Corrective Action Plans

The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into formal grant management policy. Responsible Officials: Michael Elizalde, Grants & Strategic Initiatives Director Timeline to Complete: Estimated June 2026.

Views of Responsive Officials of Auditee: Management recognizes that the City’s audits have not been completed within the required statutory deadlines in recent years, including the reporting delay noted in this finding. These delays were primarily the result of turnover and transition in key financial staff positions, which impacted continuity and the timely completion of audit-related activities. At the same time, management would like to highlight the significant progress that has been made in addressing this issue. Over the past six months, the City has successfully completed two fiscal year audits, representing meaningful advancement toward eliminating the audit backlog. Management is committed to continuing this progress and has established a plan to return to full compliance with reporting deadlines. The City anticipates being fully current beginning with the FY-2027 audit cycle and will continue implementing process improvements and ensuring staffing stability to support timely audit completion. Management understands the importance of timely reporting, particularly as it relates to maintaining eligibility for federal funding and will prioritize adherence to all applicable deadlines moving forward.

Finding Number 2024-002 Planned Corrective Action: CAMcare has implemented enhanced controls over the financial screening and sliding fee discount application process to ensure compliance with 42 CFR §56.303(g)(2). Prior to the application of any sliding fee discount, financial screening staff are now required to verify that the patient’s application rating (based on income and family size) aligns with the corresponding Federal Poverty Level (FPL) category and discount level configured within the Epic system. Discounts will not be applied unless this validation is completed. To address inconsistencies identified during the audit period, CAMcare has formalized procedures requiring that all updates to the sliding fee discount schedule, including changes to FPL thresholds or discount percentages, are communicated to registration, financial screening, and billing staff prior to implementation. Additionally, system-level updates within Epic must be validated by designated personnel to ensure that the updated fee schedule is accurately reflected before being used in patient billing. Supervisory review controls have also been strengthened. Financial screening supervisors will perform monthly spot checks of a defined sample of patient accounts to verify that sliding fee discounts have been applied correctly and are supported by complete and accurate patient application data. Any discrepancies identified will be documented, corrected, and escalated for follow-up training or process improvement as necessary. In addition, CAMcare will reinforce staff training on financial screening policies and procedures on a periodic basis and maintain documentation of completed training. Management will monitor compliance through ongoing supervisory review and periodic evaluation of screening and billing accuracy to ensure adherence to established policies. These corrective actions are designed to strengthen internal controls over financial screening and billing processes, ensure accurate application of sliding fee discounts, and reduce the risk of noncompliance in future reporting periods. Anticipated Completion Date: January 1st, 2025, with ongoing monthly monitoring and periodic training. Responsible Contact Persons: Eshan Singh, Vice President of Finance, Analytics & Technology

Response and Corrective Action Planned – The ECIWDB acknowledges the merit of this recommendation and commits to taking the following action: The establishment of a procedure that incorporates the utilization of an ‘Orientation Acknowledgement Form’ to demonstrate completion by each individual participant. This procedural change shall be implemented on or about November 1, 2025.

Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Second Harvest Food Bank expenses incurred during the fiscal year that should be allocated to the TEFAP/CSFP administrative revenue received. The Organization has historically recognized revenue based on when cash is received which is not appropriate. Recommendation: We recommend the allocation of allowable costs and activities be completed at a minimum on a quarterly basis. Also, any direct expenses related to program activities should be recorded to the respectiveidentifying program fund number within the accounting software. The amount of revenue recognized for the programs should be reflected of the expenses incurred up to the administrative funds received from the respective funders. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization will implement a standard allocation to be completed on a quarterly basis at the minimum. This process will be reviewed by management to ensure implementation. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 2026.

U.S. Department of Agriculture 2024-005 • Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 1 out of the 21 agencies tested which distributed TEFAP commodities during fiscal year 2024. Recommendation: The Organization should prioritize the timely monitoring of participating agencies to allow for changes in food distributions if any ineligible participants are discovered. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization developed a schedule to complete monitoring and created a checklist to ensure that all documentation is in the appropriate folder. In addition, the organization began conducting internal audits to ensure the developed processes are being followed. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is May 2026.

2024-007 – Special Tests and Provisions – Internal Control and Compliance over Environmental Reviews City’s Corrective Action Plan: Out of a sample size of twenty-one (21) files, one environmental review document was missing the required signatures. Current procedural documentation states that after the environmental review document is completed by the project manager, it is to be routed to the First Level Reviewer (Division Manager), then to the Certifying Officer for signature. The Department will diligently ensure that the documentation is completed and routed through the approval process and will make this a priority Responsible Person: Director of Economic Development and Housing Manager Expected Implementation Date: FY 2025

Management Response: Management agrees that eligibility determinations were not consistently documented. In some cases, eligibility was verified verbally, twice by the eligibility specialist, or through external records, but not formally documented in participant files. Planned Corrective Action: Effective October 1, 2025, RSS has implemented corrected eligibility procedures. Initial eligibility documents determinations are conducted by RSS upon initial intake. If eligible, the program participant is registered in the CRM and all supporting documentation is uploaded by a RSS help desk specialist. The Eligibility Specialist then reviews the uploaded documents and records verification in the participant’s NEON account. Lastly, the help desk coordinator, direct supervisor, will audit verifications quarterly to ensure a dual verification occurred between the help desk specialist and eligibility specialist. Name of Contact Person: Anna Eaton, Executive Director

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that additional internal controls are required to ensure eligibility is verified, current, and fully documented prior to the provision of services. The instance identified resulted from a misinterpretation of system information and insufficient verification procedures to confirm current eligibility. In response, OlyCAP has initiated corrective actions to strengthen eligibility determination controls, including reinforcing documentation requirements prior to service initiation, clarifying staff procedures for reviewing eligibility system data, and providing additional training to ensure eligibility requirements are consistently understood and applied. Management is committed to maintaining compliance with federal program requirements and improving internal controls to prevent similar occurrences in the future. Estimated Completion Date: In progress / Ongoing Responsible Party: Program Management with Finance Oversight

Corrective Action Plan: GCI has since required all staff to complete form I-9. Estimated Correction Date: September 30, 2025 Responsible Official: Nedra Sims Fears, Executive Director

The Center recognizes the importance of timely compliance with federal single audit requirements. To address this, in the Spring of 2024, management engaged an outsourced firm specializing in supporting non-profits to provide full-service Controller and CFO support. This firm monitors federal expenditures throughout the year, ensuring that thresholds triggering audit requirements are promptly identified. In addition, procedures have been established to track all federal awards and deadlines, with periodic compliance reviews performed by the outsourced team. This oversight will ensure that single audits are conducted when required and that federal regulations are met in a timely and accurate manner.

We recommend the City implement and enforce a standardized procedure for verifying and documenting suspension and debarment checks for all vendors receiving federal funds. This should include maintaining evidence of SAM.gov checks, vendor certifications, or contract clauses as part of the procurement file.

Finding 2024-001 Internal Control Over Compliance - Eligibility Program: Rural Rental Housing Loans Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.415 Internal Control Area: Internal Control Over Compliance – Eligibility Condition: The entity did not provide adequate documentation to the auditors to support eligibility determinations for certain tenants participating in the Rural Rental Housing Loans program. As a result, the auditors could not opine on compliance with this federal grant as it applies to tenant eligibility. Criteria: Uniform Guidance (§200.303) requires non-federal entities to establish and maintain effective internal control over federal programs to provide reasonable assurance of compliance with federal statutes, regulations, and the terms and conditions of federal awards. Effective internal control over eligibility with this federal award includes procedures for verifying, documenting, reviewing, and retaining tenant eligibility information. Cause: The deficiency appears to be due to insufficient internal controls over the retention of adequate documentation to support eligibility determinations made by management. Effect: Because internal controls over eligibility were not operating effectively, there was inadequate documentation available to provide to the auditors for testing of such eligibility determinations. Recommendation: We recommend that management strengthen internal controls over eligibility by establishing formal procedures for implementing supervisory review of tenant files, and ensuring eligibility documentation is retained in accordance with program requirements. Management’s Response and Corrective Action: Management agrees with this finding and will implement procedures to ensure that all supporting documentation related to tenant eligibility is retained and easily retrievable.

Action Taken: The Houston Housing Authority agrees with this fining and related recommendations. During 2024 the voucher and public housing programs converted to a new software system. Yardi is not the principal operating system for both the voucher and public housing programs. This system conversion has required that work flows had to be modified. This modification and implementation of a new processing system did not allow staff to conduct the necessary reviews of existing files to make sure that the compliance related materials that should be found in each file were to be completed. This issue has been discussed and there will be an internal review conducted on file samples to determine what compliance deficiencies are prevalent. Corrective action steps will be implemented to address these issues designed to correct them. Additional training resources will be devoted to staff in these departments designed to improve quality control with these program areas. The Senior Vice President of Voucher Operations will be focused on improving the quality of our files that support the voucher operations.

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedures to ensure all required actions are taken when a tenant becomes over-income. As of December 14, 2024 lease agreements have been updated to include language that states once a tenant is over the income limit, they are considered ineligible and their rent will immediately be adjusted to the HUD market rent.

Name of contact Person: Brittany Naylor, Director of Social Services Corrective Action: Lenoir County will implement the following for the Food and Nutrition Services case actions cited for the Single County Audit Fiscal Year ending June 30, 2024. • All workers will be given a 2nd party review form to utilize as a check off sheet to make sure everything needed was documented, attached, and forms sent correctly, etc. to ensure each case is updated correctly • Staff meeting will be held Wednesday, January 29, 2025 and the following printouts of policy/DSS Administrative letter will be given out to each worker and reviewed together as a group. DSS Administrative letter EFS_FNS_AL-35-2020 in regards to Telephonic Signature for Food and Nutrition Services Applications and Recertifications (amended) as of September I, 2020. (Where to document on applications and recertifications and must have a standalone note and cannot contain any additional characters or spaces). FNS policy 260 paragraph 12. Verbally explain and provide the ABAWD with the DSS 8569 Consolidated Work Notice, and explain that the case file must be documented with the date the notice was verbally explained, how the notice was given, if by hand deliver or mailed. Findings showed that the 8569 was created, but not changed to SENT from DRAFT. FNS 305 Rules for Budgeting Income, FNS 310 Budgeting New, Changed and Terminated Income, FNS 3 I 5 Special Budgeting Income, FNS 40 Deductions, FNS 350 Whose Income is Counted. Also explain to workers to double check attachments to make sure after being attached it could be pulled back up to review and to make sure information is attached as it should be. Ensure that SUA 's are updated correctly, that case information is documented and verified. • Supervisors will run and monitor NCF AST O&M reports daily to disparage overdue reviews or overdue applications. • Lead Worker turn in 2nd party reviews at least once or twice a week to be evaluated for error trends to the Staff Development Specialist for review. • Error trend rep011s are compiled by Staff Development Specialist and turned in monthly to Economic Services Administrator. • Staff Development Specialist will keep an excel spreadsheet detailing the errors cited and determine any error trends that need to be addressed. Unit meetings and individual conferences provided by the Supervisors in an effort to effectively catch and manage error trends that have been reported by the Staff Development Specialist. • Meetings held with Lead Workers, Medicaid Supervisors, Staff Development Specialist and Administrator to evaluate error trends. Monthly trainings held, as needed, to review error trend findings of 2nd party reviews completed with staff. • Providing staff with the knowledge of the audit information, the performance improvement plan and what staff expectations are. Staff Meeting to be held to address audit findings and to start training process for staff to obtain knowledge needed to remain in compliance with policy standards. Proposed Completion Date: February 15, 2025

Name of contact Person: Brittany Naylor, Director of Social Services Corrective Action: This finding is listed as a repeat finding on Technical Errors cited finding in previous audit 2023-002 and continues to be an issue for Lenoir County. Several of these are system issues, but the primary root causes of these findings again were due to extreme staffing shortage of trained individuals during this fiscal year. Many of new staff in this division have been employed less than a year and are still in training. The work increase has caused a significant impact on this unit, but the unit works as a team to try to ensure work demands are being met daily. New staff members have been added and are showing improvement of policy and how to apply policy to case actions, which will help reduce the increased number of technical errors found during this audit period. Supervisors and Lead Workers continue to train with staff when errors from 2nd party reviews are discovered. Lenoir County takes immediate action to correct any findings and ensure that workers are made aware of job duties and expectations. Trainings, staff meetings, and conferences have already been conducted or planned to help workers to understand these errors that were cited and the importance of mitigating these errors while completing daily case actions. Lenoir County has always been committed in completing work demands effectively, timely and efficiently as possible. Lenoir County will continue to implement the strategies and work diligently to ensure that the following goals and standards are being met. Lenoir County has effectively maintained the required accuracy standards rate of 96.8% or higher when determining eligibility for case actions, approvals, terminations and denials Implementation of new Staff Development Specialist, Jacqueline Thomas, to the team to help lead and direct Lead Worker to fulfill job duties and requirements and to ensure that work demands and goals are being met effectively and timely. Staff Development Specialist and Lead Workers to implement hands on classroom activities using a variety of sources and techniques in an attempt to guide and teach staff. Tools used to implement training would include but not limited to the following: Learning Gateway modules Magi Budgeting, Magi Budgeting: Income Determination, NC DHHS Medicaid Manual, etc. Modules are given in self learning type atmosphere and then followed up with classroom discussions and activities in an effort to enhance the retainability of information learned to the worker. Traditional lecture type atmosphere provided in a classroom setting. Structured tests given to workers to detect where weaknesses could be in an effort to streamline and strengthen a workers skill set. • NCFast Help Job Aids, NC DHHS policy for Medicaid for Families and Children or for Medicaid for the Aged, Blind, and Disabled manuals created and given to each worker for reference material to study during training processes. • Review and application templates provided to each worker to give them a guided checklist to aide them with completing case actions in work assignments. • Supervisors will run and monitor NCF AST O&M reports daily to disparage overdue reviews or overdue applications. • Lead Workers turn in 2nd party reviews at least once or twice a week to be evaluated for error trends to the Staff Development Specialist for review. • Error trend reports are compiled by Staff Development Specialist and turned in monthly to Economic Services Administrator. • Staff Development Specialist will keep an excel spreadsheet detailing the errors cited and determine any error trends that need to be addressed. Unit meetings and individual conferences provided by the Supervisors in an effort to effectively catch and manage error trends that have been reported by the Staff Development Specialist. • Meetings held with Lead Workers, Medicaid Supervisors, Staff Development Specialist and Administrator to evaluate error trends. Monthly trainings held, as needed, to review error trend findings of 2nd party reviews completed with staff. • Providing staff with the knowledge of the audit information, the performance improvement plan and what staff expectations are. Staff Meeting to be held to address audit findings and to start training process for staff to obtain knowledge needed to remain in compliance with policy standards. • Continue to complete 100% 2nd party reviews on all new workers and pull findings within month of completion. New workers should be released from 100% 2nd party review process and move to process listed above when accuracy rating meets 98% for three consecutive months. Proposed Completion Date: For policy compliance will start immediately and goal completion is set for February I5, 2025. Trainings conducted to remedy policy misinterpretations, by conducting monthly meetings, one-on-one conferences, and completion of remedial testing either through the Learning Gateway or unit created tests.

Name of contact Person: Brittany Naylor, Director of Social Services Corrective Action: This finding continues to be listed as an ongoing eligibility determination error from prior audits. Lenoir County has been actively and aggressively working on the backlog of the expa1ie reviews to complete this report. Based on NCFAST system, there are no other reports beyond June 2019, however, the expartes in question were dated prior to this date. Steps implemented to mitigate and resolve this issue have been thwarted due to limited staffing and increase work demands. The goal is for Lenoir County to have the backlog completed by July 31, 2025. The overall plan for Lenoir County has been effective even with these issues or concern. In the prior plan, Lead Workers were instructed to pull all the SSI Exparte reports (3) from the NCFAST system weekly and manage these reports effectively. Lead Worker would either complete or assign exparte reviews to staff for completion. Supervisors would then receive lists from the Lead Worker showing the number of expartes assigned to each worker and the Supervisor must check reviews each week against the workers' application pending logs. The reports are to then be checked by the Lead Worker and Supervisor for completion and verified monthly. To help mitigate this problem, the following additional steps will be implemented to the existing plan of action to ensure that Lenoir County meets this goal. •Implementation of new Staff Development Specialist, Jacqueline Thomas to the team to help lead and direct Lead Worker to fulfill job duties and requirements and to ensure that work demands and goals are being met effectively and timely. •Staff Development Specialist will meet with the Lead Worker and get weekly updates on the progress until backlog report has been completed and finalized. •Staff Development Specialist will keep a detailed report on any issues and concerns and give a weekly report to the Administrator on the status of this issue. •Administrator will give updated status report to the Director at monthly meetings. Proposed Completion Date: As of this date, Lenoir County is still working to complete the backlog from June 2019 -December 31, 2022.

Views of Responsible Officials: Management agrees and will plan to submit the June 30, 2025 Single Audit by March 31, 2026.

CHES! has implemented a new process in entering the sliding fee applications in the Electronic Health Records system (Nextgen) to ensure compliance with the program requirements of the sliding fee program. The new process includes a thru date for all sliding fee applications at which time an alert will pop-up when the file is accessed that the sliding fee application has expired.

U.S. Department of the Treasury Department of Housing and Community Development respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023-June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Housing and Community Development 2024-014 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Recommendation: We recommend that the Department review and enhance supervisor review and approval to ensure that program requirements are consistently performed. Documentation to support compliance with the requirements should be maintained and readily available for review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The subrecipient who administered the assistance for three (3) of the four (4) affected records has fully expended ERA 2 funds. DHCD will review the subrecipient’s internal approvals process and tenant notification process to determine where improvements can be made and issue recommended recordkeeping changes for the subrecipient to implement for future federal subawards. DHCD will review and make necessary changes to program policy guides as necessary to strengthen case file recordkeeping requirements and ensure that case file reviews for direct financial assistance programs include a review of notifications to clients. In prior desk monitoring and file audits, the relevant subrecipient files always included a notification of assistance to the tenant. Name(s) of the contact person(s) responsible for corrective action: Danielle Meister Planned completion date for corrective action plan: April 30, 2025 2024-015 COVID-19 – Homeowner Assistance Fund – Assistance Listing No. 21.026 Recommendation: The Department should reevaluate current process, implement proper controls, and perform additional training over time and effort reporting. The Department should not seek federal reimbursement unless they can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Monthly reporting to Senior Management of any exceptions to the federal timesheet process will be required to ensure that all federal timesheets are completed and received in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Wade Simmons Planned completion date for corrective action plan: April 30, 2025 If the U.S. Department of the Treasury has questions regarding this plan, please call Crystal Quinzani at (301) 429-7840.

Department of Labor (DOL)Financial Statement Preparationinancial Statement Preparation. Unemployment Insurance – Assistance Listing No. 17.225 Recommendation: We recommend the Department implement procedures and internal controls to ensure that it complies with program requirements, that it maintains documentation, and that documentation is readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Recommendation: We recommend the Fund establish procedures to ensure that financial reporting is performed in a timely manner and provide accurate and relevant information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The team that was assembled to work through the audit has also been enlisted to redesign the process and build new tools to create UI Trust Fund financial statements every month. While this is still in development, we plan to have it functioning accurately by May of 2025. Name(s) of the contact person(s) responsible for corrective action: John Fahnbutu. Planned completion date for corrective action plan: 5/30/2025 Recommendation: We recommend the Fund establish procedures to ensure that financial reporting is performed in a timely manner and provide accurate and relevant information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The team that was assembled to work through the audit has also been enlisted to redesign the process and build new tools to create UI Trust Fund financial statements every month. While this is still in development, we plan to have it functioning accurately by May of 2025. Name(s) of the contact person(s) responsible for corrective action: John Fahnbutu. Planned completion date for corrective action plan: 5/30/2025 Maryland Department of Labor- Unemployment Insurance Trust Fund (the Fund) respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023-June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS

14.251 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants Federal Grantor: Department of Housing and Urban Development Compliance Requirement: Internal Controls over Procurement, Suspension and Disbarment Criteria: Non-federal entities who receive federal grants may not contract with entities that are suspended, disbarred, or otherwise excluded from receiving or participating in Federal awards. Condition: The Organization did not have controls in place to ensure vendors were eligible to receive federal awards. Cause: The Organization did not implement proper internal controls to verify that all contractors were eligible to participate in programs funded with Federal awards. Effect: Without proper internal controls, the Organization may not properly identify vendors that are ineligible to participate in federal contracts. Questioned Costs: None. Auditor's Recommendation: We recommend policies and procedures be implemented related to suspension and disbarment whereby the Organization can identify any ineligible contractors prior to entering in to any contracts with vendors. Corrective Action: The Organization will implement appropriate policies and procedures related to suspension and disbarment as part of any future grant application and management process. We will identify ineligible contractors prior to entering into vendor agreements and will monitor existing contractors to ensure they have not become ineligible.

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in its waiting list management. We accept responsibility for the deficiencies in internal control over the waiting list and are committed to implementing corrective actions that address missing documentation and lack of transparency in following the Authority's Administrative Plan and HUD guidelines when selecting applicants from its waiting list. Immediate corrective actions include: • Only using the electronic records of applicants from the Authority's housing software and not creating external waiting lists. • Reconcile and Reconstruct: Immediately reconcile the waiting list and reconstruct missing documentation for voucher issuance. • Cleanup Waiting List: The Authority's waiting list is closed, and staff are currently working to purge it. • Update Procedures: Ensure staff know and are trained on waiting list procedures to ensure compliance with HUD regulations and the Authority's Administrative Plan. • Implement Controls: Establish a periodic supervisory review to verify document completeness during the voucher issuance process. • Training: Provide staff with ongoing training on proper, consistent, and compliant wailing list administration. • Retention: Ensure all records are maintained according to federal retention requirements. Name of Responsible Person: Catherine Lamberg, CEO, and Jackie Otto, COO, and Daporsha Abernathy, HCVP Director Projected Completion Date: Some of the corrective activities are underway. We anticipate completing these activities by June 1, 2026.

Finding: 2024-005 Material Weakness in Internal Control Over Eligibility – WIC Special Supplemental Nutrition Program for Women, Infants, and Children (10.557) Corrective Action: We will develop a checklist for eligibility documentation and conduct quarterly file reviews and implement corrective actions as a result of those reviews. We will also provide training to program staff on the eligibility documentation requirements. Proposed Completion Date: February 28, 2026 Name of Contact Person:Tomiko Fisher, Chief Operating Officer