Corrective Action Plans

See pdf of corrective action plan

See pdf of corrective action plan

Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should provide training and education to front desk staff related to the EMR and the process for collecting and retaining family size and income information in addition to inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information and has been obtained and charges are appropriately billed in accordance with the Organization's policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the finding. To address this issue, the Organization will reinforce procedures requiring current incomeand family size documentation prior to determining sliding fee eligibility, provide additionalstaff training, and will review electronic medical record system settings to ensure properdocumentation and application of discounts. Management will conduct periodic reviews tomonitor compliance with sliding fee discount requirements. Name(s) of the contact person(s) responsible for corrective action: Chief Operations Officer or their designee. Planned completion date for corrective action plan: September 1, 2026

Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule •Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement an additional review of all sliding fee applications received and provide additional training for intake staff. Name(s) of the contact person(s) responsible for corrective action: Jennifer Smith Planned completion date for corrective action plan: 6/29/2026

During the 2025 audit, the auditors discovered that a secondary review of eligibility determinations did not occur in a timely manner. The lack of internal control opened the possibility that an individual was incorrectly determined to be eligible to receive benefits and this error would not have been identified or corrected in a timely manner. Federal Regulations establish requirements for internal control over compliance with Federal program requirements. 2 CFR Section 200.303 requires non-Federal entities to establish and maintain effective internal control over Federal awards that provides reasonable assurance the entity is managing the award in compliance with Federal statutes, regulations, and the terms and conditions of the award. These requirements include the design, implementation, and operation of control activities to ensure compliance with applicable compliance requirements, including eligibility. As eligibility is a key compliance requirement identified in the OMB Compliance Supplement, the County is required to implement a review process and system of internal controls that allows management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, errors or noncompliance in eligibility determinations on a timely basis. The Department of Human Services (DHS) has implemented a monthly review process to audit a random sample of the IV-E cases. The review includes verification of timely and accurate determinations, client information, supporting documentation, and system entries, with results documented and approved by the reviewer. DHS Division leadership will monitor compliance to ensure the reviews are conducted each month. DHS believes this additional review procedure will provide the needed internal controls over IV-E determination.

Finding #2025-007 14.239 HOME Investment Partnerships (HOME) Program Eligibility Views of Responsible Officials and Planned Corrective Action Management’s Position: #1 Management concurs and acknowledges that approving the matter without a more thorough evaluation was an oversight. #2 Management disagrees. HOME maximum subsidy per 3-bedroom unit is $338,419.00. Total HOME investment is $112,500.00. Corrective Actions: Corrective actions include strengthening internal controls and oversight. Management will implement a more comprehensive review process moving forward. This process will include additional supervisory review, verification of supporting documentation, confirmation of regulatory and policy compliance, and consultation with appropriate program and legal staff, when necessary, before approvals are granted. Management will also establish review checklists and documentation standards to ensure that all relevant factors are consistently evaluated and adequately documented. Moving forward, the Community Development Division will undergo a more rigorous evaluation process standardized review checklists and documentation requirements will be implemented to promote consistency, accountability, and proper recordkeeping. Management will monitor compliance with these enhanced procedures to reduce the risk of future deficiencies, oversights and ensure approvals are supported by adequate due diligence. Responsible Party: Jo Lyn Terlaje, Community Development Manager Anticipated Date of Completion: Final approval checklists will be implemented by August 1, 2026.

Name of Contact Person: Jill Sampson, DSS Director Corrective Action: Training will take place to reiterate the importance of properly recording the required telephonic signature and date. After reviewing the findings listed, the availability of time reserve and how to record it as well the steps following its expiration will also be discussed. All will be addressed in the upcoming training. Proposed Completion Date: April 7, 2026.

Name of Contact Person: Jill Sampson, DSS Director Corrective Action- Internal Control Error: The Auditor Report for Bladen County disclosed finding(s) of non-compliance with laws and regulations. The audit shows that we have repetitive errors from the previous year. We take these results very seriously and are committed to implementing lasting improvements. Bladen County Department of Social Services is focused on establishing protocols that will build a standard of confidence for our Income Maintenance case workers. It has been and will remain our constant goal to strengthen our Medicaid programs through knowledge and training to eradicate errors. Bladen County DSS will implement the following program policy and procedures to improve proficiency in service delivery. We do recognize that we fell short of expectations on this audit, particularly with the repeat error findings. The nucleus of the Plan of Correction will have a framework that will involve both Income Maintenance staff and Managers to set a groundwork that will empower the Medicaid teams to meet state expectations and improved audit outcomes in the future. The Second-Party Audits completed each month by Medicaid Supervisors will track our performance and upon completion of the second party of cases training will be completed to address the errors found. Staff will be given a test that will measure our performance improvement to assure accuracy on case work. Areas Needing Correction: Internal Control Errors • Failure to comply with policy requirement: Three (3) instances of failure to complete at least one compliance component. All identified missing or incomplete verification of facts or were improperly forced. • Inaccurate Resource Calculation: Three (3) instances of inaccurate resource calculations in NC FAST. The values entered in NC FAST evidence and used in the eligibility determination did not match the supporting documentation or was lacking any substantiating documentation. • Inaccurate Budget Calculation: Six (6) instances of inaccurate budget calculations in NC FAST. The values entered in NC FAST evidence and used in the eligibility determination did not match the supporting documentation or was lacking any substantiating documentation. • Failure to document/correct system issues: Four (4) instances of system errors found that were not addressed or corrected. Cases contained benefit histories that were not representative of the benefit that was issued. Goal for Correction: • Work Number Usage Administrative Letter No: 02-19 The Work Number Procedures • The Work Number (TWN) - Job Aid dated 09/21/2023; The Work Number (Fact Sheet) Dated 09/25/2023. • Manual Calculations of Income F/C MA 3300; MA 2250 • MAF-MIC-HSF Budgeting – MA 3305 • Financial Resources MA 2230 • Evidence Dashboard Relationships - Job Aid dated11/27/2018 • Acceptable use of Medical Forced Eligibility– Last updated 03/01/2023. • NC FAST Mandatory Evidence and Verifications • Adding Evidence to Case (Job Aid) • Online Verifications (Job Aid) • MA 3515 Bladen County DSS is committed to using tools listed in this Plan of Correction to assist in recognizing any areas of concern for the Medicaid Teams. Bladen County DSS is eager to assist workers to become the most efficient and productive in their daily work routine, to reach the best desired outcome for both the clients served, as well as the overall audited scores. • Training has been completed for the Medicaid staff on February 23, 2026 (Adult Department) and February 24, 2026 (Family and Children Medicaid Department). See list of Medicaid policy, Administrative letter and NC FAST job aids that were addressed during the meeting. • Medicaid Program Checklist- each Medicaid team will have a checklist that will be utilized on each application/ recertification completed. This tool will be used to ensure Income Maintenance workers have completed all necessary actions to application/recertifications. This tool will also be used in auditing each case during the second party review of the case. *Note: Item Number 18 from the Medicaid Eligibility Testing Attribute has been updated to include The Work Number for household members age 14 and above. These tools are included in the Second Party review of the record and if the worker does not complete the tool a point is deducted as being in error. • Second Party Review of Records – Will be completed monthly by the Supervisor and Lead Worker for the specific program. Each Income Maintenance worker will be monitored by monthly review of three applications and three recertifications. Any errors that are determined during the second party review will be addressed with the worker, who will be given 3 days to make the correction to the file, refute the error finding by discussing manual policy with the Supervisor/Lead worker, workers will need the policy name and section number. This internal audit will assist in determining areas of training that staff need for overall improvement in job performance. • Medicaid Spreadsheet Internal Report Card – has been created for the Medicaid team monthly utilizing the individual scores received from the Second Party review of cases. This will be the benchmark set at 96.8% for Eligibility errors and 90% for technical errors. • Monthly Audits completed by Bladen County Finance Office will continue to be completed. Each worker is given their individual errors discovered by this audit. The worker will be coached concerning the errors found and will be required to make corrections to the case. The worker will also sign the audit form indicating that the information was reviewed with them and the date recorded. • Medicaid Spreadsheet Internal Report Card reviewed by County Boards – The Medicaid Second Party Spreadsheet (Internal Accuracy Report Card) for the Adult Medicaid and the Family and Children Medicaid Department will be reviewed monthly by the Bladen County Health and Human Services Advisory Committee. A formal presentation will be sent to the committee each month via computer. This information will be sent out in the format of spreadsheets; the spreadsheets will indicate each worker (using an alphabet identification) and will indicate if the employee met the benchmark goal of 96.8% eligibility and 90% technical error rate each month. This chart will give a three-month snapshot (window of time) for notifications of error trends identified by the audits. This report will be discussed quarterly at the Health and Human Service Advisory Committee meeting offering each committee member the opportunity to address their concerns about audit scores during that quarter. • All Medicaid Program teams will staff all pending applications (by date priority) with the IMC, Supervisor, and/or Lead worker. This will help to eliminate any questions that the IMC may have in response to completion of the application. • Second Party review of cases will be completed monthly by Supervisor and Lead worker in the Medicaid programs. Upon completion of the entire team’s second party reviews, training will be created based on the errors found at the second party of work. Once the training has been completed, workers will be given a test to determine their understanding of policy, job aid and forms reviewed in the training. A test score of 90% accuracy must be maintained by each staff member to receive a passing score. A score below 90% will require additional training. • A training outline form will be utilized during training so that staff have the opportunity to give feedback as to what they feel they need additional training in. • Newly hired staff within the first (1) year of employment will receive quarterly job performance evaluations. • Newly hired and all active Income Maintenance staff will take and pass (score of 70% or above) the NC FAST Core Functions Certification and Level 1 Training Program. • Newly hired staff will be required to have work reviewed 100%. • Warning System for Persistent Errors – Implementation of a warning system for caseworkers who persistently make errors, despite corrective actions and counseling. First Warning:  When an employee repeatedly makes errors despite individual counseling and corrective actions, they will receive a First Warning.  The employee's supervisor will meet with them to discuss the errors and reinforce the importance of adhering to policies and procedures.  As per Bladen County DSS policy, employees will be given three workdays to make necessary corrections.  The First Warning will be documented in the employee's personnel file. Second Warning:  Within three months, If the employee continues to make errors after receiving a First Warning, they will be issued a Second Warning.  The supervisor will conduct another meeting with the employee to address the persistent issues.  During this meeting, a performance improvement plan will be established, outlining specific areas for improvement and a timeline for achieving them.  The Second Warning will be documented in the personnel file. • Demotion in Position – If the employee's errors persist even after receiving the Second Warning and failing to meet the goals of the Plan of Correction, they will face demotion in position. The demotion will involve a change in job responsibilities or a transfer to a lower-level position if available within the organization. This action will be taken after thorough evaluation and consultation with Human Resources. • Termination – If, despite previous warnings, the employee continues to make errors that significantly impact their performance and the effectiveness of DSS, the last step is termination. Termination is the last resort and will be considered only after the employee has received a First Warning, a Second Warning, and a demotion in position. The decision to terminate will be made in consultation with Human Resources and higher-level management. • Proposed Completion Date: This Plan of Correction will become effective April 1, 2026. The Bladen County Department of Social Services Economic Services Division for the Medicaid Programs will take an active role in ensuring work is monitored and that staff receive training throughout the year, to minimize the error rate from the Single County Audit.

Special Tests and Provisions Condition: The Organization did not maintain documentation to show that patients had been evaluated for eligibility under its sliding fee scale policy and did not apply sliding fee adjustments consistent with the sliding fee scale assigned. Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information has been obtained in accordance with TCA’s policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA Health is strengthening controls over its sliding fee discount program. Effective FY26 (April 11, 2026), Epic will require entry of family size and income and will apply the appropriate discount based on the approved sliding fee schedule, reducing the risk of missing or incorrect discounts. Staff training on sliding fee policies and Epic workflows has been reinforced and will be refreshed at least quarterly. TCA Health will also conduct monthly audits of encounters to confirm required documentation is on file and discounts are applied in accordance with the sliding fee scale, and will use results to drive targeted follow-up and process improvements. We will increase the audit to include the total population vs. a sample when reviewing. Name(s) of the contact person(s) responsible for corrective action: Samantha O. Mitchell Planned completion date for corrective action plan: 9/1/26

AUDITOR FINDING: 2025-001 Eligibility. We noted the following issues in the 25 cases tested: 1. One instance in which client income was incorrectly entered and as such, was ineligible for benefits as they were over the income limits for all of 2025. 2. Three instances in which, although case notes indicated general contact with the participant, the County did not retain sufficient documentation that a required meeting specifically addressed or confirmed engagement in an eligible work activity or was completed within required timeframe. Recommendation: We recommend that the County continue to strengthen internal controls related to eligibility determinations. This includes issuing training alerts related to the differences of subsidized and unsubsidized employment income and the impacts to eligibility. Additionally, we recommend continued periodic quality assurance reviews of TANF case files to ensure ongoing compliance with federal and state eligibility requirements and identification of employees with performance issues. Finally, we recommend the County develop monitoring reports to identify those clients who have not had a workforce contact in the required timeframe. CLIENT PLANNED ACTION: Jefferson County agrees with the findings and has taken or will take the following steps to address the errors. The findings were caused by workers on both the eligibility and workforce teams so varying measures will be implemented based on the finding and responsible team. Jefferson County will continue and implement the following actions to address and prevent future findings. • Eligibility Team Actions o Jefferson County will issue a training alert to all eligibility staff by June 20, 2026, detailing the difference between subsidized and unsubsidized employment, correct data entry, and the impact of each on TANF eligibility. o To monitor compliance, the County will continue completing Internal Quality Assurance reviews utilizing the state mandated list to assess the case and payment accuracy. • Workforce Development Team Actions o Performance concerns related to inconsistent client contact and incomplete documentation were identified during regular performance reviews in January 2026 and have been successfully addressed via the county Employee Relations coaching and disciplinary framework. •To monitor compliance, the County will continue completing Internal Quality Assurance reviews utilizing the state mandated list. In addition, Colorado Works Supervisors review at least one case per worker each month. Beginning in June 2026, the number will be increased to a minimum of 10 cases per month if a performance concern is identified. o Tableau reports have been created or enhanced to monitor compliance. • Individual case worker accuracy reports for all IQA and Supervisor reviews were released in March 2026. Progress reviews have been incorporated into monthly supervision meetings with staff. • Enhancement to report titled, Cases Needing Action, which tracks data entry of client contact and Individual Plan development in CBMS was completed on June 1, 2026. Workers will now be notified if client contact exceeds 30 days. Workers and supervisors will review the report monthly and take proactive measures for client contact prior to exceeding rule requirement of 90 days. CLIENT RESPONSIBLE PARTY: CW Eligibility Team: Julia Zoukhri (Program Manager), Brandy Brogan (Program Manager), Karen Thomas (Program Manager) and Jennifer Martinez (Quality Assurance & Systems Administrator) CW Workforce Development Team: Tara Noble (Program Manager), Kathryn Boyd-Cordova (CW Supervisor), and Erin Encinias (CW Supervisor) COMPLETION DATE: July 2026

Recommendation: Management should strengthen its tenant file review and monitoring procedures to ensure that reasonable rent determinations and utility allowance calculations are completed, documented, and reviewed in accordance with the Housing Authority’s policies and applicable program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Authority will address the identified deficiencies and prevent recurrence by strengthening file review procedures, enhancing staff training, and improving internal controls. A standardized quality control process will be implemented to ensure required tenant file elements are accurate, complete, and properly reviewed prior to approval, along with periodic monitoring to identify and correct errors in a timely manner. Staff will receive targeted and refresher training to reinforce key requirements, calculations, and documentation standards. Additionally, the Authority will evaluate opportunities to improve system controls to reduce the likelihood of errors or missed steps. Name(s) of the contact person(s) responsible for corrective action: Lowel Krueger, Executive Director. Planned completion date for corrective action plan: December 31, 2025.

Management has implemented a comprehensive continuing education program for employees who work on the SSVF program. Monthly internal audits are conducted by the Program leadership team to monitor compliance with funder guidelines.

Memo: Cause and Corrective Action Plan for Finding 2025-003 This correspondence serves as Cook County Health (CCH) and Cook County Department of Public Health (CCDPH) response to Finding 2025-003. During the FY2025 Single Audit, one audit finding was identified by Washington, Pittman & McKeever, LLC. The root cause and corrective action plan is identified below. Condition During the current audit period, the Cook County Department of Public Health (DPH) did not comply with federal regulations regarding the use and reporting of program income as it relates to funds awarded through the RWHAP Root Cause Analysis The HIV grants transitioned to CCH from an external organization in July 2025. Award amounts were granted in multiple phases, requiring four budget revisions, with the final revision approved in December 2025. The contractual period covered March 2025 through December 2025. During the transition period, CCH lacked formal operational procedures to identify, record, and track program income. Several operational and administrative challenges contributed to this issue, including: • No written internal procedures were in place to define or track program income requirements. • No formal transition teams were established to identify core grant obligations, resulting in unclear interpretation of sponsor requirements. • CCH had not yet identified the appropriate internal systems or interdepartmental collaborations necessary to retrieve and reconcile program income data. • Organizational priorities during the transition focused on maintaining existing deliverables, including vouchering, budget compliance, hiring, and onboarding of direct and administrative staff. • Staffing Shortages, CCH onboarded personnel quickly as contractual employees, direct staff transitioned onboard as CCH employees in phases upon execution of grant contracts. Corrective Action Plan CCH Director of Grants Accounting is implementing formal written processes and procedures to ensure compliance with Federal Uniform Guidance requirements related to program income. The corrective action plan includes: • Developing standardized written procedures that clearly define program income requirements and tracking responsibilities. • Establishing shared roles and responsibilities across departments to support consistent data collection, reconciliation, and reporting. • Identifying the specific data elements required to accurately record and monitor program income. • Formalizing interdepartmental collaboration processes necessary to retrieve and validate program income information. • Defining the systems and reporting tools that will be used to track and maintain program income records. • Providing staff training on program income requirements, documentation standards, and compliance expectations. These actions will strengthen internal controls and ensure timely, accurate identification and tracking of program income moving forward, official approval/implementation is expected December 2026

2025-001 Finding SDSI Housing Corporation, Inc. (SDSI Housing) received reimbursement from the reserve for replacements of $135,824 for roof repairs that were previously funded with insurance proceeds. The reserve for replacements is under funded by $135,824 due to the reimbursement of ineligible items. A reimbursement request was submitted for major roof repairs which are traditionally contemplated as eligible for draws under HUD Occupancy Handbook 4350.3 REV-1. However, management did not consider the fact that such repairs had already been funded by insurance proceeds, so the major roof repairs resulted in no cost to the Project. Comments on Finding and Recommendations Management agrees with the finding and recomendations. Actions Taken Management returned ineligible funds of $135,824 to reserve for replacements on April 16, 2026.

2025-007 Auditor’s Recommendation: The entity should strengthen internal controls over TANF benefit payments by implementing procedures to ensure payments are identifiable by participant and reconciled to eligibility records. The entity should also establish controls to verify benefit calculations and ensure assistance is discontinued when eligibility expires, and maintain sufficient documentation to demonstrate compliance with program requirements. Corrective Action: UCM will strengthen internal controls over TANF benefit payments by implementing procedures to ensure payments are clearly identifiable by participant and reconciled to approved eligibility records before assistance is provided. Each payment will be supported by participant identification, eligibility approval, assistance type, approved amount, funding source, payment date, and supporting documentation. UCM has established TANF Eligibility Determination Guidelines, a List of Acceptable Documents, and an Assistance Agreement Form to support eligibility determinations and benefit payment documentation. Per VDSS guidance, once eligibility is established at the beginning of the program, a change in status during the participant’s stay does not disqualify the participant from receiving further services. Felony record documentation is not required in the participant file as felony record status is not part of the eligibility requirement per VDSS. Evidence of review and approval will be retained in the participant file. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Case Managers Shruti Jha, Senior Director of Finance Liya Tseye & Carmen Romero, Accountants Laura D’Ambrogi, Grants Manager Anticipated Completion Date: Substantially completed as of April 6, 2026. Ongoing payment review, eligibility monitoring, reconciliation, and supervisory review will continue during the program year.

2025-006 Auditor’s Recommendation: UCM should strengthen internal controls over TANF eligibility determinations by developing and implementing written procedures that clearly define the documentation required to support all TANF eligibility criteria. These procedures should require that participant files include sufficient documentation supporting financial eligibility, citizenship or qualified alien status, TANF benefit history, household composition, compliance with applicable legal eligibility requirements, and work participation when applicable. In addition, the entity should implement a documented supervisory review and approval process to verify eligibility determinations and supporting documentation prior to the provision of assistance. The entity should also provide training to staff responsible for eligibility determinations to ensure they understand federal TANF documentation requirements and maintain complete and accurate participant files. Corrective Action: UCM will strengthen internal controls over TANF eligibility determinations by formalizing written procedures that clearly identify the documentation required to support each eligibility criterion before assistance is provided. The procedures will define required documentation for financial eligibility, citizenship or qualified alien status, TANF benefit history, household composition, applicable legal eligibility requirements, and work participation requirements when applicable. UCM reviewed and discussed the findings with the auditor, Senior Director of Finance, and Chief Program Officer. UCM also reviewed the Virginia Department of Social Services post-training materials on TANF Employment Advancement Eligibility Determination Training, and clarified identified areas of the findings with the Virginia Department of Social Services as they relate to the subrecipient signed contract. UCM designed new Screening Guidelines for incoming program participants, including a documented supervisory review and approval process, which were completed on April 16, 2026. The new screening guidelines require participant files to include sufficient documentation supporting eligibility determinations and require supervisory review before assistance is provided. A supervisor or designated reviewer will verify that the participant file contains the required eligibility documentation, that eligibility criteria have been met, and that the assistance is consistent with TANF requirements, VDSS guidance, the subrecipient contract, and program guidelines. UCM reviewed and trained staff on the new eligibility screening guidelines, acceptable documents, and income requirements on April 28, 2026. Staff responsible for TANF eligibility determinations, case management, direct assistance, and grant compliance will continue to receive training as needed to ensure they understand TANF documentation requirements and maintain complete and accurate participant files. UCM will also periodically monitor participant files to confirm continued compliance and identify any additional training or process improvements needed. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Laura D’Ambrogi, Grants Manager Case Managers VDSS Program Consultant Anticipated Completion Date: Substantially completed as of April 28, 2026. Ongoing implementation, supervisory review, staff training, and monitoring will continue during the program year.

View of Responsible Officials: Management agrees with the finding and recommendation. Corrective Action Plan: East-West Center will designate the International Programs Specialist (coordinator of the Graduate Degree Fellowships) to prepare the list of selected students to be offered scholarships demonstrating clearly that the selections meet the ratio requirement. The Dean of the Education Program will be required to sign off on the list, checking to ensure that the ratio of students meets our designated mandate. If students decline our initial offer, each alternate also will be vetted by the Dean to ensure the balance is maintained. If there is funding uncertainty up until the date required to send invitations, and a different funding source is used as an alternative or backstop, the program will bring these students on a J-visa so that they are able to shift to Federal funds at a later date to ensure that the ratio is maintained. 27 Contact Person: Director and Dean of Professional Development and Education Programs Anticipated Completion Date: May 2026 28

Description of Finding: Criteria or Specific Requirement: The lead agencies, who are subrecipients under the Federal Awards, are required to have clients sign the Form 502045-A CSFP Sub-Agency Monthly Participant Sign-in Sheet to self-declare program eligibility before food is disbursed. Issue and Cause: There were two instances out of 40 distributions tested where this signoff was not completed. Due to the hectic environment at the lead agencies during food distribution day, oversights have occurred when obtaining the required client signoff. Statement of Concurrence or Nonconcurrence: PARF management has reviewed the 2025-001 finding and concurs with the recommendations as stated. Corrective Action: PARF has an extensive training process in place for lead agencies, in relation to grant award compliance requirements, which includes the provision of training manuals and monthly phone calls to review matters. In addition, PARF provides updates to the lead agencies as new or amended requirements are enacted. Further, PARF does periodic reviews of the lead agencies and completes the biennial review Form 502035 CSFP Management Evaluation. PARF will continue to reiterate the required signoff process with the lead agencies during phone calls, training session and reviews. In addition for FY 2026 PARF will be conducting a mandatory webinar to ensure all the lead agencies are understanding the procedure and why it is important for 100 percent accuracies -https://docs.google.com/presentation/d/1YZgcq7SY4DmvhYrKZE8sp-NDhpuzn827PZDZ0xAKDw/edit?usp=sharing

Healthy Start has implemented procedures to double check coding and input with final review, first by initial review of parent application by Program Director who codes, then by review of parent application by Admin Asst for accuracy and then by input of parent application in data base where input and classification is reviewed for correctness.

Audit Firm: CohnReznick Period Covered by Audit October 1, 2024 - September 30, 2025 Corrective Action Plan Prepared By: Name: Nancy Thomas Position Chief Financial Officer and Executive Vice President Telephone Number: 336-917-6066 Finding No. 2025-002; Eligibility - Material Weakness PUBLIC HOUSING Name of Federal Agency: Department of Housing and Urban Development Federal Program Name: Public Housing Operating Fund Assistance Listing Number: 14.850 Federal Award Identification Number and Year: NC012-00000325D; NC012-00000625D; NC012-00000825D; NC012-00000925D; NC012-00001225D; NC012-00002125D; NC012-00002225D; NC012-00003025D; NC012-00003125D; NC012-00003225D; NC012-00034325D; NC012-00003525D; NC012-00003625D; NC012-00003725D; NC012-00003825D; NC012-00004025D; NC012-00004125D Criteria: In accordance with Uniform Guidance, internal controls are required to be in place to ensure compliance with federal requirements and to maintain complete and accurate participant files as noted in 24 CFR 5.233. Condition and Context: Our testing of 40 participant files noted the following: • No electronic income verification was done within the required time period for 20 of 40 participant selections. Effect or Potential Effect: The Housing Authority of the City of Winston-Salem (“ASPIRE”) is not in compliance with federal requirements regarding Eligibility. Cause: Tenant lease files were not maintained, and tenant eligibility was not determined in accordance with Uniform Guidance. Questioned Costs: Unknown Identification as a Repeat Finding: This finding is not a repeat finding. Recommendation: ASPIRE should maintain complete and accurate participant files to ensure compliance with federal requirements. Views of Responsible Official(s) and Planned Corrective Actions: ASPIRE will improve internal controls to maintain complete and accurate participant files to ensure compliance with federal requirements. CORRECTIVE ACTION TO BE TAKEN: 1. No electronic income verification was done within the required time period for 20 of 40 participant selections. Response: Electronic Income Verification (EIV) reports were not completed within the required timeframe for 20 of the 40 public housing tenant files selected for review. The delays were the result of staff oversight and a lack of adequate monitoring to ensure EIV reviews were completed and documented within HUD-required timeframes. To address this issue, Public Housing staff have been retrained on EIV requirements, including HUD-required review and documentation deadlines. Management has reinforced expectations regarding the timely completion of EIV reviews and implemented additional monitoring procedures to ensure compliance. The Assistant Director has also established a tracking system and compliance calendar to assist staff in monitoring and completing required EIV reviews within the prescribed deadlines. In addition, the Assistant Director of Compliance conducts monthly reviews of a random sample of tenant files to verify compliance with EIV requirements and identify any deficiencies including the 120-day move in EIV reports and requires corrective action. Any findings are addressed through staff coaching, corrective action, and additional training as necessary. These measures are intended to strengthen internal controls, improve compliance monitoring, and ensure EIV reviews are completed in accordance with HUD requirements.

Audit Firm: CohnReznick Period Covered by Audit October 1, 2024 - September 30, 2025 Corrective Action Plan Prepared By: Name: Nancy Thomas Position Chief Financial Officer and Executive Vice President Telephone Number: 336-917-6066 Findings and Questioned Costs - Major Federal Award Program Audit Finding No. 2025-001; Eligibility and Reporting - Material Weakness-HCV Voucher Program Name of Federal Agency: Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster (Section 8 Housing Choice Vouchers Program; Mainstream Vouchers Program) Assistance Listing Number: 14.871; 14.879 Federal Award Identification Number and Year: NC012VO 2025; NC012EF 2025; NC012DV 2025 Criteria: In accordance with Uniform Guidance, internal controls are required to be in place to ensure compliance with federal requirements and to maintain complete and accurate participant files as noted in CFR 5.233, 982.151, 982.405(d), and 982.516. Condition and Context: Our testing of 40 participant files noted the following: • No support was able to be provided regarding tenant lease files for 4 of 40 participant selections. • No tenant addendum was able to be provided for 1 of 40 participant selections. • No HAP contract was able to be provided for 2 of 40 participant selections. • No electronic income verification was done within the required time period for 13 of 40 participant selections. • Annual recertifications were not completed timely for 3 of 40 participant selections. Effect or Potential Effect: The Housing Authority of the City of Winston-Salem (“ASPIRE”) is not in compliance with federal requirements regarding Eligibility and Reporting. Cause: Tenant lease files were not maintained, and tenant eligibility was not determined in accordance with Uniform Guidance. Questioned Costs: Unknown Identification as a Repeat Finding: Repeat finding 2024-001 Recommendation: ASPIRE should maintain complete and accurate participant files to ensure compliance with federal requirements. Views of Responsible Official(s) and Planned Corrective Actions: ASPIRE will improve internal controls to maintain complete and accurate participant files to ensure compliance with federal requirements. CORRECTIVE ACTION TO BE TAKEN: 1. No support was able to be provided regarding tenant lease files for 4 of 40 participant selections. Response: The agency underwent a relocation of its main office and experienced the loss of five Housing Choice Voucher Specialists, which necessitated the engagement of a contractor to assume responsibility for more than 1,800 participant case files. Due to the transition of these caseloads to the contractor and the limited storage capacity at the agency's new office location, physical participant files were transferred to an off-site storage facility. During the process of boxing, inventorying, and relocating more than 5,000 physical files, four participant files were inadvertently misplaced. Upon discovery, management took immediate action to reconstruct the missing files using available electronic records, third-party documentation, and information maintained within Yardi. To mitigate the risk of future file loss and strengthen document retention practices, the agency implemented enhanced procedures effective January 1, 2025. Staff are now required to electronically upload and attach all supporting documentation to the applicable HUD Form 50058 action within Yardi, in addition to maintaining the required physical file. This dual-record retention process ensures that participant documentation is preserved in both electronic and hard-copy formats, providing redundancy and improving accessibility, accountability, and compliance with record retention requirements. 2. No tenant addendum was able to be provided for 1 of 40 participant selections. Response: The absence of the tenant addendum was the result of an oversight by the Housing Choice Voucher Specialist. To prevent similar occurrences in the future, staff have been reminded of the requirement to maintain complete participant files, including all required HUD forms and addenda. In addition, the agency now requires that tenant addendums and all supporting documentation be maintained in both the participant's electronic file within Yardi and the physical file. This dual-record retention process provides an additional level of quality control and helps ensure that required documentation is readily available for future reviews and audits. 3. No HAP contract was able to be provided for 2 of 40 participant selections. Response: The agency was unable to provide a copy of the HAP Contract for two of the forty participant files selected for review. This was the result of an oversight in the maintenance of the participant files. Upon notification, management conducted a review of the files and implemented corrective measures to strengthen document retention practices. Staff have been retrained on the requirement to maintain complete participant files, including all required Housing Assistance Payment (HAP) Contracts and supporting documentation. In addition, the agency now requires that HAP Contracts be maintained in both the participant's electronic file within Yardi and the physical file. Management has also implemented periodic file reviews to verify that required documentation is present and properly retained. These measures are intended to improve recordkeeping controls and prevent similar occurrences in the future. 4. No electronic income verification was done within the required time period for 13 of 40 participant selections. Response: Electronic Income Verification (EIV) reports were not completed within the required timeframe for 13 of the 40 participant files selected for review. The delays were the result of staff oversight and workload challenges experienced during a period of significant staffing turnover within the Housing Choice Voucher Program. To address this issue, Housing Choice Voucher staff have been retrained on EIV requirements, including required timeframes for obtaining and reviewing EIV reports. Management has reinforced expectations regarding timely completion and documentation of EIV reviews. Additionally, the department auditor conducts monthly reviews of a random sample of participant files to verify compliance with EIV requirements and identify any deficiencies requiring corrective action. These measures are intended to strengthen compliance monitoring and ensure EIV reviews are completed within HUD-required timeframes. 5. Annual recertifications were not completed timely for 3 of 40 participant selections. Response: Annual recertifications were not completed within the required timeframe for three of the forty participant files selected for review. The delays were primarily attributable to staffing shortages and caseload transitions that occurred during the audit period, resulting in increased workloads and processing delays. To address this issue, staff have been retrained on annual recertification requirements and processing timelines. Management has reinforced expectations regarding the timely completion of annual recertifications and implemented additional monitoring procedures to track upcoming and overdue recertifications. The Director has also developed an Annual Recertification Calendar for staff to follow. This calendar outlines each step of the annual recertification process and establishes deadlines to ensure timely completion of all required actions. In addition, the department auditor conducts monthly reviews of a random sample of participant files to verify compliance and identify any deficiencies requiring corrective action. These measures are intended to improve timeliness, strengthen oversight, and ensure annual recertifications are completed in accordance with HUD requirements.

U.S. Department of Housing and Urban Development Housing Voucher Cluster: ALN-14871 Section 8 Housing Choice Vouchers and ALN-14.879 Mainstream Vouchers Noncompliance - Eligibility A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of the Agency’s compliance with requirements applicable to each program funded under Uniform Guidance requirements. B. Actions Taken or Planned: Management implemented changes to ensure that upon move-ins a copy of the executed lease is obtained, and management has included on the check list completed with each move in a reference to obtaining and scanning the new lease. The lease is scanned into the Corporation’s web-based system and retained for as long as the person remains on the program. Management will continue to evaluate their controls with respect to current federal awards and requirements to ensure accurate information captured, reported and maintained. Anticipated completion date: 9/30/26 Responsible party: Michelle Worthington, Section 8 Housing Director

Corrective Action Plan: Management acknowledges the finding relative to formal documentation for eligible project costs and will enhance review procedures for monthly WIFIA loans draws to have written contemporaneous evidence from the lender in addition to preliminary approval received for project transfers or changes (i.e. renaming of subprojects listed in the loan closing documents within the same scope approved in the loan). The project changes materialized due to a change in expected timing of Sewer Utility work included in joint projects with the City’s Department of Public Works. As a result, standalone projects were executed to complete the required work by the October 2025 deadline mandated in the Sewer Consent Decree. The changes were discussed with the lender upon notification from the Department of Public Works and included in WIFIA quarterly reporting while the formal project approvals are in process. The Utility’s Project Delivery Unit Director is responsible for ensuring that this corrective action is accomplished with an estimated timeline for completion by September 30, 2026. The WIFIA project scope is defined as: I. Water Line Replacement via the Joint Infrastructure (JIRR) Program; II. Sewer Line Replacement via the Joint Infrastructure Recovery Roads (JIRR) Program; III. Sewer System Evaluation and Rehabilitation Program (SSERP); and IV. Sewer Force Main Replacement and Improvement. The eligible activities include, restoration and replacement of damaged gravity sanitary sewer mains, manhole rehabilitation and repair, CIPP lining and point repairs, Water line replacement and repair, Roadway restoration and ADA curb ramp improvements associated with the utility work.

2025-005 Allowability – Interprogram Activity Public Housing Operating Fund ALN 14.850 Significant Deficiency in Internal Control Other matter required to be reported in accordance with Uniform Guidance Condition: The Authority maintains a material interprogram receivable balance in the asset management program (“AMP”), which is due from other programs of the Authority. This interprogram receivable increased by $373,091 from the September 30, 2024 balance of $433,981, for a total receivable balance of $807,072 as of September 30, 2025. Auditor Recommendations: We recommend that the Authority immediately discontinue using Public Housing Operating Fund resources to fund costs or cash shortfalls of other programs or component units. The Authority should prepare a detailed reconciliation of all interprogram receivable and payable balances by program and implement a repayment plan to restore the Public Housing Operating Fund. We further recommend that the Authority implement written cash management and interprogram accounting procedures to prevent future unauthorized advances. These procedures should include monthly reconciliation of all interprogram balances, supervisory review, and approval of interprogram activity. Management Response: Management acknowledges and accepts responsibility for the deficiencies in internal control over allowability and eligibility and are committed to implementing corrective actions that address missing documentation and lack of verifiable procurement procedures to ensure compliance. Reconcile intercompany balances • CHA is currently working with its fee accountant to complete this process Cease Additional Borrowing • Effective immediately, CHA will discontinue the practice of increasing interprogram borrowings from AMP 1 except where expressly authorized by HUD regulations. Implementing a Repayment Plan • CHA will implement a repayment plan to prioritize repayment from unrestricted or otherwise eligible funding sources in compliance with HUD requirements. Monthly Interprogram Reconciliation • Finance staff and fee accountant will reconcile all interprogram receivable and payable balances monthly. • Any new interprogram activity will be reviewed by the Executive Director and Fee Accountant to ensure allowability before recording. Strengthen Budget Monitoring • Management will perform monthly budget-to-actual reviews for every program to identify operating deficits before they require interprogram borrowing. • Programs experiencing budget shortfalls will implement corrective spending measures or identify alternative eligible funding sources. Improve Cash Flow Management • With the assistance of the fee accountant, CHA will prepare monthly cash flow projections for each program to monitor liquidity and prevent the use of restricted Public Housing Operating Funds for other programs. Implement Internal Control Procedures • Written procedures governing interprogram transactions will be incorporated into the Authority's financial policies. • All interprogram transactions will require documentation supporting the purpose, funding source, and regulatory allowability. Oversight by Fee Accountant • The Authority's Fee Accountant will review interprogram balances during monthly financial statement preparation and report unusual activity or growing receivable balances to management. Board Oversight • The Board of Commissioners will receive monthly financial reports that include interprogram receivable and payable balances to provide ongoing oversight of repayment progress and compliance. Monitoring • The Executive Director and Finance Department will monitor compliance with this corrective action plan monthly and adjust operating budgets as necessary to eliminate future interprogram borrowing. Name of Responsible Person(s): Jackie Otto, Executive Director, Sherdana Wade, Director of Operations, Michelle Guidry, Finance Director Projected Completion Date: Some of the corrective activities are underway. We anticipate full compliance ahead of the June 30, 2027 audited submission.

Need Analysis Planned Corrective Action: Management acknowledges the audit finding related to errors in need analysis, including instances of over-awarded Federal Direct Loans and under-awarded Pell Grants. These errors were the result of deficiencies in oversight and review processes within the Financial Aid Office during the audit period. The identified discrepancies have been corrected. To address this issue, the College has implemented significant changes within the Financial Aid Office, including elevating leadership to the Assistant Vice President (AVP) level and hiring experienced, qualified staff. These changes strengthen both technical expertise and supervisory capacity. Additionally, the College has enhanced review procedures related to awarding, including increased oversight of need analysis calculations and enrollment verification prior to disbursement. These measures are intended to improve accuracy and ensure compliance with Title IV requirements. Management believes these corrective actions have addressed the root causes of the finding and will continue to monitor awarding processes to ensure ongoing compliance. Person Responsible for Corrective Action Plan: Missy Perry, AVP for Financial Aid Anticipated Date of Completion: June 30, 2026