Corrective Action Plans

Policy Implementation: The Town is developing and implementing a written internal policy and checklist to ensure full compliance with suspension and debarment requirements for all federally funded projects. This policy will include procedures for: o Conducting and documenting searches in the SAM.gov Exclusions system, o Requiring written certifications from all contractors and subcontractors, and o Ensuring that federal compliance clauses are incorporated in all future contracts funded with federal dollars. 2. Engineering Oversight Coordination: The Town acknowledges that coordination with its contracted engineering firm(s) is essential in maintaining federal compliance. Moving forward, we will work closely with our engineers to verify and document that all contractors and subcontractors meet federal eligibility requirements prior to award and contract execution. 3. Training and Compliance Awareness: The Town will ensure that applicable municipal personnel, as well as project managers working with federal grant funds, receive training or instruction on Uniform Guidance procurement standards, including suspension and debarment protocols.

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal requirements for allowable activities. Name, address, and telephone of District contact person: Jennifer Larson, Executive Director of Finance 124 E. Lawrence Street Mount Vernon, WA 98273 360-428-6110 Corrective action the auditee plans to take in response to the finding: The district concurs with the finding and has taken corrective action. The employee referenced in the findings is no longer employed by the district. Throughout the months-long investigation performed by OSPI, the district worked to implement changes in our internal controls to ensure strong oversight of Migrant Education Program (MEP) grant compliance, including the eligibility determination process. Changes to internal controls include: • A monthly audit of the families who were visited that month. • A trained program recruiter will conduct the eligibility interviews and home visits. • Recruiter will work with regional trained recruiter for support. • A spot check audit of students determined to be eligible district program director. • Monthly logs from staff identifying students they worked with and services provided. • Monthly meetings between MEP district director and MEP regional program manager to ensure ongoing grant compliance. • Monthly meetings with MEP Parent Advisory Committee for ongoing feedback of services provided. • Appropriate staff including the program director are required to attend Migrant grant training provided by OSPI. We thank OSPI and the Washington State Auditor’s Office for their work and collaboration. We will continue regular monitoring of the Migrant Education Program in the Mount Vernon School district to ensure compliance with all program requirements and only eligible students are being served. Anticipated date to complete the corrective action: August 31, 2025

Major Federal Award Programs Audit: Section 8 New Construction and Substantial Rehabilitation, Federal Assistance Listing Nunber 14.182 a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In connection with out lease file review, we noted the following deficiencies: 3 out of 16 existing tenants tested did not have the Enterprise Income Verification (EIV) form completed within 120 days, as required by HUD. 1 out out of 16 existing tenants tested income reported on HUD Form 50059 did not agree to income verified using the Enterprise lncome Verification (EIV). 10 out of 16 existing tenants tested did not have the annual recertifications done timely. 1 out of 2 former tenants tested did not have security deposit returned within 30 days of departure, as required by HUD.- b. Action(s) Taken or Planned on the Finding At the time of tenant file review, the current staff was not made aware of EIV documents stored in a separate area in the office. This since has been corrected and the EIV information is now in the tenant files. Management was aware due to staffing issues of the annual recertifications being behind. We have resolved the staffing issues and have a Compliance Manager that monitors this now whom help the site with any questions to bring all tenants up to date. With staffing issues being updated we are working with them to make sure to process security deposit refunds in a tinely matter.

The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.

Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creating a temporary strain on resources. The few instances of noncompliance noted in the finding were missed during this influx. Management is actively reviewing intake procedures to ensure capacity adjustments are made in response to future changes in referral patterns.

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has controls in place to properly verify assets for cases when required and ensure reviews are being performed consistently with documentation retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure casefiles are reviewed consistently and document that review. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer, Amie Gendron Administrative Services Supervisor Planned completion date for corrective action plan: December 31, 2025

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410, H8N53897, and H8L50850 for 2024 Finding 2024-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in September 2024 We agree with the auditors finding. We acknowledge that, within the current audit sample of 57 patient files, 2 were found to contain instances of noncompliance with the Sliding Fee Scale (SFS) requirements. We recognize the importance of full compliance and remain firmly to continuous improvement in this area. It is important to note that this represents a significant improvement from the prior year’s audit. The identification of only 2 errors out of 57 patients’ files selected highlights the effectiveness of the corrective actions plan we implemented in response to the previous finding. Corrective Actions and Improvements Implemented: 1. Staff Training- Following the prior audit, front desk staff received additional training emphasized accurate application of SFS policies, required documentation, and proper income verification protocols. 2. Internal Auditing- Beginning in September 2024, The CEO designated the Compliance Officer to conduct daily audits of SFS related documentation. These real time audits help identify and correct issues promptly, with findings continuously incorporated into staff training programs. While we are encourage with the progress made, we remain focused on achieving full compliance and will continue to refine our processes and training to meet that goal. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Daniel Desire, CFO

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.

Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign various processes and work flows. This project is expected to address the gap in SFA transactional review and approval internal controls that are arising due to the SFA program size, limited number of subject matter experts, and the management turn; and result in mitigating controls and policies being implemented to ensure the accuracy and completeness of all SFA transactions. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign the reporting structures, process work flows, and procedures within the Student Financial Aid (SFA) office, the Business office, and Student Services specifically as those areas relate to student status and records. It is expected this engagement will ensure that the internal controls within the entire SFA office will improve, including that the SFA IT Systems are documented and tested and that any compensating controls identified as needed are implemented. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action plan. .

Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grants, the Organization was unable to provide enrollment forms or supporting documentation. These forms are necessary to verify that participants met the program's eligibility criteria. YWCA Response- The YWCA Victim Services acknowledges this finding and has implemented the following corrective action plan to ensure compliance. Corrective Action Plan - Procedures exist to ensure all clients are enrolled and eligible for services under the STOP grant. In addition to documentation in the Apricot system, an additional legal screening process and intake forms are used to determine eligibility and complete client enrollment within a Victim Services application called MyCase. During the audit, documentation for the four identified cases from MyCase was erroneously excluded, causing the finding. As a subsequent event, the documentation for intake and eligibility for the four identified cases was provided to the external auditors. This process will continue, and future audits will include client documentation for both systems. Additionally, Enforcement of enrollment procedures within Apricot, and oversight from department Directors, has been made a priority. Time Frame for Correction -Appropriate procedures were in place during the full audit year of 2024 and will continue into future years. Corrective action related to documentation within the Apricot system was implemented in August 2025. Individuals Responsible - Jessica Glynn, Vice President of Victim Services and Kellie Swikoski, Grant Manager.

View of Responsible Officials and Planned Corrective Action Plan: Going forward, all Adoption Subsidy case files will include Criminal Background Checks and Statewide Central Registry (SCR) clearances, in accordance with the updated OCFS-4401. Each Adoption Subsidy determination will be reviewed by the Senior Caseworker in charge of the FAHD Unit and subsequently verified by a Services Eligibility Unit Social Services Specialist to ensure that all required documentation is included prior to case opening.

Federal Award Findings and Questioned Costs – Year ending December 31, 2024 Finding 2024-001 – Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, reporting, and special tests and provisions related to amounts reimbursed for the project worksheets. Identification of the federal program: Assistance Listing Number 97.036: • COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) • U.S. Department of Homeland Security • Federal award identification number: o Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers • Federal award year – January 20, 2020 to May 11, 2023 • Pass-through entity – Arizona Department of Emergency and Military Affairs (Arizona DEMA) Condition: During the testing over the expenditures included in the project worksheets, management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheets were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Cause: Management did not have effective internal controls in place over the compliance requirements as stated in the criteria or specific requirement section of the report. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on actual paid expenditures which resulted in an overstatement of the amount reimbursed by FEMA. Without sufficient internal controls, other compliance matters could occur in the future. Questioned costs: $1,406,446 – Assistance Listing Number 97.036 – Federal award identification number – Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers Questioned costs were computed by calculating the difference between the expenditures submitted for reimbursement in the FEMA project worksheets and the actual paid expenditures. Context: During the testing over the expenditures included in the project worksheets, the auditors obtained a listing of expenditures submitted for reimbursement to FEMA and selected a sample of 67 for testing the compliance requirements. There was 1 out of 67 selections where the expenditure reported for reimbursement was not based on actual paid expenditure. The sampling was a statistically valid sample. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Management’s control regarding the review of the project worksheet expenditures did not identify this matter when submitting the project worksheet for reimbursement to FEMA. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in the FEMA project worksheets are actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Views of responsible officials: Management concurs with the audit finding and has implemented a corrective action plan to address the identified issue. Management has notified Arizona DEMA of the identified expenditures and has begun the process of reimbursing the $1,406,446 to FEMA. For all future FEMA project applications, Management will conduct a comprehensive reconciliation process prior to submission. This process will include a detailed review of invoice documentation and verification of payment to ensure compliance with applicable federal requirements. Responsible Parties: Heather Mahoney, Network Controller Anticipated Date of Completion: September 30, 2025

Planned Corrective Action: To strengthen internal controls over this program, the Tribe will implement a quarterly reivew of participants compared to those included in indirect cost pools. Name of Responsible Party: Serge Davis, Controller and Stephanie Moyers, Operations Director HHS Anticipated Completion Date: 12/31/2025.

Federal Single Audit Finding: 2024-001 - Significant Deficiency in Internal Control and Noncompliance with Special Tests and Provisions in Application of Organization's Sliding Fee Discounts Policy Name of Contact Person: Jennifer Youngberg, Chief Financial Officer Corrective Action: We have reviewed our Sliding Fee Discount Policy to ensure alignment with HRSA requirements. Staff responsible for eligibility and billing will receive refresher training. Supervisory reviews of a sample of applications will occur quarterly, with results tracked and reported to the Leadership Team. Each individual involved in the process will be made aware of their role, with clear separation of duties between operational and accounting functions. These actions will strengthen internal controls and ensure consistent application of the Sliding Fee Discount Policy going forward. Proposed Completion Date : December 31, 2025

Housing Voucher Cluster-Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their process and internal controls for new tenants to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Housing will review our process and internal controls for new tenants to ensure compliance with HUD requirements and our administrative plan. Name(s) of the contact person(s) responsible for corrective action: Director of Housing Planned completion date for corrective action plan: December 31 , 2025

2024-001: Eligibility – Community Service Block Grant - Assistance Listing #s 93.569 - Grant Period - Year Ended December 31, 2024 Criteria: Only individual households that fall under the 200% Poverty Guideline based on family size would be eligible to receive benefits from the Community Service Block Grant. Condition: During our Eligibility Compliance testing, we noted two incorrect eligibility calculations out of our sample of forty applicants. We consider this Single Audit finding to be an instance of noncompliance relating to the Eligibility Compliance Requirement. Corrective Action Plan: Additional review of eligibility will be performed by management to assure proper eligibility going forward. The program Director will also be conducting additional training with the program staff on calculating income and required documentation. Responsible Person for Corrective Action Plan: Darlene Johnson, Deputy Director Implementation Date of Corrective Action Plan: November 1, 2025

Corrective Action Plan Provided by Management: Philadelphia Legal Assistance Center, Inc. (PLA) agrees with the finding. In November 2024, PLA hired a Legal Compliance Specialist whose full-time job is to review open and closed cases for compliance mistakes. The Legal Compliance Specialist did not have time to review every case closed in 2024. However, the Legal Compliance Specialist has been reviewing cases all year in 2025 and catching issues with missing citizenship attestations, which should reduce the chances of a case being reported to LSC without the documentation required by 45 C.F.R. 1626. In the summer of 2025, we required all case handlers to watch compliance training videos and answer multiple-choice questions to test their knowledge. The videos and questions included content related to 45 C.F.R. 1626. We plan to require staff to complete a similar training process in 2026, which will include additional content related to 45 C.F.R. 1626 compliance.

Recommendation: The Company should consider reevaluating their established procedures and controls currently in place to ensure full compliance with regard to eligibility and proper maintenance of tenant information, including policies for handling missing files during management transitions to ensure compliance with HUD requirements. Action Taken: The Company will start randomly testing a small sample of tenant files, as part of our quarterly site inspection. Additionally, Kay-Kay Realty, a third-party vendor is already engaged to review tenant move-in and recertification files, but the prior resident manager was selecting the files to review. We will now ask Kay-Kay Realty to randomly select tenant files for their review process. Contact person: Patrick Delaney; (808) 523-5681, ext. 693 Anticipated Completion Date: October 1, 2025

Ref. No. 2024-001: Missing Signatures Recommendation: The Company should consider reevaluating their established procedures and controls currently in place to ensure full compliance with regard to eligibility and proper maintenance of tenant information, including policies for handling missing files during management transitions to ensure compliance with HUD requirements. Action Taken: The Company will start randomly testing a small sample of tenant files, as part of our quarterly site inspection. Additionally, Kay-Kay Realty, a third-party vendor is already engaged to review tenant move-in and recertification files, but the prior resident manager was selecting the files to review. We will now ask Kay-Kay Realty to randomly select tenant files for their review process. Contact person: Patrick Delaney; (808) 523-5681, ext. 693 Anticipated Completion Date: October 1, 2025

2024-002 Program: Crime Victim Assistance Federal Agency: Department of Justice AL #: 16.575 Federal Award Identification Number and Year: Various – See SEFA Pass-through Entity: Missouri Department of Social Services Type of Compliance Finding: E - Eligibility Internal Control Impact: Material Weakness Finding: When a participant arrives at the Shelter, the admission checklist, procedures, and forms must be completed by program staff. During our audit of the Organization’s fiscal year ended December 31, 2024 federal award program, we noted the Organization did not have necessary supporting documentation, such as admission checklists for eligibility, to evaluate twenty-one out of twenty- five participants in their files. Corrective Action Plan: All supporting documentation for client eligibility will be maintained for the period required by the grant. Person(s) Responsible for Implementation: Danielle Brown, CEO, dbrown@ywcasj.org, 816-232-4481

Moving to Work Demonstration Program – Assistance Listing No 14.881 Recommendation: We recommend that HABC staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Housing Choice Voucher Program response: Out of 40 files reviewed, one exception was noted where recertification was not performed in a timely manner. HABC developed a strategy to verify that all existing recertifications are processed on time. The goal is to catch up by January 2026 and maintain timely processing going forward. HABC has updated its recertification tracking system as part of this plan. This includes measures for weekly progress monitoring, tracking upcoming deadlines, and implementing quality control to support the timely processing of recertifications. Housing Operations response: Housing Operations response: Out of 40 files reviewed, there were two exceptions noted: (1) Documentation was not provided to support the rent amount showing on the rent roll; in that instance, the transaction was corrected after the rent roll had been generated, and the rent amount billed was corrected. The resident was not responsible for paying an incorrect rent amount; Exception (#2) and (#3) are related to same file folder: (2) one requested resident file folder was not submitted for testing; and (3) Third party income verification documentation (including the resident’s signed personal declaration) could not be identified; the file folder was not properly scanned into the electronic document management system and select documents were not otherwise maintained. HABC’s Housing Operations Department will require that all transactions have two levels of review/approval to ensure complete and accurate documentation is scanned into the electronic document management system. Name(s) of the contact person(s) responsible for corrective action: Stefanie Beale, Senior Manager, Continued Assistance & Site Based (HCVP), and Rhonda VanDyke, Senior Manager of Public Housing Administration (LIPH). Planned completion date for corrective action plan: 01/31/2026 for HCVP and 12/31/2025 for LIPH