Corrective Action Plans

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/24 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County has policies and procedures as well as systematic processes and oversight set up to ensure accurate assessments and determinations are made regarding the Federal or Non-Federal Eligibility of youth in the Foster Care system. It is Solano County’s policy to conduct these assessments at the onset of the case and ensure quality documentation. In addition, the Foster Care unit has a Lead worker and Supervisor who conduct periodic reviews of open cases to ensure accuracy of documentation and adherence to timelines are met. The specific corrective actions identified in this audit found errors related to the migration of data to the CalSAWS program in 2023, where two cases were inadvertently converted from Non-Federal to Federal cases due to errors or information which existed in CalWin and were transferred improperly to CalSAWS. These conversion errors occurred automatically. As a result, the Foster Care Eligibility Unit has implemented the following changes. • Corrections to identified cases: o The two identified cases were corrected immediately, and all payments adjusted as appropriate. • Changes to workflow to ensure accuracy: o The entire caseload of open Foster Care Eligibility cases will be reviewed to ensure that the original determination or as found in the FC3 or FC3A and granting comments, is correctly input in CalSAWS, and any payment errors corrected as needed. o The case aid code (noting eligibility type) will be included next to the youth’s name to ensure that it shows in the workload report in CalSAWS to ensure the information is easily accessible and any future errors can be identified. o Cases will be reviewed to ensure the above changes are completed through the unit supervisor’s ongoing qualitative review of cases. • The Foster Care Eligibility Supervisor will discuss the findings and requirement with subordinate staff in the following ways: o Unit meeting communication regarding Corrective Action findings and Agency steps to remediate. o Issue a reminder to all staff regarding the above remediation plan. Responsible Individual(s): Kim McDowell, Social Services Manager Neely McElroy, Deputy Director, Child Welfare Services Anticipated Completion Date: May 31, 2025

Federal Agency: U.S. Department of Agriculture Program/Cluster: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number: 10.557 Pass‐through: California Department of Public Health Award No. and Year: 22-10294 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Condition #1. Five (5) instances out of 60 cases were missing all eligibility documentation. This included the documentation of the determination of eligibility and redetermination in the period under audit. The missing documentation included the records to evidence compliance with the eligibility criteria. Condition #2. Two (2) instances out of 60 cases were missing the Self Declaration Statement form when the applicant was unable to provide acceptable documentation for proof of income, proof of address, or proof of identification. Response to Condition #1 Per California Department of Public Health, Women, Infant, Children division (CDPH/WIC), the categories of non-breastfeeding, breastfeeding, and partially breastfeeding women files remain accessible to the local agency. For children five years of age, the files are purged six months after the fifth birthday. The WIC WISE records for the 5 files were not available due to the file purge by CDPH/WIC, therefore the auditor was unable to determine compliance to eligibility requirements for each of the five files. The auditor suggests the local agency retain eligibility documents. According to the California WIC Policy and Procedure Manual, WIC WISE Forms JOB AID section, eligibility documents provided by an applicant or a re-certifying client are not required to be retained by the local agency. The County has communicated this finding to CDPH/WIC and the risk it presents. At this time, the County is working with CDPH/WIC to address this finding. Specific Corrective Plan Procedures addressing Condition #1 Staff participate in a robust Quality Assurance (QA) plan which involves periodic file reviews and observations as documented in Solano County’s Continuous Quality Improvement (CQI) Monitoring Plan. Additionally, CDPH/WIC conducts a Program Monitoring Visit (PMV) every two years which includes a random record review of the agency’s compliance to eligibility policies. Solano County WIC program will continue to conduct the QA plan, and participate with the CDPH/WIC PMVs. Response to Condition #2 Solano County agrees with the finding. This use of the Self Declaration Statement (SDS) is a specific consideration in the QA plan. The WIC Supervisor was aware of the matter as it was discovered that both SDSs were missing from the family file as part of a regular QA review. The error was addressed with the employee shortly after the mistake occurred. Specific Corrective Plan Procedures addressing Condition #2 Staff participate in a Quality Assurance (QA) plan which involves periodic file reviews and observations as documented in Solano County’s Continuous Quality Improvement (CQI) Monitoring Plan. Additionally, CDPH/WIC conducts a Program Monitoring Visit (PMV) every two years which includes a random record review of the agency’s compliance to eligibility policies. Solano County WIC program will continue to conduct the QA plan, and participate with the CDPH/WIC PMVs. Responsible Individual(s): Christopher Husing, Senior Health Services Manager, Solano Public Health Anticipated Completion Date: April 1, 2025

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Health Care Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County agrees that eligibility determinations and redeterminations including obtaining documentation and verifications should be performed annually to determine if individuals are eligible in accordance with the compliance requirements of the program. There are overdue redeterminations in our system due to the Medi-Cal expansion and increasing need for IHSS services in our communities without a substantial increase in staffing to support this service need. This year, we continue to have uncovered caseloads related to Social Worker job transition or leave, fair hearing and the growing complexity of our client population requiring more case management throughout the year. In FY 2024-25, we were granted seven additional social workers. We are anticipating these additional social workers will reduce the number of overdue redeterminations. We also have hired two Extra Help Social Workers who will focus on overdue redeterminations. We participate in State level discussions related to advocacy and increased IHSS administrative funding to support the growing number of IHSS clients. Responsible Individual(s): Gwendolyn Gill, Health Services Administrator Bela Matyas, Chief Deputy Director Anticipated Completion Date: July 1, 2025

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Eligibility and Special Tests and Provisions Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: CW 2.1: Solano County has policies and procedures as well as systematic processes set up to ensure the required collection and documentation of the applicant’s intent to cooperate with child support. It is Solano County’s policy that the Child Support Questionnaire (CW 2.1Q) and Notice and Agreement (CW2.1NA) be processed in accordance with regulations, which require workers to: • Conduct an interview either via telephone, or in-person with the applicant, print the forms, and document the County Use Section which requires worker’s signature and date. • Mail the forms to the applicant for a wet signature or collect the signature via electronic means. • Ensure the CW2.1 forms are received and complete. • Initiate the required case action(s) based upon information provided on the forms. Solano County has a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent this error in the future: • A post-Audit meeting will be held with all stakeholders to discuss the specific audit findings and action steps needed. • The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the applicable eligibility handbook with verbiage to emphasize the following: o The requirement to review and collect the information needed to complete the notice and agreement (form CW2.1) for child, spousal, and medical support from the applicant. o That the case be authorized according to program rules only after required forms are received by the county, reviewed to ensure that the case is updated with the correct information, documented in the case journal, and the form(s) scanned into the document imaging system. o Highlight these requirements when training this topic. • The CalWORKs Program Specialist will address the findings and requirements as follows: o Present at the Monthly Program Support Forum conducted with managers, supervisors, and lead workers. o Written guidance and reminder will be published in the Monthly Program Support Newsletter to all staff. o Present and discuss this requirement with lead workers at the Lead Worker Coordination Meeting, and with supervisors at the Division Coordination Meeting. • In addition to regular case reviews, focused case reviews will be added to review for completion of the Notice and Agreement for Child, Spousal, and Medical Support (form CW 2.1). SAWS 2A SAR: Solano County has policies and procedures as well as systematic processes set up to ensure the worker has reviewed the Rights and Responsibilities (SAWS 2A SAR) with the applicant/recipient and obtain their signature. It is Solano County’s policy that the SAWS 2A SAR be processed at application and redetermination which require workers to: • Conduct an interview either via telephone, or in-person with the applicant, print the form, and document the worker’s signature and date. • Mail the form to the applicant for a wet signature or collect the signature via electronic means. • Ensure the completed form is on file prior to authorizing benefits. Solano County has a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent this error in the future: • A post-Audit meeting will be held with all stakeholders to discuss the specific audit findings and action steps needed. • The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the applicable eligibility handbook with verbiage to emphasize the following: o That the case be authorized according to program rules only after the signed SAWS 2A SAR form is received by the county, documented in the case journal, and the form(s) scanned into the document imaging system. o Highlight these requirements when training this topic. • The CalWORKs Program Specialist will address the finding and requirement in the following ways: o Present at the Monthly Program Support Forum conducted with managers, supervisors, and lead workers. o Written guidance and reminder will be published in the Monthly Program Support Newsletter to all staff. o Present and discuss this requirement with lead workers at the Lead Worker Coordination Meeting, and with supervisors at the Division Coordination Meeting. • In addition to regular case reviews, focused case reviews will be added to review for completion of the Rights and Responsibilities (SAWS 2A SAR). Responsible Individual(s): Daniel Horel, Employment and Eligibility Services Administrator Thomas West, Employment and Eligibility Services Manager Diana Hernandez, Employment and Eligibility Services Manager Jennifer Stephenson, Employment and Eligibility Services Manager Anticipated Completion Date: May 31, 2025

Student Financial Assistance Cluster - Assistance Listing No. No. 84.268 Recommendation: We recommend the University review its process around sending exit counseling information to students to ensure this information is received and the University is performing required procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has hired additional staff, enhanced training efforts, and established a standard procedure to send loan exit counseling notifications to students at the end of each term, ensuring regulatory compliance. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: June 2025

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Section 8 Housing Choice Vouchers Programs to ensure that established internal control policies are being followed on a timely basis. Julio Marenco, Interim Executive Director, will be responsible to implement this corrective action by June 30, 2025.

2024-004. Inadequate Procedures to Identify Healthcare Providers with Expired Licenses State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Out-of-state providers and the provider whose license expired during the PHE. During the PHE an expired license report was not properly monitored. Prospectively, DHHS will ensure license expiration notifications are reviewed on a monthly basis. Additionally, DHHS will work with the PRISM contractor to explore pathways to identify all providers (out-of-state and in-state) whose licenses may have already expired. DHHS will follow the current license expiration process and close those providers as appropriate. Provider initially granted eligibility in the legacy system. In any future event involving data conversion, DHHS will ensure that all relevant data from the existing system is thoroughly collected and reviewed prior to the conversion process. This will help guarantee data integrity and minimize the risk of issues arising during the transition. Implementation Date: July 31, 2025 Contact: Shandi Adamson, Director, Office of Medicaid Operations, shandiadamson@utah.gov

2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took approval actions on these cases will be scheduled to discuss what led to the incorrect decision and review the policy and procedure for learning. In addition, all eligibility workers who manage refugee programs will receive training on common error elements. All one-on-one meetings and team training will be completed by April 30, 2025. Anticipated correction date: April 30, 2025 Responsible person: Muris Prses, Division Director, Eligibility Services Division, 801-889-9712

Management agrees with the auditors and has initiated the necessary corrective action plan to mitigate the deficiency from occuring again. The plan is to implement new procedures to ensure the reporting to the NSLDS is done on a timely basis.

Name of Responsible Individual: Brandon Rhone, Analyst, Financial Aid Systems, and Chad Wick, Director Financial Aid Corrective Action: During the 2024 fiscal year, the Financial Aid office experienced several staffing changes, including hiring of a new Director of Financial Aid. The University transitioned from a manual awarding process to an automated process after last year’s audit but not in time to change some of the 23-24 awards. In the past FSEOG funds were used to assist students to pay off balances allowing them to register for the next semester. This practice in no longer being followed beginning with the 24-25 academic year. In addition, the Financial Aid office will review all 2024-2025 FSEOG awards to ensure that FSEOG is only awarded to Pell recipients. Anticipated Completion Date: March 31, 2025

Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding. In selecting among eligible students for FSEOG in each award year, the office of Financial Aid will select first those students with the lowest expected family contribution and the highest need who also received Federal Pell Grants in that year. Management will implement and document an internal audit review. A monthly reconciliation will be completed to ensure Pell recipients are awarded FSEOG, based on the guidance provided by the Federal handbook. Anticipated Completion Date: June 30, 2025

Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate costs in a manner that aligns with the eligibility and income requirements of the award. Using this methodology, management will identify the eligible population and appropriately incur allowable expenses associated with the award. Management will initiate a bi-weekly process to review upcoming appointments and the most recent eligibility check on recurring patients. If, during this process, a patient is identified who requires an eligibility check based on award criteria (i.e., whichever is later: four weeks or the individual's next appointment), Management team will perform re-enrollment procedures to validate that the individual is still eligible. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that all participant information is retained and for management to perform and document periodic reviews of eligibility determinations. As required to maintain the Organization’s Pending Recognition status with the Diabetes Prevention Recognition Program (DPRP), Quincy Asian Resources, Inc. has complied with all data collection and reporting requirements.

Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to process Medi-Cal applications. o Ongoing recruitment efforts will continue to fill vacant positions, including the hiring additional trainees to build capacity for timely eligibility determinations. • Improving Internal Processes: o The County is conducting a review of workflows to identify inefficiencies and implement streamlined processes that eliminate bottlenecks. o Digital tools and automation are being introduced to enhance efficiency and accuracy case processing. • Providing Additional Support: o Overtime opportunities are being offered to eligibility specialists to expedite the processing of pending cases. o Applications are being assigned to Eligibility Specialists on a weekly basis to ensure consistent progress in reducing the backlog. • Enhancing Monitoring and Reporting: o Administrative staff are generating weekly reports from CalSAWS to track the status Medi-Cal pending applications and monitor progress. o Weekly meetings are being held with supervisors to review performance, discuss challenges, and adjust strategies as needed. • Strengthening Internal Controls: o The County is improving its internal controls to prevent future delays, including increased use of system reports to identify applications nearing the 45-day processing requirement, regular audits of the eligibility determination process and enhanced compliance training for staff. • Ongoing Evaluation and Adaptation: o Progress will be assessed weekly to ensure the implemented measures are effective. Adjustments will be made as needed to maintain compliance with the 45-day requirement. Proposed Completion Date: The county has already implemented this process and expects it to be completed by July 31, 2026.

Identification and Review • Conduct an internal audit of all financial aid awards for the affected students to determine the extent of the overaward • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year. • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies. • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed. Process and Policy Improvements • Implement a cross-check system for all financial aid components and strengthen internal controls to ensure total aid does not exceed COA before disbursement • Implement additional system checks and alerts in the financial aid management system to flag overawards automatically. • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent overawards • Train financial aid staff on COA regulations and best practices for awarding aid Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25

Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written procedures for verifying loan amounts prior to disbursement • Implement a two-step verification process for loan packaging System Controls • Collaborate with IT to implement automated system checks to flag discrepancies • Enhance reporting tools for regular audits and monitoring Staff Training • Conduct comprehensive training sessions for financial aid staff on federal regulations regarding Direct Loans • Provide ongoing refresher courses and updates as federal policies change Monitoring Continuous Improvement • Establish a quarterly audit process to ensure compliance • Monitor loan discrepancies detected and correct as needed • Conduct regular audits to confirm compliance with federal loan regulations. • Collect feedback from staff on the effectiveness of training Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 03/03/25

Identification and Review • Immediately review and recalculate the subsidized need for the affected students. (Completed) • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year • Adjust the loan amounts as necessary and return any excess funds to the Department of Education. (Completed) • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies • If the excess aid cannot be adjusted within the same academic year, follow federal guidelines to return any over awarded federal funds through the Common Origination and Disbursement (COD) system • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed System Enhancements • Implement system-level edits and warnings in the financial aid software to flag over-awards before disbursement. • Schedule regular audits of loan disbursements to ensure ongoing compliance Policy and Procedure Update • Update the financial aid packaging policy to include stricter controls for verifying subsidized need calculations. • Implement a cross-check system for all financial aid components before loan disbursement • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct training sessions for financial aid staff on loan eligibility calculations. • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent over awards • Provide guidance on using the financial aid management system's tools to avoid over-awards Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 02/25/25

2024-008 Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Health Care Services Award No. and Year: Various Compliance Requirements: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: Title 42 Chapter IV Subchapter C Part 435 Subpart J Section 435.916, Regularly Scheduled Renewals of Medicaid Eligibility, states that the agency must renew MAGI-based determination of eligibility once every 12 months and no more frequently than once every 12 months. For non- MAGI beneficiaries, entities must renew eligibility at least once every 12 months. Condition: During our testing of the Social Service Agency’s (SSA) provisions for eligibility requirements, we noted that for one (1) of sixty (60) samples tested the department did not suspend, or pause, program eligibility despite being over the income limit for MAGI. Cause: The SSA department did not ensure the department’s policies and procedures relating to eligibility determination were followed. We noted that when a participant is determined to be over the income limit for MAGI, the participant is placed on a “soft pause” until a determination of eligibility under non-MAGI or Covered California is made. The department had erroneously marked the application as complete rather than placing the account on “soft pause” which caused the case to auto-renew. Effect: The County’s control was not consistently followed which caused an inaccurate determination of eligibility. Questioned Costs: None noted. Context/Sampling: A non-statistical sample of sixty (60) out of all active program participants were selected for testing. The condition noted above was identified during our procedures related to eligibility. Repeat Finding: No. Recommendation: We recommend the SSA department adhere to their policies and procedures to ensure that participant eligibility determinations and redeterminations are performed accurately. Management Response and Corrective Action: 1. Person Responsible: Michael Ueda, Human Services Manager and Yesenia Zapien, Human Service Manager 2. Corrective Action Plan: SSA will add administrative controls to track cases in soft pause to ensure eligibility determinations and redeterminations are performed accurately. Additionally, staff will be reminded of the policy and procedures surrounding soft pause. 3. Anticipated Implementation date: May 2025

2024-014 Program: Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.566 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Eligibility Type of Finding: Material Deficiency in Internal Control Over Compliance and Material Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Per Title 45 Subtitle B Chapter IV Part 400 Subpart E Section 400.53, General Eligibility Requirement, states that eligibility for refugee cash assistance is limited to those who: (1) Are new arrivals who have resided in the U.S. less than the RCA eligibility period determined by the Office of Refugee Resettlement (ORR) Director in accordance with Section 400.211; (2) Are ineligible for TANF, SSI, OAA, AB, APTDD, and AABD programs; (3) Meet immigration status and identification requirements in Subpart D (Immigration Status and Identification of Refugees); (4) Are not full-time students in institutions of higher education, as defined by the ORR. Per Title 45 Subtitle B Chapter IV Part 400 Subpart E Section 400.66, Eligibility and payment levels in a publicly-administered RCA program, states that in administering a publicly-administered refugee cash assistance program, the agency must operate its refugee cash assistance program consistent with the provisions of its TANF program including the determination of initial and on-going eligibility. Condition: During our testing of the SSA’s compliance with eligibility and allowable cost/cost principles, we noted the following: For two (2) out of forty (40) cases selected for testing, the participants’ country of origin did not meet the general eligibility requirements of the program. For two (2) out of forty (40) cases selected for testing, participants received cash assistance outside of the eligibility period. For six (6) out of forty (40) cases selected for testing, the SSA did not retain the required documentation to evidence eligibility under the program. Cause: The SSA did not follow their policies to verify and withhold the information described in the condition and did not consistently ensure that participants were eligible. Effect: Benefits were provided to ineligible participants. Questioned Costs: Questioned costs for cases tested in which we determined to be ineligible to receive cash assistance or cases in which there was insufficient documentation to substantiate the eligibility determination was $7,578. Context/Sampling: A nonstatistical sample of forty (40) out of all active program participants were sampled. For ineligible or unsupported cases we have projected the amount of questioned costs against the remining population for a total of $460,581. The condition above was identified during our procedures over eligibility, activities allowed or unallowed, and allowable costs/cost principles testing. Repeat Finding: No Recommendation: We recommend that the SSA department strengthen its internal controls to ensure that program eligibility criteria are properly supported and retained in case files. Management Response and Corrective Action: 1. Person Responsible: Rosa Palacios, Human Services Manager 2. Corrective Action Plan: SSA will implement the following to enhance internal controls over compliance with eligibility: • Policy and Procedure Review & Update: Review and update existing policies and procedures to ensure clarity of eligibility criteria, including country of origin, eligibility period, and documentation retention requirements. These actions will provide clearer guidelines to prevent future eligibility issues and ensure proper documentation retention. Complete by April 2025. • Ongoing Monitoring & Compliance Review: Establish a dedicated team to perform monthly reviews of all approved cases, ensuring compliance with eligibility requirements. A monthly report will detail trends, non-compliance issues, and corrective actions results. With these actions, we will have continuous oversight and prompt corrective actions to maintain program integrity. Implement reviews by May 2025. • Mandatory Eligibility Checklist: Implement a mandatory eligibility checklist for all staff to confirm the required eligibility documents, system entries, and action notices at initial application and semi-annual reporting. These actions ensure staff consistently follow eligibility requirements and semi-annual reporting processes. Implement by May 2025. 3. Anticipated Implementation date: April 2025 and May 2025

A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information captured and reported. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117

A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under Uniform Guidance requirements. B. Actions Taken or Planned: Management implemented changes to the capturing and files maintained for documenting a participant’s eligibility for participation in program services. 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: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Forty-two (42) names were selected from the new move-in list and those names were to be traced to the waiting list to verify new move-ins were chosen in an order that was in accordance with the Authority’s policy. It was determined that thirty-eight (38) out of forty-two (42) new move-ins selected could not be traced with any certainty back to the Authority's waiting list. Known Questioned Costs: $741,293. Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Housing Voucher Cluster will implement internal control procedures that will ensure compliance with federal regulations. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025.

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871, 14.879, and 14.EHV Noncompliance – L. Reporting - Special Reporting Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Reporting Criteria: The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Cause: There is a significant deficiency in internal controls over the compliance for the reporting type of compliance related to special reporting. The Authority has not maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the reporting type of compliance related to special reporting. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed accurately and on a timely basis. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025. Condition: Based upon inspection of the Authority’s files and on discussion with management, the Authority included income that was miscalculated during their annual reexamination. Context: Of a sample size of fifty-eight (58) tenant files, three (3) tenant's annual recertification (HUD-50058 form) included income that was miscalculated. Our sample size is statistically valid. Known Questioned Costs: $32,407

Finding 2024-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 3,785 units. Of a sample size of fifty-eight (58) tenant files, the following was noted: • Seven tenant files were missing entirely • Original application was missing in 1 file • Declaration of Section 214 Status form was missing in 1 file • HUD-9887 form was missing in 1 file • Lead based paint form was missing in seven files • Signed lease was missing in 8 files • HUD-50058 form was missing in 1 file • Verification of income and assets was missing in 2 files Our sample size is statistically valid. Known Questioned Costs: $297,971 Cause: There is a material weakness in the Housing Voucher Cluster in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Housing Voucher Cluster and will implement internal control procedures that will ensure compliance with federal regulations. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025.