responsibility: Isamar Pina Rivera (787)480-5500 Director of Housing Department Status: June 30, 2023

Finding Number: 2022-003 Title and Program Name: Section 8 Project Based Cluster-CFDA No. 14.856 Category and Award No.: Internal Controls-Eligibility - Notice of Re-certification sent within 90 to 120 days Awards No. RQ006MR0001, RQ006MR0003 & RQ006MR0004 Management Response and/or Corrective Action: The Municipality of San Juan concurs with the finding. As part of the corrective action plan, the Housing Department reemphasized its technicians and staff in writing on the importance of filing copies of recertification letters once submitted and documenting in the case file any type of communication with the participant. Also, as part of the internal controls the Department will require quality control inspection on a weekly basis once the technicians perform their scheduled recertifications. Assigned Responsibility: Isamar Pina Rivera (787)480-5500 Director of Housing Department Status: June 30, 2023

2022-029 Oregon Housing and Community Services Ensure accessible documentation to evidence compliance with program requirements Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 21.023 Emergency Rental Assistance Program (COVID-19) Federal Award Numbers and Years: ERA 1, 2021 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles; Eligibility Type of Finding: Material Weakness Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.302(a); 2 CFR 200.332(a)(5) Department management is responsible for communicating to subrecipients that they are required to permit the department and auditors access to their records as necessary to ensure the department is compliant with program requirements. To ensure compliance with program requirements, subrecipient records must also be sufficiently detailed. The department passed through $140 million phase one program funds to community action agencies (subrecipients) to provide program delivery. The department performed limited fiscal monitoring during the audit period which included procedures to address compliance with activities allowed and allowable cost requirements for administrative costs. The department did not perform any program monitoring during the audit period which primarily addresses compliance with eligibility requirements. To determine whether the department complied with program requirements for the fiscal year, auditors attempted to reconcile detailed subrecipient ledgers with the intent of selecting and testing sample items at each individual subrecipient organization. We noted issues with two individual subrecipients, resulting in an inability to perform testing procedures over a total of $21,438,521 in program expenditures. For the first subrecipient we were able to reconcile their detailed ledgers to the department?s financial records, however their detailed ledger included pass-through payments to a third organization for program delivery. As a result of the combination of direct and pass-through payments, we were unable to obtain sufficiently detailed data that also reconciled to the department?s financial records to select individual transactions for testing. This subrecipient represents $19,877,962 of the unaudited expenditures. For the second subrecipient we were able to reconcile their detailed ledgers to the department?s financial records and select administrative and program transactions for testing. However, the subrecipient was unresponsive to documentation requests to substantiate expenditures. This subrecipient accounted for $1,560,559 of the unaudited expenditures. We recommend department management obtain and reconcile sufficiently detailed subrecipient ledgers and support to substantiate expenditures to allow for fiscal and program monitoring to ensure subrecipients are administering program funds in accordance with program requirements. MANAGEMENT RESPONSE: We agree with this recommendation. To effectively deliver much needed funds to maintain the housing stability of tens of thousands of Oregonians on the brink of experiencing homelessness during the pandemic, agency staff raced to stand up a first-of-its-kind ?single entry point? program for Oregonians to apply for assistance regardless of zip code. In our efforts to focus on speed we acknowledge that there was insufficient planning and capacity to stand up a large-scale emergency program including sufficient assurances our subrecipients could generate evidence of compliance with program requirements including transaction level details to assist with reconciliation. Oregon?s experience is in line with national findings. According to the January 2021 research brief conducted by the National Low Income Housing Coalition around key program challenges with administering emergency rental assistance programs. Survey respondents listed the two most common limitations to be staff capacity and the completeness of applications. Many agencies leaned on whatever local capacity was available to develop programs, review, and process applications, make payments and conduct outreach. Corrective action plan: OHCS had significant compliance monitoring staff turnover in FY22 leading to incomplete subrecipient monitoring reviews. OHCS completing these reviews would?ve ensured subrecipients had adequate time to produce necessary documentation to evaluate compliance, or if not, subrecipients would?ve been required to take corrective actions. For fiscal compliance, OHCS hired a contractor to perform fiscal monitoring of federal funded Grantees. OHCS also hired fiscal staff to pre-FY22 levels, fully trained them, conducted coordinated working sessions, and reached out to the CAA network for discussions on improving processes. OHCS continues to work with the contractor for much needed assistance in monitoring of back log while internal staff move forward to allow for all monitoring to be back on schedule and coordinating both fiscal and program compliance during future fiscal years. Program compliance employees have been hired and compliance efforts are underway. All providers will have internal compliance visits at regular intervals to ensure they have necessary documents and eligibility is being determined in compliance with program requirements. Additionally regular and ongoing check ins and trainings are being offered by program staff. Finally, program compliance teams are working with the Finance compliance team as well as a contracted expert to develop systems and processes in alignment with the Finance compliance team. As a result of program compliance efforts, a risk evaluation is being developed and incorporated into future contracting decisions. Efforts in hiring and systemic investments in infrastructure, processes, and procedures in addition to partner communications have taken place to ensure agency readiness in the event another emergency occurs. As part of our commitment to continual learning, our OHCS research team is collaborating closely with university and national partners to analyze our ERA program data and findings to see what themes emerge for improvement both nationally and in Oregon. Anticipated Completion Date: December 31, 2023 Contact: Jill Smith, Director of Housing Stabilization Division and Dean Criscola, Controller

2022-027 Oregon Housing and Community Services Ensure Monthly and Quarterly reports are accurate and adequately supported Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 21.023 Emergency Rental Assistance Program (COVID-19) Federal Award Numbers and Years: ERA 1, 2021; ERA 2, 2021 (COVID-19) Compliance Requirement: Reporting Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.302(a) and (b)(3); 2 CFR 200.303(a), (c)-(d) Department management is responsible for establishing and maintaining effective internal control that provides reasonable assurance the department is managing, evaluating, and monitoring the federal award in compliance with the terms and conditions of the award and taking prompt action when instances of noncompliance are identified. Additionally, the department is responsible for maintaining records to allow for submission of reports that are accurate and adequately supported. We tested four randomly selected monthly reports and found one report did not accurately report the number of unique households assisted and the amount of the assistance based on the supporting documentation. The department stated the differences were likely due to a transition in subsystem reporting formats and delays in report processing. We tested four quarterly reports, two of which were randomly selected and two of which were judgmentally selected. We found one report where the cumulative obligation amount did not agree to supporting documentation and were not accurate, and one report where the cumulative obligation and cumulative expenditures amounts did not agree to supporting documentation and were not accurate. The department stated these errors were due to erroneously entered information in the federal awarding agency?s reporting portal. Information included in these reports is used by the federal awarding agency to determine whether the department qualifies for receiving reallocation payments, as well as how much of a reallocation would be awarded to the department. Errors in these reports could result in errors in the federal awarding agency?s determination of eligibility for funding, and/or the reallocation formula. We recommend department management update and correct erroneous reports and establish controls to ensure reported amounts are accurate and adequately supported. MANAGEMENT RESPONSE: We agree with this recommendation. Numerous Community Action Agencies (CAAs), after months of exponential growth in program resources without time to strategize and scale operations, reported major capacity issues a chronic backup of applications at the local level. OHCS took the unprecedented step to augment CAA staff to contract with a third-party vendor to clear the backlog. This approach rapidly increased production and moved the federal program closer in line with the state?s then 60-day safe harbor period but came with additional monitoring and reporting challenges. OHCS did meet the reporting timelines and requirements of US Treasury. OHCS relied on information within the applicant tracking system that does have some discrepancies when compared to our accounting records. These discrepancies are due to various factors such as dates within the system causing application activity to be pulled into the reporting detail more than once, or the application tracking system not being updated with the most current payment record information by some grantees disbursing payments. These variances were overcome by relying on our accounting system and records as a control source of actual disbursements. During the audit, it was brought to our attention that the compilation of the application tracking system data at a point in time was not stored to demonstrate the reconciliation with the accounting information. SOS was then not able to verify the application tracking system data figures in one monthly reporting instance that were used to support the numbers reported to US Treasury as the file had likely been overridden. Similarly in one instance, the quarterly cumulative report was also impacted, however future cumulative figures were reported correctly. Corrective action plan: While OHCS submitted monthly and quarterly reports since program inception that include program and fiscal information, we acknowledge that there were some discrepancies between systems when one file was overridden with new information and one other file contained an error. We have taken steps to ensure data integrity and records retention moving forward and future compilations of the application tracking system data will be stored to support the point in time reconciliations and figures reported to US Treasury. One quarterly report will also be refiled if allowable by US Treasury to ensure quarterly figures reported are accurate. Data integrity is of the utmost importance to the agency, and we appreciate the thorough review by the auditing team. Anticipated Completion Date: June 30, 2023 Contact: Beth Brown, Accounting Manager

1. Correcting Plan CHEDA staff are aware of income eligibility documentation and will implement an internal control process. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding.3. Official Responsible for Ensuring CAP Karie Kirschbaum ? Executive Director 4. Planned Completion Date for CAP Immediately. 5. Plan to Monitor Completion of CAP The Executive Director will monitor completion of the CAP.

The finding was due to a human error. The Registrar?s Office failed to notify the Finance Division and Financial Aid Division of the student enrollment cancellation. These kinds of human errors will be prevented with the following procedure established by the university: Beginning with academic year 2022-2023 (August-2022), the university is taking the following measures: 1. A MSSharePoint was created in collaboration among the Registrar?s, Financial Aid and Finance Offices staff to serve as an easy access documentation repository and to enhance communication. Information of changes in the enrollment status of any student is documented internally for discussion among the offices (Monthly Withdrawal Conciliation Report). 2. Monthly meetings with the Registrar?s, Financial Aid and Finance Offices staff takes place. Personnel from the Institutional Effectiveness Office, and the Offices of the Dean and the Assistant Dean of Academic Affairs also attend to facilitate the discussion. During these meetings the three offices reconcile data on student enrollment status (as documented in the MSSharePoint). This best practice assures that: a. Student enrollment status is recorded accurately and on time. b. Withdrawal cases in which transactions are required with the USDoE are documented early so that funds are returned within the allowable prescribed period. c. As an extra bonus, communication is improved among the Registrar?s, Financial Aid and Finance Offices staff. 3. The dean of student affairs and the dean of academic affairs have provided faculty development seminars on the expectations of a faculty member to comply with federal regulations. Among the topics discussed is the importance of attendance recording and documentation. As well, faculty were required to refer to the Registrar?s and to the Dean of Admissions and Student Affairs Offices any student absent to two consecutive significant academic events. The purpose is: a. Early detection of a student that might be at risk of academic difficulties. b. Early awareness of a student that might be changing enrollment status. 4. To date four (4) attendance surveys have taken place taken place (3/semester). The attendance surveys provide the opportunity to capture any students at risk of changes in enrollment status. As a consequence, student enrollment status may be recorded accurately and on time and as well funds are returned to the USDoE within the allowable period. 5. Periodic letters to the faculty from the Office of the Dean of Academic Affairs to highlight the importance pf promptly referring any changes in student attendance to activate retention efforts or in order to identify and record accurately and on time any changes in student enrollment status.

The identified instances were recorded before the university put in place the controls described below. In order to assure compliance with NSLDS reporting requirements, determinations of funds earned, and timing, beginning with academic year 2022-2023 (August-2022) the university is taking the following measures: 1. A MSSharePoint was created in collaboration among the Registrar?s, Financial Aid and Finance Offices staff to serve as an easy access documentation repository and to enhance communication. Information of changes in the enrollment status of any student is documented internally for discussion among the offices (Monthly Withdrawal Conciliation Report). 2. Monthly meetings with the Registrar?s, Financial Aid and Finance Offices staff takes place. Personnel from the Institutional Effectiveness Office, and the Offices of the Dean and the Assistant Dean of Academic Affairs will also attend to facilitate thediscussion. During these meetings the three offices reconcile data on student enrollment status (as documented in the MSSharePoint). This best practice assures that: a. Student enrollment status is recorded accurately and on time. b. Withdrawal cases in which transactions are required with the USDoE are documented early so that funds are returned within the allowable prescribed period. c. As an extra bonus, communication is improved among the Registrar?s, Financial Aid and Finance Offices staff. 3. The dean of student affairs and the dean of academic affairs have provided faculty development seminars on the expectations of a faculty member to comply with federal regulations. Among the topics discussed is the importance of attendance recording and documentation. As well, faculty were required to refer to the Registrar?s and to the Dean of Admissions and Student Affairs Offices any student absent totwo consecutive significant academic events. The purpose is: a. Early detection of a student that might be at risk of academic difficulties. b. Early awareness of a student that might be changing enrollment status. 4. To date four (4) attendance surveys have taken place (3/semester). The attendance surveys provide the opportunity to capture any students at risk of changes in enrollment status. As a consequence, student enrollment status may be recorded accurately and on time and as well funds are returned to the USDoE within the allowable period. 5. Periodic letter to the faculty from the Office of the Dean of Academic Affairs to highlight the importance to promptly refer any changes in student attendance to activate retention efforts or in order to identify and record accurately and on time any changes in student enrollment status. n addition to the above-mentioned procedures the following measures will be taken: 1. Late reporting of graduation dates in NSLDS and effective dates: a. Prior to graduation all academic program directors review the degrees to be conferred and certify candidates eligible for graduation b. The Registrar?s Office changes the status to graduate in the NSLDS Report after graduation date. c. To assure that all degrees are reported on time and accurately to the NSLDS system from now on, the Registrar?s Office, within ten days after graduation date, will process the changes in the NSLDS system. After the Registrar?s Office processes the changes in the NSLDS system, it will send to all program directors the list of all the students processed as graduated in the NSLDS system and they will be asked to double verify and attest accuracy of the lists of conferred degrees and asked to provide a certification within two days that the changes processed were accurate and that they agree with their record of students officially graduated during the last graduation date. This double certification of conferred degrees within the proposed time-frame will provide a second opportunity to add or delete any missing information within the NSLDS system increasing accuracy and timelines. d. A copy of the certification will be submitted to the Office of the Dean of Academic Affairs as evidence of the compliance with the new process established.

The Harlem United management team has established a new policy to ensure compliance of tenant lease files. Specifically, when intake staff receive a referral from the NYC HIV/AIDS Services Administration (HASA), an interview will take place to determine if the individual fits the program criteria (including documentation of their income, medical status, psychosocial assessment and/or psychiatric evaluation and proof of citizenship). If the individual fits the criteria and accepts an efficiency unit at North General / Foundation House East, the person?s documentation will be forwarded to our consultant, P & L Management, to verify the income and complete all leasing documentation for HUD approval (background checks and security deposits are not required of this program). Upon completion of the HUD documentation process, the intake staff will check to verify that all documentation have been signed and dated by the appropriate persons which includes P & L Management and North staff, and the tenant. Annually, the income information of all tenants at North General will be sent to P & L Management for verification; if the tenant?s income status continues to meet the HUD guidelines, the updated documentation will be forwarded back to the staff at North General. If the tenant?s income status does not meet the HUD criteria, the individual?s income information will be forwarded to NYC HASA for alternate housing placement. In addition, the Managing Director of North General will perform quarterly mock audits to ensure that tenant lease files are in compliance.

Name of Contact Person: Vickie K. Smith, DSS Director Income Maintenance Medicaid Supervisors will complete monthly second party reviews for application approvals/recertifications/denials/withdrawals for applications and ongoing cases. Based on findings from the monthly second party review of applications/recertifications individual meetings will be held with the responsible Income Maintenance Caseworker to discuss the errors found and ways to improve the work performance. The individual counseling will assist in assuring that the worker understands the error and what they need to do for improvements. Monthly a spreadsheet is created from each individual score, from each Income Maintenance Caseworkers audit. The spreadsheet is reviewed monthly and presented quarterly at the Bladen County Health and Human Service Advisory Committee meeting. In addition to the above ongoing process a meeting was held with the Medicaid staff on September 7, 2022 and the following manual sections were addressed (handouts given): MA 2506 (US Citizenship Requirement); MA 3300 (Income); MA 3335 (Residency); MA 3365 (Child Support); MA 3410 (Terminations, deletions, ExParte reviews); MA 3515 (Automated Inquiry Match Procedures). Due to a repeat finding for the Work Number error, training was held on September 7, 2022. The repeat finding was discussed with the county as possibly continuing due to the timeframe from one audited year into the next year. The audit did reflect a decline in the Work Number error as the audited timeframe moved into the cases completed after the prior year training. DMA Administrative Letter No. 02-19 (The Work Number Procedures). Proposed Completion Date: July 1, 2023 (Improvements from 06/01/2022 - 07/01/2023)

Name of Contact Person: Vickie K. Smith, DSS Director Income Maintenance Medicaid Supervisors will complete monthly second party reviews for application approvals/recertifications/denials/withdrawals for applications and ongoing cases. Based on findings from the monthly second party review of applications/recertifications individual meetings will be held with the responsible Income Maintenance Caseworker to discuss the errors found and ways to improve the work performance. The individual counseling will assist in assuring that the worker understands the error and what they need to do for improvements. Monthly a spreadsheet is created from each individual score, from each Income Maintenance Caseworkers audit. The spreadsheet is reviewed monthly and presented quarterly at the Bladen County Health and Human Service Advisory Committee meeting. In addition to the above ongoing process a meeting was held with the Medicaid staff on September 7, 2022 and the following manual sections were addressed (handouts given): MA 2506 (US Citizenship Requirement); MA 3300 (Income); MA 3335 (Residency); MA 3365 (Child Support); MA 3410 (Terminations, deletions, ExParte reviews); MA 3515 (Automated Inquiry Match Procedures). Due to a repeat finding for the Work Number error, training was held on September 7, 2022. The repeat finding was discussed with the county as possibly continuing due to the timeframe from one audited year into the next year. The audit did reflect a decline in the Work Number error as the audited timeframe moved into the cases completed after the prior year training. DMA Administrative Letter No. 02-19 (The Work Number Procedures). Proposed Completion Date: July 1, 2023 (Improvements from 06/01/2022 - 07/ 01/2023)

Name of Contact Person: Vickie K. Smith, DSS Director Income Maintenance Supervisor and Lead worker will complete monthly second party reviews for application approvals/denials/withdrawals. Based on second party findings an individual meeting will be held with the Income Maintenance Caseworker responsible for case actions, to discuss the errors found and ways to improve the work performance. The individual counseling will assist in assuring the worker understands the error and what they will need to do for making improvements. Every month the Income Maintenance Supervisor (IMS) will report the findings in a written report to the Program Administrator for review. The IMS will report all findings as well as what actions have been taken on making case corrections. Any reports to include reasons of untimely process of applications will require a written explanation from the Income Maintenance Caseworker to the Agency Director and Program Administrator. For the Energy programs (LIEAP, LIHWAP and CIP) workers are given the opportunity to staff the case with the program Supervisor and Lead worker. This staffing will allow discussion in making proper decisions based upon DHHS Energy Policies. Staffing's are requested on an "as needed basis". A detailed checklist for Energy Programs has been created that will be utilized by all staff when taking and processing any Energy program applications. The checklist has been siloed for each specific program area; Low Income Energy Assistance Program, Low Income Household Water Program and the Crisis Intervention Program. Upon completion of the application for any specific program a checklist will be required to be signed, completed and scanned into the client record to indicate all actions have been taken properly. Proposed Completion Date: July 1, 2023 (Improvements from 06/01/2022 - 07/01/2023)

Context: During the annual A-133 Audit, external auditors from Adams Brown Strategic Allies reviewed 2020-2021 Annual Performance Report documentation from Barton sponsored TRIO Programs Barton County Upward Bound, Central Kansas Upward Bound, Central Kansas Educational Opportunity Center, and Student Support Services. Findings: Student Support Services Program ? The auditors identified key reporting items from the Uniform Guidance Compliance Supplement and reviewed a sample of ten participant files relevant to the reporting items as noted in the files and on the Annual Performance Report. ? The auditors noted no discrepancies were found and concluded that "the Annual Performance Report prepared by Rita Thurber for the 2020-2021 year appear[s] to have been completed correctly in all material respects." Central Kansas Educational Opportunity Center Program ? The auditors identified key reporting items from the Uniform Guidance Compliance Supplement and reviewed a sample of ten participant files relevant to the reporting items as noted in the files and on the Annual Performance Report. ? The auditors noted no discrepancies were found and concluded that "the Annual Performance Report prepared by [Patrick Busch] (corrected: Ray Kruse) for the 2020- 2021 year appear[s] to have been completed correctly in all material respects, aside from the items noted below."* * "One student's Secondary School (or equivalent) status was reported inaccurately due to entry error." Barton County Upward Bound Program ? The auditors identified key reporting items from the Uniform Guidance Compliance Supplement and reviewed a sample of ten participant files relevant to the reporting items as noted in the files and on the Annual Performance Report. ? The auditors noted no discrepancies were found and concluded that "the Annual Performance Report prepared by Kelsey Hall for the 2020-2021 year appear[s] to have been completed correctly in all material respects, aside from the Date of First Service as noted below."** ** "When Kelsey first started, she was told to enter program acceptance date (not the enrollment), in the Date of First Project Service. However, at a new Director training recently, she learned that it should actually be the true first service date, as recorded in the activity logs." Central Kansas Upward Bound Program ? The auditors identified key reporting items from the Uniform Guidance Compliance Supplement and reviewed a sample of ten participant files relevant to the reporting items as noted in the files and on the Annual Performance Report. ? The auditors noted no discrepancies were found and concluded that "the Annual Performance Report prepared by Patrick Busch for the 2020-2021 year appear[s] to have been completed correctly in all material respects, aside from the items noted below."*** *** "Date of Last Project Service was incorrect on several students due to activities being logged after the most recent project service date was entered into the system." *** "(One participant's) eligibility status was accidentally recorded incorrectly. Likely just an entry error." Actions/Action Plan: Barton Community College assembled the appropriate TRIO and other related personnel to review the findings and identify a corrective action plan. The individuals noted below met on November 29, 2022 for this purpose. Patrick Busch, Central Kansas Upward Bound Project Director Kelsey Hall, Barton County Upward Bound Project Director Raymond Kruse, Central Kansas Educational Opportunity Center Project Director Angie Maddy, Vice President of Student Services Cathie Oshiro, Director of Grants Not present: Rita Thurber, Student Support Services Project Director ? Barton TRIO standard data entry processes were reviewed to confirm that practices are in place in each program for ensuring a double-check approach to data entry, to help minimize data entry errors. ? Kelsey Hall reported her contact with Student Access (the TRIO/Upward Bound participant tracking and reporting software that Barton County Upward Bound uses), noting to them the discrepancy between the Upward Bound APR terminology of First Date of Service as compared to Student Access' use of Program Entry Date for the same field. ? United State Department of Education (ED) guidance on reporting for TRIO programs was reviewed. It was noted that current ED guidance on Upward Bound Program Year 2021-2022 Annual Performance Reporting (0MB Approval No.: 1840-0831 0MB Control No: 1840-0831) cautions preparers against conflating Date of First Project Service and Date of Acceptance. This guidance states regarding Date of First Project Service: "Accuracy is particularly important for this field. For new students, use the date the student first received service from the Upward Bound project that is submitting this report. Do not use date of acceptance into project unless that is the same as the date of first service. Students first served in the summer program should have a date of first project service no earlier than June 1. Use the original date of service at this project even if the student subsequently left and reentered. If the student transferred from another UB project, in this field give the date of first service at the project submitting the report." However, the guidance goes on to state: "You do not need to provide the exact day; you may use 15 (midpoint of the month)." ? It was determined that, based on the review of the ED guidance, going forward the Barton County and Central Kansas Upward Bound Programs would ensure that Date of First Project Service is confirmed, double checked, and recorded as such, and not erroneously reported as Date of Acceptance, or utilize the ED-accepted "15th day of the month" designation (along with the appropriate month and year information). It was noted that the guidance allows "15th day of month" reporting for additional fields as well such as Date of First Project Service, High School Graduation, College Degree Attainment Date, Date of Certificate/Diploma, Date of Associate Degree, Date of Bachelor's Degree, and Date of Last Project Service. ? It was determined that each Upward Bound Program Director will identify an appropriate place to document the corrective action step regarding Date of First Project Service, whether within the program's policy and procedure manual or another appropriate documentation source. This step will help support accurate information and training on this item for future Upward Bound employees. The Barton team tasked with reviewing these findings and determining a plan for corrective action feel confident that the findings are understood, have been thoughtfully considered, and will be remedied based on the actions outlined here.

Corrective Action Plan PURPOSE: This Plan describes Internal Control Audit findings; documents responsibility for addressing the findings; and describes progress towards addressing the findings. Provide enough information to enable the reader to understand the nature of the finding, the impacts, and the planned remedy. Audit Name: New River Valley Agency on Aging - September 30, 2022 Audit Finding No. & SS Concurrence Short Title Summary Anticipated Completion Date Responsible Person(s) and Due Date * Status Status Date Concurs: Planned Action & Status Does Not Concur: Mitigating Controls & Risk Acceptance 2022-001 Updating and offsetting future Vehicle Sales Correction implemented immediately Completed and ongoing Senior Services Program Director C 9/30/2022 Concur 2022-002 UAI Forms Properly Completed Correction implemented immediately Completed and ongoing Aging and Disability Services Supervisor C 9/30/2022 Concur * Status Legend: NS = Not Started; U = Underway; C = Completed

CORRECTIVE ACTION PLAN September 5, 2023 Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS- FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (CFDA 93.224/93.527) Finding 2022-01 - 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 is calculated properly. Action Taken This finding was also reported in the calendar year 2021 audit. As part of our corrective action plan, we instituted monthly audits to capture any issues early. Unfortunately, the same finding was noted by the auditors in this 2022 audit. There were several factors that impeded us from resolving the sliding fee scale finding. We continue to have high staff turnover in the front desk position. In addition, the population generated from the system to select our sample on a monthly basis included both self-pay and insured patients, even though self-pay was the only criteria selected. It made a proper audit -inefficient. We are committed to putting in place a process that will prevent the reoccurrence of this finding. We have hired a consulting firm, "Health Efficient", to do a comprehensive review of our EMR systems to ensure that the system setup is correct and proper reports are being generated. In addition, we have retained them to train all front desk staff, including the director and supervisor. The consulting firm will also conduct bi- weekly audits for six months to ensure the issue is resolved. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext. 226. Sincerely yours, Daniel Desire

The District Federal Programs Coordinator will: 1. Attend professional development activities provided by our Federal Programs Consultant, Dr. Cheryl Sattler with Ethica, LLC. These activities include monthly technical calls, annual Title 1 Bootcamp, and Spring Coordinator's Workshop. 2. Seek help and advice from Dr. Sattler as needed. 3. Attend FASFEPA Conferences, twice per year, to learn about updates and changes to federal laws regarding Title 1 funds. 4. Review the budget entered into the district's accounting system to ensure there are no discrepancies.

Finding 2022-005, Non-Material Non-Compliance - Eligibility Corrective Action Plan: Goal: To ensure timely completion, review, and all required signatures are obtained on the Family Services Agreements and retained on file. Plan: The County will require F&C Supervisors to log the most recent PPR/CFT meetings on the monthly spreadsheet to track when the next FSA will be due for review. Performance Improvement Strategies: 1. All PPR/CFT meetings will be held for each child in FC DSS custody every three months. 2. The meeting includes but is not limited to completion of FSAs and any other review tools necessary. All completed forms will have two-level review and signature and be maintained in the record. 3. The F&C Division already has a monthly spreadsheet to track monthly contact with youth in care. Two additional columns will be added to track the most recent meeting/form and the second column will target when the next id due to be reviewed. 4. All Supervisors will be expected to complete the two additional columns monthly recording the date of the last FSA review and projecting the next FSA review due date. 5. The Program Manager and Division Director will review the spreadsheet monthly to ensure that all FSAs have been completed timely. 6. In the event that an FSA is found to be untimely, the Supervisor/Program Manager/Division Director will ensure that the assigned caseworker completes the FSA review within 5 business days and routes any untimely forms for Program Manager review. Responsible Parties: Family & Children?s Services Division Director, Foster Care/Adoptions Program Manager, All Foster Care Supervisors, and Social Workers Timeframes: Policy will be communicated to responsible parties no later than April 1, 2023 and implemented effective immediately.

Finding Number: 2022-002 Condition: We examined $1,746,599 of federal funds reimbursed to the City from the State Revolving Fund award during the year. Management informed us and we verified that $134,102 of reimbursements were for ineligible construction costs as these amounts were bid alternates that were not allowed uses of the federal award. Further, management informed us and we verified that $17,253 of federal reimbursements were received for a duplicate construction invoice. Further, as a result of reviewing the ineligible costs, management found that in fiscal year 2021, ALN 66.458 included $5,768 in ineligible expenditures, and the overall total expenditures was understated by $184,073. In addition, ALN 14.228 had expenditures of $229,554 that were understated in fiscal year 2021, and ALN 10.760 had expenditures totaling $81,228 that were understated in fiscal year 2021. Planned Corrective Action: The City adopted an allowable cost policy on 04/17/23. Contact person responsible for corrective action: Kathryn Beemer, City Administrator Email: kbeemer@fennville.com Office Phone: 269-561-8321 Cell Phone: 269-543-2645 Anticipated Completion Date: 04/17/23

2022-002 CFDA#14.871 ? Housing Voucher Cluster ? Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. The agency has begun implementing the Yardi software system that will include a landlord portal that will streamline W-9 and direct deposit documentation, while also creating a digital, cloud-based file for each landlord. This will enable the agency to better serve the needs of our landlords while also improving our records retention and filing systems. This function will also improve redundancy for continuity of operations and disaster planning. The new management team also created two (2) Fraud Specialist positions within the Housing Choice Voucher ? Assisted Housing department that will audit landlord documentation to mitigate fraud risk. Person Responsible for Correction of Finding: Mr. Justin Brooks, Executive Director Projected Completion Date: December 31, 2023

Staff will update policies and procedures to ensure compliance specifically with Section 105(a)(8) of the HCDA and 24 CFR 570.201(e) of the CDBG entitlement regulations.

There is no disagreement with the finding. Management will review procedures to implement mitigating controls to reduce the risk of error.

Action Taken: The Health Center is committed to serving patients that are underserved and under- or un-insured. Staff will be re-trained on how to implement annual updates of the sliding fee discount schedule for Department of Health and Human Services annual poverty guidelines changes, across all types of visits, on a timely basis, to ensure that self-pay and patients with third-party health insurance are assessed and charged a discounted fee based on their income and family size according to CBWCHC?s sliding fee discount schedule. In addition, they will periodically self-check patient records to see if the training was effective. This training will begin in the 2nd quarter of 2023 and will be on going as new staff are added. Person responsible: Kaushal Challa, CEO

Management agrees with the summarized findings. Management has reviewed the current policies and procedures to ensure that the steps to be performed are clearly stated for the underwriting and disbursement staff. Management has discussed the findings with staff members and provide additional training as deemed necessary.

Management agrees with the summarized findings. Management has discussed the findings with the third-party vendor administering the application process. The vendor has provided additional training in the affected areas to ensure a thorough application review is completed and proper documentation is included in the file prior to disbursement.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Dan Durrwachter Contact Phone Number: 765-473-3081 Views of Responsible Official: We agree with these findings. Description of Corrective Action Plan: Our Food Service Director will receive the poverty status application and review them as they are inputted into skyward. Our Food Service Treasurer will review to make sure the application was completed correctly and calculated accurately. Additionally, the food service treasurer will review and approve the uploaded direct certification and income guidelines. Anticipated Completion Date: 6/01/2023

During the COVID-19 pandemic, DCH Health System (DCH) developed a methodology to identify eligible costs in accordance with the Health and Human Services (HHS) produced COVID-19 Provider Relief Fund (PRF) Reporting Requirements and FAQ guidance. DCH's methodology identified costs used to prevent, prepare for, and respond to coronavirus that fell into the following categories: COVID-19 specific costs, direct and indirect incremental costs due to COVID-19, and calculated lost revenue. To calculate direct and indirect incremental costs due to COVlD-19 for DCH Regional Medical Center, DCH leveraged HHS FAQ guidance from October 28, 2020, that introduced examples demonstrating how providers could calculate marginally increased expenses related to coronavirus using a reasonable methodology comparing pre-pandemic to post-pandemic average expenses for an office visit. OCH utilized this methodology to calculate direct and indirect incremental costs due to COVID-19 on a per-patient discharge basis, which is akin to an office visit for a hospital, per the HHS FAQ guidance. Though this specific example was removed in subsequent versions of the FAQ, HHS never communicated that the guidance that DCH relied upon to calculate incremental expenses was incorrect. DCH's view is that the total cost of patient discharge includes direct patient care and indirect costs (overhead and general administrative (G&A) costs). Indirect costs (e.g., facilities, maintenance, utilities, and management salaries) were incurred by DCH to prepare, prevent, and respond to COVID-19, consistent with the intention of the purpose of the PRF to 'provide financial support to providers who experienced lost revenues and increased expenses during the pandemic in order to maintain national health system capacity.' For instance, the ability to serve COVID-19 patients relied on incurring utility expenses to keep ventilators and other equipment functioning, of which the organization utilized well more than the norm which resulted in higher utility costs. These costs were vital for accommodating COVID-19 patients during the pandemic, just as they were necessary for serving other patient types before the onset of COVID-19. These incremental indirect costs were also not reimbursed through other sources. DCH allocated indirect costs in accordance with other accepted government rules as defined in various government regulations such as 2 CFR and the Federal Acquisition Regulation. The indirect costs allocated to patient care costs were considered part of the total cost of patient discharge. In addition, though DCH calculated lost revenue, DCH did not report on lost revenue as part of the system's use of funds (please note that there was one reporting period where Fayette had to report separate from DCH because of targeted funds received. Fayette did report lost revenue in that period based on a budget to actual calculation). DCH believes that the funds identified and reported are consistent with HHS guidance and the spirit of the law to maintain national health system capacity It is DCH's understanding that Single Audit Finding 2022-001 is particularly focused on DCH's approach to identifying indirect incremental costs due to COVID-19, citing these expenses as ineligible costs that were included in the HHS PRF portal submission. Similarly, DCH did not report lost revenues, resulting in 'inaccurate lost revenues reported.' Both FORVIS and DCH acknowledge that DCH incurred eligible expenses and lost revenue sufficient to cover the PRF funds received. Therefore, based on the FORVIS finding, and assuming the finding is sustained, DCH will implement processes to submit future PRF reports as suggested in Single Audit Finding 2022- 001, which includes identifying specific individual expenses incurred during the reporting period to prevent, prepare for, and respond to COVID-19, rather than utilizing the initial HHS guidance for calculating incremental costs due to COVID-19. In addition, OCH will include lost revenue in the PRF portal submission.