Corrective Action Plans

Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF retrained staff on FFATA reporting deadlines and documentation expectations so that if new subawards are entered into in FY 26, this requirement will be met in a timely fashion. Details relating to FFATA reporting requirements are documented in the CIF Subaward Management & Subrecipient Monitoring Policy and Procedures.

CASA 624 W Jones St. Raleigh, North Carolina 27603 CORRECTIVE ACTION PLAN December 9, 2025 Single Audit Clearinghouse 1201 East 10th Street Jeffersonville, Indiana 47132 CASA (the "Organization"), respectfully submits the following Corrective Action Plan for the year ended June 30, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Greensboro, North Carolina 27410 Audit period: Year ended June 30, 2024 The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs: Section II - Findings relating to the financial statements which are required to be reported in accordance with generally accepted Government Auditing Standards and Section III - Findings and questioned costs relating to the major programs which are required to be reported as defined by the Uniform Guidance [2 CFR 200.516(a)]: Finding 2024-001: U.S. Department of Housing and Urban Development, HOME Investments Partnerships Program Recommendation: Management should implement procedures to track tenant's annual recertification dates to ensure timely recertification; utilize checklists to ensure all required documentation, including income verification, disability and homelessness statuses, utility allowance calculations, background checks, and HOME lease addendums are properly maintained; conduct periodic internal audits of tenant's files; and evaluate staffing capacity of the leasing department. Management's Response and Corrective Action Plan: Management agrees with the recommendation and has already adjusted procedures to track annual recertification dates, supported by checklists to ensure all required documentation is complete and accurate. Periodic internal audits of tenant files will be conducted to maintain compliance. Additionally, a newly hired Senior Director of Operations will have total oversight of this process to ensure all recommendations are followed. Leasing staff continue to complete training to develop their knowledge and abilities. If you have questions regarding this plan, please call Everett McElveen at 919-754-9960. Sincerely yours, Everett McElveen CASA

Planned corrective actions: As a response to concerns about disruptions in processes and the turnover of key staff in several departments, the Enrollment Alliance group that includes director-level staff in Admissions, the Registrar, Financial Aid, Advising, Bursar, and IT began meeting under the facilitation of the VP of Student Affairs on January 7, 2025. This group will continue to work on implementing the proper controls to ensure that the determination of student eligibility for Title IV aid is appropriate and has supporting documentation. Name of Responsible Party: 1. Nancy Benavides,Financial Aid Director 2. Corey Hodge, VP for Student Affairs 3. Joanne Fernandez, Controller 4. Marla Withers, Assistant Controller 5. Sagrario Armenta Jimenez, CFO 6. Dr. Christopher Gilmer, President Anticipated completion date: 6/30/2026

AHC has revised its patient intake procedures to ensure that all required documentation is collected and verified at the point of service. An electronic eligibility checklist has been integrated into the EHR, and staff have been trained to collect alternative income documentation where appropriate. Monthly audits of ten patient files per site are conducted, and exceptions are logged and resolved within ten business days. Policies and procedures have been updated to reflect documentation and compliance standards. Ongoing monitoring and periodic staff retraining continue to support program integrity and compliance with federal requirements. Moving forward, responsibility for managing the sliding fee discount process will transition from front-desk personnel to the Revenue Cycle department to ensure stronger oversight and accountability.

Condition: During the review of 60 sampled cases, 2 cases were found where redeterminations were performed outside the required 12-month window, indicating non-compliance with federal renewal timing requirements. And one of the two cases were deemed ineligible during the re-evaluation. Recommendation: CLA recommends that the County implement or reinforce tracking procedures, such as a monitoring checklist, to ensure lead and supervisor reviews are completed and accountability is maintained. Additionally, CLA recommends that the County conduct targeted refresher training for staff and supervisors on renewal timelines and review protocols to strengthen procedural compliance and minimize errors. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Retrain supervisory staff and line-staff regarding the importance of timely redetermination. Increase reporting, especially exceptions reporting, on the status of outstanding redeterminations. Commitment to continued periodic trainings. Name(s) of the contact person(s) responsible for corrective action: Connie Beck Planned completion date for corrective action plan: Fiscal year ended June 30, 2026

Unexpected staffing challenges contributed to the late inspections. Action taken to date by the Vice President of Program Services. 1. Staffing Structure Strengthened: o A new Program Director has been hired and is fully trained in all HOPWA program requirements, including inspection procedures. o Additional staff members have now been trained to conduct HOPWA inspections to always ensure operational coverage. 2. Cross-Training of Staff: o Multiple team members, including the Director and program service staff, are cross-trained and able to step in to complete inspections if the assigned case manager is unavailable due to illness, emergency leave, or other unforeseeable circumstances. 3. Backup Coverage Plan Implemented: o A formal backup coverage system is now in place. In the event of staff absence, either the Program Director or another trained staff member will complete the scheduled inspection to avoid any delay. o Coverage responsibilities also include providing client support and ensuring continuity of services when primary staff are out. 4. Scheduling and Monitoring: o Inspection schedules are now reviewed monthly (between case mgr. and director) to ensure upcoming deadlines are clearly identified, monitored, and met. Outcome Expected: These corrective measures ensure that all annual HOPWA inspections will be completed on time, regardless of staffing changes or unforeseen absences. The increased number of trained staff and the implementation of a clear backup plan reduce the risk of future delays and strengthen program compliance.

Finding: Significant deficiency in internal control for late submission of data control form and Single Audit report package. Corrective action: Pacific Forum has authorized its outsourced accounting service to take on a larger role in fulfilling auditor requests to ensure the information submitted is accurate and complete. PFI has also consolidated financial management policies and other required documentation in a secure cloud network. PFI has also adopted more features available through Bill.com, which has enhanced documentation of expenditures and management reviews. Procedures for filing documents and utilizing financial management procedures available through Bill.com will be integrated into PFI financial management policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director

Finding: Material weakness in internal control over documenting suspension and debarment reviews for vendors receiving federal funds Corrective action: PFI has adopted a policy to document the screening of all vendors receiving federal funds via the suspension and debarment list provided in SAM.gov. These procedures will be incorporated into PFI procurement policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will reassign roles to ensure clear separation between allowability determinations and expenditure approvals. If staffing constraints prevent full segregation, management will ensure that the Finance Manager performs secondary reviews. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct periodic internal monitoring with documented review of approvals.

CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including surveys conducted by Accrediting Organizations. CHCQ has already taken steps by reiterating this requirement at a recent statewide management meeting. CHCQ will continue reminding staff of expectations at appropriate meetings and provide additional training as needed to ensure all offices follow consistent procedures when completing the required CMS 1539 forms. Headquarters management will provide oversight and conduct periodic audits to ensure staff complete and sign all CMS 1539 forms according to expectations. Estimated Implementation Date: Fiscal Year 2025-26 Contact: Nate Gilmore, State Surveyors Branch Chief, CHCQ

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Through the reinstatement of county performance standards and Focused Reviews, DHCS can identify and address eligibility concerns, such as the proper use of aid codes, and work with counties through the corrective action plan process to address staff training to ensure correct eligibility determinations for all Medi-Cal programs, including pregnancy programs. Estimated Implementation Date: Fully Implemented Contact: Sarah Crow, Medi-Cal Eligibility Division, Division Chief Harold Higgins, Medi-Cal Eligibility Division, Branch Chief Amy Halim, Medi-Cal Eligibility Division, Section Chief

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Additionally, DHCS resumed the Aid Code Cleanup effort in September 2025, as outlined in MEDIL I 25-19. The purpose of the aid code cleanup effort is to assist counties in identifying records that require eligibility re-evaluation to either transition individuals to the correct Medi-Cal aid code or appropriately discontinue coverage. Through these initiatives, DHCS can identify and address eligibility concerns, such as processing timeliness and proper aid code usage. Estimated Implementation Date: Fully Implemented Contact: Sarah Crow, Medi-Cal Eligibility Division, Division Chief Harold Higgins, Medi-Cal Eligibility Division, Branch Chief Amy Halim, Medi-Cal Eligibility Division, Section Chief

The EDD has policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the employee did not follow the proper procedure to include the penalty. EDD accepts this oversight and is committed to reviewing its applicable policies and procedures to ensure they are clear, and the penalty requirements are emphasized. Regarding internal controls, EDD leverages a process known as the Field Office Basic Evaluation System (FOBES). This process includes a standardized form that is utilized by leadership to evaluate the quality of their employees’ work on a variety of processes, including overpayment processing. EDD continues to review and modernize the existing assessment form and FOBES process to ensure effectiveness and consistency while evaluating employee compliance with policies and procedures Estimated Implementation Date: Currently Implemented Contact: Diane Underwood, Division Chief, Unemployment Insurance Branch, California Employment Development Department

Finding 2024-227: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Related to Prior Finding: 2023-211 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This process was shared with LSO following receipt of the FY23 review findings. Supporting documents can be provided again as needed. Anticipated Corrective Action Date: 03/06/2025 Responsible for Corrective Action: Kristin Matthews, Programs Bureau Chief, Self Reliance kristin.matthews@dhw.idaho.gov 208-334-5553

Finding 2024-226: The Bureau of Facility Standards within the Department failed to complete timely health and safety surveys for three long-term care facilities. Agency’s View: The Department Agrees with this finding. Corrective Action: During SFY24, Bureau of Facility Standards (BFS) was still coming out of the COVID response for recertification time frames and actively recruiting new health facility surveyors to ensure proper multidisciplined teams were available to complete the overdue surveys. BFS also contracted with Healthcare Management Solutions, LLC. to supplement overdue recertification surveys. On October 3, 2025, during the government shutdown, we were able to complete the final overdue surveys to be compliant with 15.9 months between surveys. Due to the government shutdown, CMS paused recertification surveys for nursing facilities. This may restrict our ability to maintain the required recertification timeline of 15.9 months. We have recruited and maintained staffing posture but are still actively recruiting to round out of staffing to meet the statutory timelines. Anticipated Corrective Action Date: 10/31/2026 Responsible for Corrective Action: Nate Elkins, Programs Bureau Chief, Licensing & Certification nate.elkins@dhw.idaho.gov 208-364-1874

Finding 2024-222: Four providers lacked documentation to support continued eligibility within the Medicaid program. Related to Prior Finding: 2023-223 Agency’s View: The Department Agrees with this finding. Corrective Action: Medicaid is currently under a Corrective Action Plan with CMS requiring all Managed Care providers to enroll with Medicaid. This project is currently underway. The initial date of completion of having all providers enroll was 12/31/2025. However, there were unforeseen system enrollment issues that delayed the project. The go live date is now April 1, 2026. Once all providers are enrolled Medicaid will audit provider rosters throughout the year to ensure those providers are in fact enrolled within Medicaid's system. Anticipated Corrective Action Date: 10/31/2026 Responsible for Corrective Action: Alex Scott, Program Bureau Chief, Medicaid alex.scott@dhw.idaho.gov 208-364-1928

Finding 2024-219: The Medicaid Enterprise System was not properly updated for members deemed ineligible, resulting in capitation payments issued to Managed Care Organizations for ineligible members within the Medicaid program. Related to Prior Finding: N/A Agency’s view: The agency agrees with this finding. Corrective Action Plan: Medicaid recognizes that this appears to be an interface issue with Self Reliance, and their inability to send correct eligibility records to Medicaid in certain instances. Medicaid will investigate and work with Self Reliance to mitigate these issues while working through our new system implementations and interfaces. Self-Reliance is looking at the issue to identify root causes and will work closely with MC to determine next steps to implement. System integration is expected in 2028. In the interim, we’ll identify issues and develop implementation strategies by 2027. Strategies will align with system updates and builds for both Self-Reliance and Medicaid. Anticipated Corrective Action Date: 07/31/2026 Responsible for Corrective Action: Matt Clark, Programs Bureau Chief, Medicaid matthew.clark2@dhw.idaho.gov 208-332-7979

Finding 2024-217: The Department lacked documentation to support continued eligibility for providers within the Medicaid program. Agency’s View: The Department Agrees with this Finding Corrective Action: As part of the Provider Enrollment project, the division will audit provider payments starting in 2026. The health plans will be required to validate that the providers are fully enrolled with Medicaid prior to enrolling with the health plan in early 2026. These are audits will begin in May 2026 and continue through the end of the year depending on when provider reports are due to Medicaid. This is also part of the Corrective Action Plan mentioned in finding #5. The information required to validate that no payment was made inappropriately is part of the audits that will be conducted this year with the provider rosters. Anticipated Corrective Action Date: 12/31/2026 Responsible for Corrective Action: Alex Scott, Program Bureau Chief, Medicaid alex.scott@dhw.idaho.gov 208-364-1928

The tenant recertifications will be monitored by the owner to ensure they are being completed in a timely manner.

Finding Number: 2024-032 Audit Type: Single Audit Finding Title: Delayed Final Reimbursement Due to Unresolved Agency Requests Related Finding: 2024-023 (Yellow Book) 1. Contact Person Responsible for Corrective Action Name: Shannah Weaver Title: City Clerk Department: Finance Department 2. Planned Corrective Action The City will designate a grants coordinator to monitor agency requests and ensure timely responses. 3. Anticipated Completion Date September 30, 2026 4. Management's Response Management concurs and will improve communication with funding agencies. 5. Status of Prior Year Finding This is a newt finding.

Finding 5: Cost of Attendance (COA) Budget Documentation Condition: Cost of Attendance Budgets to determine students unmet need were not provided by the College. (34 CFR 685.102(b)) • New SOP requiring documentation (e.g., printout, electronic file) of the student's specific COA be included in their financial aid file. • A full reconstruction of COA budgets is underway using historical tuition and fee schedules, room and board, and survey data. • Documentation has been compiled and saved for all student budget categories and dependency statuses. • Formal COA Development Process: o COA budgets are now reviewed and approved annually by the Financial Aid Director in collaboration with the Finance Office. o Data sources include tuition/fees, room and board, bookstore pricing, transportation estimates, and student expense surveys. • Component Breakdown: o COA budgets are broken down by: § Enrollment status (full-time, part-time) § Housing status (on-campus, off-campus, with parent) • Staff Training: o Financial Aid staff trained annually on COA development and documentation requirements. • Expected date of completion: 06/2026 Finding 6: Federal Programs Expenditure Submission Condition: The Office of Financial Aid submitted unreconciled expenditures within the Fiscal Operations Report and Application to Participate (FISAP) for Federal Pell Grant, Federal SEOG and Federal Work-Study. • New SOP requiring a formal monthly reconciliation of all Federal Pell, SEOG, and FWS program expenditures between the Financial Aid ledger and the Business Office/General Ledger. • Development of a detailed FISAP preparation checklist, requiring final reconciliation sign-off by both the DFA and the Business Manager prior to submission. • Cross-training for new FA and Business Office staff on the specific accounting and reporting requirements for all Title IV program funds reported on the FISAP • Submitted an amended FISAP to correct discrepancies and reflect accurate expenditures. • Conducted a line-by-line reconciliation of all federal fund expenditures for Pell, SEOG, and FWS for the reported year. • Implemented a dual-approval process for FISAP data involving both Financial Aid and Finance teams. • Monthly Reconciliation Protocol: o Financial Aid Office and Business Office will jointly reconcile Title IV disbursements, drawdowns, and expenditures on a monthly basis. o Reconciliations will be documented and archived for audit purposes. • Training and Accountability: o Annual training on FISAP completion and reconciliation best practices for all involved staff. o One staff member from each office designated as the FISAP lead and held accountable for data accuracy. • Expected date of completion: 06/2026 Finding 7: Reconciliation of Title IV program Condition: The College did not reconcile all Title IV programs between the office of Financial Aid and the Business Office, including Federal Pell Grant, Federal SEOG, Federal Work- Study, and Federal Direct Loans. (34 CFR 685.309(b)(5)) • Conducted a full reconciliation for all Title IV programs for the 2024–2025 award year to identify and resolve discrepancies. • Verified drawdowns in G5 against actual disbursements and adjusted ledger entries where necessary. • Establish Monthly Reconciliation Process: o A formal monthly reconciliation schedule is now in place for Pell, SEOG, FWS, and Direct Loans. o Both offices jointly reconcile: § Disbursements from SIS § G5 drawdowns § COD (Common Origination and Disbursement) data § General ledger entries • Clear Division of Responsibilities: o Financial Aid Office: Responsible for accurate awarding, disbursing, and reporting to COD. o Business Office: Responsible for drawdowns, cash management, and posting to the general ledger. o Both sign off monthly on reconciliation reports. • Training and Internal Controls: o Cross-training provided to both teams on Title IV reconciliation best practices and compliance standards. o Developed and implemented internal procedures for handling discrepancies • Expected date of completion: 06/2026

Inadequate Approval Controls Over Adjusting Journal Entries and Invoices Recommendation: We recommend following documented controls to enforce approval for adjusting journal entries. We also recommend ensuring invoice processing workflows include mandatory approvals before payment. We further recommend conducting periodic audits to verify compliance with approval policies. Action Taken: CMJTS migrated to a new accounting software in February of 2025. This software has systematic approval workflows built in to ensure approvals are done on journal entries before they are posted and invoices before they can be paid.

Finding: 2024-004: Significant Deficiency in Internal Controls over Compliance – Eligibility Name of Contact Person: Tray Miller Controller Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: Management will ensure eligibility forms are thoroughly reviewed. Proposed Completion Date: 6/30/25

2024-002: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and for both the required documentation to determine eligibility, as required by the HUD regulations, could not be located as follows: • Form HUD-50059, Owner’s Certification of Compliance with HUD’s Tenant Eligibility and Rent Procedures was not updated before the tenant’s anniversary date. • There was no verification of income by a third party provided. • There was no signed move-in/move-out inspection form provided. • There was no signed lease provided. Additionally, our testing indicated that the required deposits to the replacement reserve account had not been made for the last quarter of the Corporation’s fiscal year for any tenants. Recommendation: We recommend the Corporation establish procedures and internal controls to ensure that all required documentation is maintained, and all required reserve deposits are made timely, in accordance with HUD requirements. Action Taken: Management concurs with this recommendation. Since assuming property management on June 1, 2025, ULREDC has conducted a tenant file audit. All property management staff have been properly trained to ensure compliance with certification, documentation, and inspection requirements. Missing documentation, including Form HUD-50059, income verifications, and leasing inspections, is being corrected. Replacement reserve deposits were delayed because properties were not cash flowing. As leasing stabilizes, deposits will resume and be verified once RealPage is fully active. RealPage will serve as the compliance and record-retention platform. Quarterly internal compliance reviews will be instituted to confirm file accuracy and documentation completeness.

MATERIAL WEAKNESS 2024-002: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing and the following findings were noted: • Form HUD-50059, Owner’s Certification of Compliance with HUD’s Tenant Eligibility and Rent Procedures was not updated for the year tested • Move-in/move-out inspection form was not provided • Lease was not provided • Annual recertification of income by a third party was not provided Additionally, our testing indicated that the required deposits to the replacement reserve account had not been made for the last quarter of the Corporation’s fiscal year for any tenants. Recommendation: We recommend the Corporation establish procedures and internal controls to ensure that all required documentation is maintained, and all required reserve deposits are made timely, in accordance with HUD requirements. Action Taken: Management concurs with this recommendation. Since assuming property management on June 1, 2025, ULREDC has conducted a tenant file audit. All property management staff have been properly trained to ensure compliance with certification, documentation, and inspection requirements. Missing documentation, including Form HUD-50059, income verifications, and leasing inspections, is being corrected. Replacement reserve deposits were delayed because properties were not cash flowing. As leasing stabilizes, deposits will resume and be verified once RealPage is fully active. RealPage will serve as the compliance and record-retention platform. Quarterly internal compliance reviews will be instituted to confirm file accuracy and documentation completeness.