Corrective Action Plans

Corrective Action Plan Assistance Listing Number 21.029 COVID-19 Coronavirus Capital Projects Fund U.S. Department of the Treasury Missouri Department of Economic Development Program Year 2024 Condition – The Cooperative was unable to provide evidence that vendors used in covered transactions were not suspended, debarred, or otherwise excluded. Due to the current year finding, management set a goal to ensure the Missouri ARPA Broadband Infrastructure Grant Program guidelines related to debarred or suspended vendors are being met. To meet these guidelines management has compared the current vendor list to Excluded Parties List System found on SAM.GOV and found none of the currently used vendors on the list. Management has added this verification step to its new vendor process and will conduct annual self-assessment to ensure vendor eligibility documentation is current and up to date. Responsible Official: Jay Wallace, Manager of Accounting & Finance Implementation Date: April 25, 2025

The Agency has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Agency will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Agency has determined that the cost of eliminating this material weakness in internal control would exceed its benefit.

The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Authority has determined that the cost of eliminating the deficiency would exceed its benefit.

MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2025 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Due to non-compliance with timely and accurate student enrollment change submissions to the National Student Loan Data System (NSLDS), Brigham Young University – Hawaii (BYUH) Management proposes the following corrective action plan to mitigate reporting errors. The Registrar’s Office, in coordination with BYUH’s Enterprise Information Systems team, will review and enhance the processes used to extract student data from PeopleSoft and transmit it to the National Student Clearinghouse (NSC) and NSLDS. This includes: -Reviewing all relevant PeopleSoft updates and ensuring that corresponding changes are reflected in the data transmitted to NSLDS. -Testing and validating the reporting processes within PeopleSoft to confirm data accuracy and completeness. -Verifying that the correct data is being transmitted to NSLDS. -Testing the student data within NSLDS to ensure its integrity. -Documenting the entire process for future reference and ongoing quality assurance. In addition, the Registrar’s office has already added additional resources to run all reporting processes. The Registrar’s office has also reached out to Ensign College to learn about their reporting process. The University is considering contacting the PeopleSoft reporting specialist that Ensign used, although that decision will be made at a later date, and if necessary. These actions will enable the Registrar’s Office to more effectively review credit load determinations and accurately establish program begin dates for students. Daryl Whitford, Registrar, will remain responsible for enrollment reporting at BYUH. She will oversee the implementation of the revised process, provide training to all relevant staff members, and lead the development and implementation of a control mechanism to ensurefuture compliance with NSLDS reporting requirements within PeopleSoft. Timing: Daryl Whitford, Registrar, will be responsible for overseeing that all items noted in the corrective action plan will be implemented by September 1, 2025. Signed and Acknowledged Daryl Whitford, BYUH Registrar

Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-002 – Non-Compliance with Financial Need Requirements for Subsidized Direct Loans Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268 Award Titles: Federal Direct Student Loan Program Award Years: 7/2023 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan The incomplete installation of a student information system (PeopleSoft) update resulted in certain EFCs not prorating correctly. The incomplete system update that created this issue has been corrected. Moving forward, all PeopleSoft updates will be reviewed upon completion by Jesus Garcia, PeopleSoft project manager, to ensure all steps have been finalized as expected. Additionally, with the implementation of the 2024–25 FAFSA Simplification Act, prorated EFCs are no longer applicable. As such, this issue will not recur in future processing cycles. Timing The incomplete PeopleSoft update was corrected in March 2024. PeopleSoft updates are done every quarter and will be reviewed upon completion by Jesus Garcia. Because the 2024-25 FAFSA Simplification Act eliminated the use of prorated EFCs in this process there will be no further action taken. Sincerely, S. Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-001 – Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan Campus Status Matt Smith, College Registrar, will work with Tom Cote, NSC Enrollment Reporting Consultant, to adjust the enrollment report produced by PeopleSoft. With this change, PeopleSoft will report a student's campus-level enrollment as withdrawn when they withdraw in the middle of a semester instead of leaving them as less than half-time. Program Status Matt Smith, College Registrar, and Riley Niemand, Director of Financial Aid, will use the NSLDS Enrollment Error Report to reconcile what is being reported from NSC to NSLDS to ensure it is accurate. Timing Campus Status Matt Smith is currently working with Tom Cote to make these changes and work will be completed by the end of May 2025. Program Status Matt Smith and Riley Niemand will have this reconciliation implemented by the end of June 2025. Sincerely, S. Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

Those charged with governance agreed with the finding and will work to maintain tenant files in accordance with legislation, regulations, and the terms and conditions of the major federal award program.

We acknowledge that system configuration errors in the Student Financial Aid Department resulted in the disbursement of federal direct student loans exceeding aggregate loan limits for three students. The University reimbursed the over-awarded funds to the Department of Education in February 2025 and adjusted the affected students' accounts accordingly. To address these deficiencies and ensure compliance with aggregate loan limits, the University has reviewed the financial aid management system to identify and correct configuration errors. Furthermore, the University will assign an independent reviewer to monitor loan disbursements monthly, ensuring they remain within aggregate loan limits and promptly addressing any discrepancies.

Management Response: The College concurs with the finding and is in the process of implementing a policy when satisfactory academic progress is run, students will be notified via mail or email of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.

Planned Corrective Action: ● Since learning of this issue, our Food Service Director has manually checked every application. ● Our Food Service Director is rewriting our policy to include reviewing at least 2 applications per week for any week in which 2 or more applications are received through PaySchools. We intend to fully implement this policy with the start of the 2025-26 school year. ● This new policy will allow us to randomly verify applications throughout the year to be sure that all Federal guidelines are being met. Anticipated Completion Date: In Process Responsible Contact Person: Tim Walker, Treasurer

View of Responsible Officials and Planned Corrective Actions: MCHWC understands and agrees with the finding. Measures have been taken or will be taken for immediate resolution as follows: a) Sliding fee patients will be scheduled with an enrollment counselor to review options, including sliding fee. b) Sliding fee applications will be reviewed and recommended by the respective clinic manager. c) Sliding fee applications will go through a final approval by the Chief Operations Officer. d) Due to staff limitations, the revenue cycle (billing) team will sample applications through the year.

Northern Tier Community Action Corporation concurs with the audit finding. The Organization did not maintain all client information in accordance with the requirements set forth by the grantor Agency. The Weatherization Department of the Organization had employee turnover in the 2023/2024 Fiscal Year including the Director of Weatherization, which caused a disruption in maintain client files. The Organization has reviewed the current system for maintaining files and identified any gaps in compliance with the grantor Agency requirement. The Organization then developed and implemented controls for maintaining client files that align with the grantor Agency’s requirements and provided training to all relevant personnel. This will ensure that the Organization is in compliance with all guidelines set forth by the grantor Agency. Northern Tier Community Action Corporation has implemented the above controls as of the report date.

Management will review the HUD Handbook 4350.3 with staff to ensure compliance and provide follow up training of current company policies and procedures.

Management made improvements to internal controls surrounding the recertification process when initially made aware of procedures not being performed timely and in accordance with HUD guidelines. Management monitors those initial improvements in internal controls as well as continually makes additional adjustments, as deemed necessary, to tighten these internal controls. Management’s improvements to the controls consist of the following: 1. Recertification reminder letters are being consistently sent to residents at 120, 90, 60, and 30 days prior to recertification date. 2. Incentives were put in place to encourage site associates to complete recertification tasks timely including staff lunches. After working hour sessions are also being held. 3. Third party consultants are being utilized when necessary. 4. A HUD specialist was hired during the year to address ongoing terminations and ensure site teams were aware of current and upcoming terminations related to the Section 8 program (improvement of control that occurred during 2024). 5. Site associates are going door to door and enlisting help from Resident Services teams to engage residents.

Finding 2024-003 – Major Federal Award Programs Audit a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In connection with our lease files review we noted the following deficiencies: • 2 out of 8 existing tenants tested, the Project completed Enterprise Income Verification ("EIV"), but it was not performed within 120 days prior to tenant's annual recertification, which constitutes noncompliance with HUD regulations regarding tenant eligibility and the maintenance of lease files • 1 out of 1 new tenant tested, the Project completed Enterprise Income Verification ("EIV"), but it was not performed within 90 days after the tenant's move-in date, which constitutes noncompliance with HUD regulations regarding tenant eligibility and the maintenance of lease files. b. Action(s) Taken or Planned on the Finding Management has implemented compliance monitoring measures that ensures every file is fully audited for signatures, dates and proper calculations. The compliance manager utilizes a monthly checklist which now includes confirming signatures and dates are present.

Internal Control Over Eligibility Department of Human Services Medical Assistance – Assistance Listing No. 93.778 Recommendation: We recommend the county implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input or updated in maxis and issues are followed up in a timely matter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County will continue to train staff to ensure they are aware of the requirements. Names of the contact person responsible for corrective action: Denise Gaida, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2025

Comments on the Finding and Each Recommendation: During the year ended June 30, 2024, 1 of the 12 resident files selected for testing under the HUD Consolidated Audit Guide was missing the most recent executed HUD-50059 and most recent lease agreement and/or amendment. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. The resident file noted in the statement of condition was for a resident who moved out of the Property during the year ended June 30, 2024. No further action is required related to this resident's file. However, the Corporation intends to review and update, as necessary, the other resident files to ensure the Property is in compliance with HUD requirements.

Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, the control is adequately documented and retained in accordance with organizational policies and program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has reviewed the process for intake of patient information and has revised the process outlining the order of the steps that need to be followed in detail. We have also provided staff with additional training and will self audit going forward. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: May 15, 2025

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-001: Disbursements: Pell Grant Condition Found: The University utilizes a standard term calendar and therefore should calculate federal student aid under Formula 1 (Volume 7, Chapter 1). Under Formula 1, institutions generally calculate a student’s Scheduled Award and splits such award evenly between the fall and spring semesters. The University offers a winter intersession, but did not combine the winter intersession with the fall or spring semester as prescribed by the Federal Student Aid Handbook when calculating federal student aid awards under Formula 1. Instead, the University used Formula 3 to calculate Pell Grant awards and treated the winter intersession as a separate term and awarded Pell Grants to students for the Winter 2024 intersession. In 2024, the University identified that such approach did not align with applicable Title IV regulations and Department guidance. By using Formula 3 to calculate Pell Grant awards, the University exceeded the students’ standard Scheduled Award. The total amount of over-awarded Pell Grants for the 2023-2024 academic period was $698,000. Recommendation: The auditors recommend the University enhance our internal control over compliance with the federal regulations related to disbursement of Pell Grant awards. The University should enhance how we receive, and process external information to ensure the University is properly awarding federal student aid in accordance with Title IV regulations and Department guidance. Additionally, a control should be designed and implemented for the review of such information. University of Delaware Corrective Action Plan: The University agrees with the finding. The University identified this issue as a result of an extensive review of processes, procedures and internal controls within Student Financial Services with the assistance of both external consultants and outside counsel. Through the University’s research, it was determined that this issue began in 2018 with the reintroduction of Year-Round Pell. The over-awarded amount resulted from the misinterpretation of the regulations and associated guidance and use of the incorrect formula. The University self-identified the issue with the Department of Education and is working towards resolution. The questioned costs of $698,000 related to fiscal year 2024 were refunded to the government through COD system as of September 30, 2024. The University is working with the Department of Education to open prior periods to finalize the repayment of an additional $1.9 million which is expected to be completed by June 30, 2025. The University has implemented internal controls which include the use of the Peoplesoft delivered tools to ensure that Pell is awarded using Formula 1 in accordance with Title IV regulations and Department guidance. The information related to winter intersession aid has been updated to specifically address winter Pell and ensure that it meets required regulations for attaching an intersession to a standard term when using Formula 1 for calculating Pell grant eligibility. Additionally, the University has implemented a weekly reconciliation and over-award reports to monitor for compliance. Completion Date: Return of $698,000 Questioned Costs: September 30, 2024 Implementation of Weekly Reconciliations: November 1, 2024 Return of Additional $1,900,000: Anticipated June 30, 2025 Contact Person: Amanda Steele-Middleton, Assistant Vice President for Enrollment Management

Beginning in fiscal year 2025, the District has implemented the Community Eligibility Provision (CEP) at all three of its school buildings. The CEP program is in place for four years and it will not be necessary for the District to verify income for free and reduced school lunches during that time period. If in the future the District no longer participates in CEP, control procedures will be implemented to ensure that all students selected for income verification are being correctly categorized and reported to ODEW. This will include the Cafeteria Manager reviewing the free and reduced lunch applications and forwarding any without necessary documentation to the Superintendent and Treasurer for additional verification for eligibility.

All electronic free and reduced meal applications are completed in the PaySchools system. Since PaySchools does not have a SOC1 for Ohio eligibility, all applications will be sent to a pending folder requiring the Food Service Director to review and approve the determination before providing it to the parents/guardians. They began this process reaching out to PaySchools 3/5/2025 and making the change to the account. Because this process started mid-year, the School District will review all of the approved applications prior to 3/31/2025 to avoid a comment in the future.

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2024 The findings from the October 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2024.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients’ needs and complies with all federal guidelines. Care for you. Care for me. Care for all. Our mission is to provide high-quality, comprehensive medical and dental care, patient advocacy and related services to people who need them most, regardless of their ability to pay. info@carealliance.org • www.carealliance.org Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will oversee the training. 3. The Revenue Cycle Manager will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results.

Identification: 93.889 United States Department of Health and Human Services, COVID-19 National Bioterrorism Hospital Preparedness Program, Significant Deficiency; Eligibility Requirement. Corrective Action Plan: The Association will implement controls related to future awards so that federal funding is only provided to eligible recipients once a signed subaward agreement is on file. Anticipated completion date: The Association anticipates completion in 2025.

CP-1011 CORRECTIVE ACTION PLAN Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2024 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 Signature:___________________________________ The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2024-001 a. Comments on the Finding and Each Recommendation The Project did not perform a review of the Enterprise Income Verification (“EIV”) system within 90 days of the tenant moving into the project. And we agree with this finding. b. Action(s) Taken or Planned on the Finding There have been multiple users (Property Managers) assigned to the Enterprise Income Verification System (EIV) to prevent a repeat of this occurrence going forward.

The District has already been in contact with PaySchools. PaySchools will now put all application information in "Pending Status" and the District will be responsible for review and verification. The District did go back and verify that all applications that were approved by PaySchools did in fact meet the threshold levels for all benefits that were approved and denied.