Corrective Action Plans

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Various agencies Award Names: Enabling Low Temperature Plasma (LTP) Ignition Technologies for Multi- Mode Engines Through the Development of a Validated High Fidelity LTP Model for Predictive Simulation Tools, Greater Alabama Black Belt Region (GABBR) LSAMP, and Reimagining controlled environment agriculture in a low carbon world Award Numbers: 211809, 200634, and 205280 Assistance Listing Title: Conservation Research and Development, STEM Education (formerly Education and Human Resources), Agriculture and Food Research Initiative (AFRI) Assistance Listing Number: 81.086, 47.076, and 10.310 Award Year: 2023 - 2024 Pass-through entity: University of Texas Dallas, Association of Public & Land Grant Universities, Tuskegee University, and Clemson University To ensure Auburn University is in compliance with 2CFR 200.332(f), Auburn University has implemented the following corrective action plan: Since the audit period, the University has started a comprehensive review of its subrecipient monitoring framework and has been working to distribute workload more effectively with the goal of building consistency in subrecipient monitoring procedures. This includes efforts to clarify ownership of monitoring tasks, implementing a more centralized and standardized approach to documentation, and balancing the day-to-day operational duties across the subaward team to allow for appropriate focus on Uniform Guidance compliance. Brief internal training sessions or check-ins will be conducted to reinforce expectations and ensure that all staff are aligned with the updated documentation practices. Current procedures will be revised to address risk assessments and annual monitoring. These improvements are designed to ensure consistency, accountability, and compliance with Uniform Guidance expectations moving forward. We will document when all reviews of sub-recipients’ financial statements/Uniform Guidance reports occur and who completed the reviews. These reviews will be entity-specific and conducted annually. The corrective actions noted herein are in process and implementation is expected before the end of the current fiscal year to allow adequate time for review, development, and benchmarking. Contact: Tony Ventimiglia Asst. VP Research Administration Office of the Senior VP for Research & Economic Development Amy Douglas Associate VP Financial Services/Controller Anticipated Completion Date: October 1, 2025

2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services (DHS). Our review found missing documents, time gaps between submissions, or untimely paperwork, including the following: (a) 29 CUA Safety Assessments, (b) 30 CUA Safety Plans, (c) 7 CUA PA Model Risk Assessments, (d) 3 CUA Documented Client Visits (Structure Case Notes), (e) FAST Family Advocacy Forms, (f) 17 Life Skills Assessment/ Biopsychosocial Evaluation/ IEP or Ages & Stages Questionnaire (ASQ), (g) 11 School Aged Report Cards, (h) 6 CUA Authorization to Release Information, (i) 9 CUA Immunizations, (j) 3 DHS Court Order Sheets, (k) 14 Child’s Photo, (l) 10 Initial CUA Single Case Plan, (m) 7 Monthly Updates to CUA Single Case Plan, (n) 17 Initial CUA Case Service Conference Summary Report, and (o) 16 Six Month Ongoing CUA Services Conference Summary Report. Furthermore, each child's file needed to contain specific documents from the DHS, which had to be supplied by the department or shown evidence of request by the CUA. Missing documents consisted of: (a) 34 DHS Service Authorization Forms, (b) 21 DHS CUA Provider Referral Forms, and (c) 30 DHS CUA In-Home Services Referral Forms. Recommendation: We recommend that management continue to develop policies and procedures in order to properly include all pertinent documentation within each client file as required by the City of Philadelphia, Department of Human Services. In addition, we recommend that program leadership and/or quality control department performs periodic audits of the client files to ensure all required documentation is included. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. FINDINGS – FEDERAL AWARD PROGRAM AUDITS (CONTINUED) Action taken in response to finding: 1. Hiring of Chief Compliance Officer to oversee Concilio Quality Assurance and Compliance process 2. Staffing of Quality Assurance department 3. Monthly review of client files for accuracy and completeness 4. Additional training of staff to review audit findings and implement corrective action Name of the contact person responsible for corrective action: Albert Essilfie, Chief Financial Officer albert.essilfie@elconcilio.net (215) 627-3100 Planned completion date for corrective action plan: June 30, 2025

Recommendation: We recommend that management and those charge with governance to improve internal controls to ensure that all required EIV reports are included in tenant files. View of Responsible Officials: Management agrees with the finding.

Finding 2024-023 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-019 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

Finding 2024-012 U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Significant Deficiency in Internal Controls and Noncompliance over Eligibility Repeat Finding: Yes; 2023-009 Auditee’s Corrective Action Plan: Condition #1 Response MOHS acknowledges that 1 of 60 files did not have evidence of the case manager’s review of the file for eligibility requirements. Corrective Action: The HAP Housing Contract Specialist will conduct an annual review of the client eligibility documentation to ensure that all eligibility documentation is maintained in the client’s file. Condition #2 Response MOHS acknowledges that 1 out of 60 selections did not contain the rent calculation worksheet. Corrective Action: MOHS collects client income at intake and annually to determine eligibility and the tenant’s rent portion. The rent calculation worksheet ensures that the tenant’s rent portion does not exceed 30% of the client’s income. This rent calculation worksheet and income verification is maintained in the client’s file. Condition #3 Response MOHS acknowledges the 1 out of 60 selections did not have evidence of property inspection. Corrective Action: MOHS requires that all housing units under the program be inspected prior to the client’s lease up and annually. We will ensure that units assisted under the program are inspected annually and the passed inspection is maintained in the client’s file. Condition #4 Response MOHS acknowledges that 1 out of 60 selections did not have the supporting third-party documentation of income. Corrective Action: MOHS policy requires that clients are required to submit third party verification of income, assets, and medical expenses at program entry and annual recertification to ensure proper calculation of tenant rent. Contact Person: Lakeysha Williams, Director of Programs, Mayor’s Office of Homeless Services Completion Date: April 7, 2025

Finding 2024-009 U.S. Department of Housing and Urban Development (HUD) AL No. 14.239 Home Investment Partnership Program Significant Deficiency in Internal Controls and Noncompliance over Eligibility Repeat Finding: No Auditee’s Corrective Action Plan: The agency concurs with and accepts these findings. Our grantees are aware of HOME record keeping requirements and are reminded of these requirements annually in the text of our file inspection compliance notifications. The management of the cited properties will be given a formal letter making them aware of the findings of this audit and reminded of HOME Investment Partnership Program record keeping requirements. We will also add the record keeping reminder to our Annual Desk Review notification. We will ensure that 100% of active HOME properties receive the record keeping requirements reminder, not just properties that receive file inspections. Additionally, the one file missing support documentation will be selected as a part of that property’s annual file inspection in 2025. We will also instruct the property that failed to submit its requested tenant file to continue searching for the file. The file in question is for a former tenant and was maintained by the previous management company. DHCD will reach out to the former management company to see if they can assist in the search. Contact Person: Eugene Greene, Operations Officer, Baltimore City DHCD – Development Division Completion Date: Effective immediately.

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2024-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all current and new staff are trained on tenants’ 90-day EIV reports and ensuring they are generated within the required time period to verify tenant information promptly and help reduce errors in subsidy payments. ACTION TAKEN The Project will be monitoring use of the EIV system for move ins and recertifications.

Condition: During testing, it was noted that although there was a process in place to review eligibility criteria received by program, there was not an independent review or control to ensure eligibility was accurate. Planned Corrective Action: After the initial review for eligibility, a second employee will verify that eligibility was properly determined and provide a signoff to document review. This was implemented in September of 2024. Contact person responsible for corrective action: Lucy Rosenberg and Michelle Estell Anticipated Completion Date: 09/01/2024

Cochise County WIC leadership and staff is committed to full adherence with WIC policy and will continue to implement training, monitoring, and communication to ensure compliance with federal and state regulation. The County immediately corrected this issue by conducting a mandatory training session for all WIC staff regarding the Rights and Obligations policy. During this session, the policy was read aloud and distributed in written form to all attendees. Staff were directed to inform all participants of their rights and responsibilities to include having the rights and responsibilities form signed by the participants, prior to issuing benefits, during the participant’s initial certification, and recertifications for ongoing benefits. Staff received the Rights and Obligations Pledge for review and reference. Procedures for obtaining signatures from participants not physically present in the office were reviewed. Acceptable alternatives include sending the form via email for electronic or physical signature, scheduling a follow-up in-office visit for signature collection. All staff questions were addressed to ensure clarity and consistent understanding. Ongoing reminders have been disseminated through emails and during regular staff “huddles” since the training. In addition to the immediate actions taken to correct the finding, the County also implemented long-term action steps. These steps include annual training of all WIC Staff on the Rights and Obligations policy the 2nd Monday of January. Each employee will sign an attestation confirming their understanding and compliance post-training. This attestation will be stored in the employee’s personnel record. Monthly, the WIC Manager, or designee, will review the WIC Cert. for Audit Report the last Friday of each month to identify and address any instances of missing client signatures. Additionally, the WIC Manager will manually audit 3% of the total WIC members for the month. Continuous actions implemented by County staff to correct this finding includes consistent reinforcement of signature collection protocols and policy reminders during monthly meetings and weekly “huddles”. Of note, a request was submitted to the Arizona WIC Service Desk to determine whether a report could be generated identifying all participants lacking a signed Rights and Obligations form to strengthen monitoring efforts. The response received indicated that generating this type of report is extremely complex, and at this time it is not possible.

University awarded Subsidized Federal Direct Loans to one student in excess of their Subsidized Federal Direct Loan eligibility, and therefore did not comply with all requirements associated with excess loan proceeds. Corrective Actions Taken or Planned: This finding is considered an isolated occurrence and is not indicative of Roosevelt University’s standard administrative practices or institutional policies. The University has taken the following corrective actions to address the issue and prevent recurrence Student Account Adjustment: A reallocation of $2,900 from the Federal Direct Subsidized Loan to the Federal Direct Unsubsidized Loan was completed to correct the student’s account. All necessary updates were submitted to the U.S. Department of Education on May 16, 2025. Root Cause Analysis and System Improvements: The University will conduct a thorough root cause analysis to determine the underlying factors that led to the overaward. This analysis will be completed within 30 days. Preventative Measure and On-going Monitoring: Based upon the outcome of the root cause analysis, Roosevelt will implement appropriate system controls and develop an on-going monitoring plan to prevent similar issues in the future. These preventative measures will be established within 45 days. Roosevelt University remains committed to maintaining compliance with federal regulations and to continuously strengthening its internal controls to ensure accurate administration of Title IV funds. Anticipated Completion Date: July 15, 2025 Contact Person: Michelle Hayes, Senior Director, Financial Aid and Compliance // Michelle Stipp, Associate Vice President, Enrollment Management

– Enrollment Reporting Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Name: Pell Grant Program and Federal Direct Student Loans Award Number: Various Assistance Listing Title: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Number: 84.033 and 84.268 Award Year: 2023-2024 Pass-through entity: Not applicable Stanford agrees with this finding and will be taking proactive steps to ensure that similar issues do not arise in the future. For the issue affecting 6 out of 25 students, whose status change effective dates did not match their program level information, the Academic Records and Compliance Officer will work closely with systems staff to perform tests to identify a cause and ensure accuracy between the enrollment file extract and records themselves. Expected completion by December 31, 2025. For the issue affecting 2 out of 25 students, whose graduated status was not accurately reflected in their enrollment history, the Academic Records and Compliance Officer is leading a system enhancement currently in progress to replace the ‘G from DV’ file to a ‘Grads Only’ file to report degrees, which is expected to be completed by December 31, 2025. The new and improved file type will ensure the third-party servicer applies graduated statuses for students enrolled in multiple programs. Until the system enhancement is completed, the Academic Records and Compliance Officer will begin carefully reviewing ‘G Not Applied’ error files for manual correction after degrees are reported at the end of each quarter.

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal eligibility and paid lunch equity requirements. Name, address, and telephone of Fife School District contact person: Dany Wanner, Business Services Director 1720 Oak St, Milton, WA 98354 (253) 517-1000 ext 29121 Corrective action the auditee plans to take in response to the finding: The Fife School District implemented the following to Ensure Adequate Internal Controls for Compliance with Federal Eligibility: The Business Services team and Nutrition Services staff have conducted a thorough review of the process of monthly paid lunch equity and modified its procedures including developing a checklist for the process to ensure that it is completed in a timely manner, signed/dated and saved both electronically and in hard copy on a shared district server folder. The Fife School District implemented the following to Ensure Adequate Internal Controls for the annual completion of the Paid Lunch Equity Tool. The Business Services team and Nutrition Services staff have conducted a thorough review of the process of completing both the PLE tool and GL 828 reconciliation and modified its procedures to ensure that it is completed, signed and saved both electronically and in hard copy on a shared district server folder. Further, the Business Services team and Nutrition Services staff have developed a checklist for the completion of the tool and the checking of the box that indicates that we will be opting not to increase meal prices, but instead to demonstrate using the GL 828 Reconciliation (signed and dated) that we have sufficient fund balance to offset the paid lunches and not utilize Federal funds, including calendar reminders and a shared Google Drive to hold all related documents and procedures. Anticipated date to complete the corrective action: 5/16/2025

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal eligibility and paid lunch equity requirements. Name, address, and telephone of District contact person: Marci Bannan, Director of Business Services 121 Whitesell St NE Orting, WA 98360 Corrective action the auditee plans to take in response to the finding: Eligibility: The District will document the internal controls that are in place for the monthly direct certification downloads and will print the certification download along with saving it electronically so that the files are easy to provide for future audits. Paid Lunch Equity: The District will document the internal controls that are in place for the completion of the PLE tool and ensure that the form is completed appropriately to show the continued use of nonfederal funds that are used yearly to fund the food service account fully. The District will also make sure to ‘print’ the GL 828 tab of the Fund Balance Reporting tool that is done yearly no later than November and sign it immediately after completion of the year end process to provide for the proof that the district has and continues to contribute sufficient nonfederal funds to the food service account. Anticipated date to complete the corrective action: July 31, 2025

CareerWise will implement enhanced internal control procedures to ensure that all eligibility documentation, including selfattestation forms verifying date of birth, is consistently collected, signed, and retained in each apprentice's case file. These procedures will include standardized checklists, mandatory document review prior to disbursement, and staff training to reinforce compliance expectations. Additionally, CareerWise will conduct a comprehensive review of all case files under the ABA grant to identify and remedy any gaps in eligibility documentation. This retrospective review will be completed as part of the corrective action plan. All corrective actions, including implementation of the updated documentation process and the full case file review, will be completed on or before December 31, 2025.

Planned Corrective Action: The Seattle Indian Health Board has adopted a sliding fee program that provides discounts to eligible patients and Indian tribes. To address the auditors' concerns and further strengthen our internal controls, we are implementing a comprehensive corrective action plan. Firstly, we will ensure that all personnel involved in eligibility checks, including front desk staff and benefits specialists, are fully trained and aware of federal regulations and internal policies. This will be achieved through comprehensive training sessions and the development of a detailed training manual outlining eligibility criteria, documentation requirements, and procedural steps. Periodic refresher training sessions will reinforce adherence to these policies. Secondly, we will establish a robust internal audit system to regularly review and verify compliance with eligibility requirements. This includes integrating a monthly audit of eligibility determinations into the month-end reporting process, conducted by the clinical operations team. The clinical operations team will use a standardized checklist during these audits to ensure consistency and thoroughness. They will document findings and follow up on any issues or discrepancies with the relevant personnel to ensure timely corrections and adherence to procedures. Management believes that we have adequate internal control systems to safeguard the organization's assets and comply with federal and local regulations. However, we remain committed to further strengthening our controls and processes where necessary. Name of Responsible Party: Mary Kelley, Director of Revenue Cycle Anticipated Completion Date: September 30, 2025

Previously, all sliding fee scale applications were reviewed and processed by the billing manager. Effective September 10, 2024, the Center assigned a specific billing specialist (Stephanie Rivera Rivera) to process the sliding fee scale applications. Billing managers’ responsibilities now include auditing the applications that are processed by the billing specialist. The auditing process completed by the billing manager, Yeny Roggie, is to ensure that the application is complete and that the proper sliding fee scale was offered to the patient.

Corrective Actions: Implement a Pre-Closure Checklist for every client file to ensure a signed retainer is present. Train all administrative and legal staff on document retention policies. Require all supervisors to review and initial the checklist before a case is marked complete. Monitoring Plan: Quarterly audits of 10% of closed cases; reports to Executive Direcotr and included in board compliance summary.

Management agrees with the finding. Corrections have been made to the tenant file. A refund has been processed.

2024-001 ALN 14.871 – Section 8 Housing Choice Vouchers Program - Eligibility The Executive Director agrees with the finding as listed in the Schedule of Findings and Responses and will follow the Auditor's recommendations. Person Responsible for Correction of Finding: Ethan M. James, Board Chairman & Julie A. Davis, Executive Director Projected Completion Date: September 30, 2024

Management agrees with the finding. Corrections have been made to the tenant file and a refund was processed for the tenant.

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of South Boston, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that all initial and ongoing tenant eligibility documentation is obtained timely and maintained in tenant files as required by HUD. Action Taken: The Project has implemented additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips Irene Phillips CFO

Finding 2024-001: Community Health Worker Training Program Eligibility Federal Agency: Department of Health and Human Services Program: Community Health Worker Training Program Assistance Listing #: 93.516 May 27, 2025 ________________________________________ Management Response: Sunset Park Health Council Inc. acknowledges the audit finding related to the lack of documented verification for eligibility criterion (2)—proof of U.S. citizenship or permanent residency—for participants in the Community Health Worker Training Program (CHWTP) for the year ended August 31, 2024. While management initially performed a verbal verification, management subsequently began a retroactive verification to obtain documentation supporting that all trainees met eligibility criteria. We also recognize the need for a formalized control process to ensure documentation of compliance at the point of enrollment is maintained.________________________________________ Corrective Action Plan: To prevent recurrence of this issue, the following steps will be implemented: 1. Revised Intake Process A standardized intake form will be implemented and must be completed at the time of screening by the FHC Program Supervisor in collaboration with the participant. This form will: o Attest that all required eligibility documents have been collected, including proof of U.S. citizenship or permanent residency (criterion 2). o Include a checklist for all documentation required for program participation. o Require three signatures: - Participant - FHC Program Supervisor (who conducted the screening and verified eligibility documentation) - Program Director (PD) or Principal Investigator (PI), who will review and approve the documentation to confirm completeness. 2. Privacy and Data Security o All documentation will be redacted to block any sensitive Personally Identifiable Information (PII) to prevent potential identity theft. o Documents will be digitally archived in a secured, access-controlled location with appropriate cybersecurity protocols in place. 3. Training and Oversight o All staff involved in intake and eligibility verification will receive training on the updated intake process, documentation standards, and data privacy requirements. o A quarterly internal review will be conducted by the Program Director to ensure continued compliance.________________________________________ Timeline for Implementation: Sunset Park plans to begin the above actions in May of 2025 and complete implementation in August 2025. Responsible Individual Leonardo Arias - Director of Grants Email : Leonardo.Arias@nyulangone.org

In response to this finding, the Culinary Services department under the guidance of the Operations team in SPS has made the following adjustments and changes to business practices: 1. The PLE tool has been formally integrated into the annual budgeting process to ensure routine compliance with this guidance and accurate financial planning. 2. If a price increase is deemed necessary, it will undergo a thorough review and approval through the SPS board governance process. This will include a landscape review of meal prices in other districts in the Puget Sound region as well as similarly scaled districts nationally. This structured approach guarantees alignment with strategic objectives while maintaining transparency and accountability. 3. As of May 2025, the Culinary Services department under the direction of the Operations department will be taking action on a price increase for school lunches beginning for the 2025-26 school year with annual reviews scheduled for subsequent years.

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal Title I eligibility requirements. Name, address, and telephone of District contact person: Dan King 250 E Campus Dr. Belfair, WA 98528 (360) 277-2107 Corrective action the auditee plans to take in response to the finding: The district is strengthening its internal controls for monitoring the Per Pupil Expenditure (PPE) to match higher poverty concentration in its schools by the following: 1. Developing and utilizing an Excel Spreadsheet as a “PPE Tool” to allocate funds appropriately a. The PPE Tool will be a shared working document between the Business Office, Human Resources, and Title I Coordinator, b. The PPE Tool will be utilized when applying for the 2025-2026 Consolidated Grant and all future Consolidated Grant applications; and, c. The PPE Tool will be used when completing budgetary reviews at cabinet meetings. These measures will be implemented going forward as internal controls for ensuring compliance with eligibility requirements for Title I funding. Anticipated date to complete the corrective action: Beginning July 2025 when the District will be completing the Consolidated Grant application in the Education Grants Management System (EGMS).

FINDING 2024-003: Late Audit Submission (Repeated 2024-010) Response: The District will implement more timely actions to be taken.