Corrective Action Plans

Need Analysis Corrective Action Plan: The Office of Financial Aid & Scholarships (OFAS) will do the following: • Correct the procedures for data entry in Workday. • Revise internal procedures to review loan awards prior to disbursement. • Explore/implement system checks in Workday to flag potential over-awards. • Conduct random reviews of aid packages to ensure compliance. • Document system changes and over-award resolution. Person Responsible for Corrective Action Plan: Mike Sapienza, Senior VP for Enrollment Services Anticipated Date of Completion: May 31, 2026

Finding 2025-004: Internal Control Structure Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2024-02 I agree with this finding. Continued steps will be taken to ensure no errors are made with extra effort and detail. – No estimated date of completion

The University has found a critical breakdown in communication between the Ranch Management department and the Registrar’s Office, stemming from informal, ad hoc processes that have not scaled with institutional needs. Specifically, there is no formal mechanism to ensure that updates to student statuses for the ranch management program are consistently reported or verified. To prevent recurrence of this issue, a process is being implemented that all Non-Degree programs will now be required to perform formal degree audits within the student information system. This ensures consistency in processing and aligns with practices currently used for degree-seeking students. Targeted training and communication will be provided to all Non-Degree program administrators to ensure clarity on new expectations, tools, and timelines. The Registrar’s Office will conduct periodic audits of non-degree program records to verify compliance and identify any further process improvements.

FINDING NO. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should implement procedures to ensure that all initial and ongoing tenant eligibility documentation is obtained timely and maintained in tenant files as required by HUD. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the audit Oversight Agency has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO

Single AUdit Report for 2024-2025 Reference/Finding Number 2025-001 Management's Planned Corrective Action Management acknowledges and understands the finding associated with Eligibility. The student's Pell award has already been corrected and accepted by COD. Management is working with IT to automate the enrollment change report to be sent on a weekly basis to validate that all increases in hours have been appropriately updated and processed. This will also become part of our required annual reconciliation process of the Pell grant program. Responsible Official Bridget Moore Director of Student Financial Services Abilene Christian University Estimated Completion Date July 24, 2025

Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education Assistance Group to provide a comprehensive business process review of its financial aid operations. The objective of this review is to improve upon the functionality of processes, internal controls, and systems to ensure regulatory compliance and the effectiveness of service deliverables to students receiving financial aid. This review will include updates to policies, procedures, and internal controls for the import and export of electronic records, document tracking and file review, packaging and awarding, satisfactory academic progress, disbursement and reconciliation, withdrawal and Return to Title IV. Workflow and gap analysis will be performed to ensure intraoffice Title IV program compliance and best practices. Second, the institution has entered into a professional services agreement with Higher Education Assistance Group to provide interim staffing and third-party federal student aid processing including, but not limited to, counseling students and families on financial aid options, assisting with the management of Federal Direct Loan and Federal Graduate PLUS Loan programs to include student eligibility, file review, awarding, and origination and disbursement authorization using Populi, COD and other Department of Education software. In addition, Higher Education Assistance Group will provide additional Title IV training for personnel involved in federal student aid processing. With more than 35 years of experience, Higher Education Assistance Group and its team of seasoned consultants, all of whom have worked in federal student aid administration, whether in public/private colleges and universities or for the Department of Education itself, specializes in the compliant administration of Title IV student financial aid programs. The institution will adopt a supplemental internal control to cross-check student eligibility for Direct PLUS loans to ensure that an over-award is not originated and disbursed. Anticipated completion date: November 15, 2025

Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility requirements.

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration, Electronic Health Records (EHR) not operating as expected for one line of the SFDS and error not caught and corrected, and a significant process change from percentage to fixed fee SFDS causing inconsistent application during transition and training period. Planned corrective action: System Configuration:  Leaders for all service lines and Billing Department will work with EHR Support Team and vendor to review and test all possible SFDS options to verify rules are functioning as expected and as outlined in the SFDS policy.  Annual review and testing of EHR rules governing SFDS to validate ongoing compliance. Contact person: Jennifer Velez, Revenue Cycle Director Completion date for action: 10/31/2025 Staff Training and Documentation:  All staff responsible for registration and income verification in all service lines, programs, and sites will receive a review of income eligibility assessment, documentation, and application.  Registration Program Manager and EHR Trainers will work with Learning and Development Department to develop competency standard for income eligibility assessment, documentation, and application for all staff responsible for registration and income verification in all service lines, programs, and sites. All identified staff will be required to demonstrate competence annually using the Learning Management System (LMS).  The Center will audit 5 patient records for FPL (Federal Poverty Level) documentation per site or program two times annually during C-Qual (the Center’s internal audit process). This will result in 180 charts each year.  Site Managers or Department Administrators will review front office dashboard in monthly management meetings and develop site specific action plans if exceptions are identified. This was added to the standing agenda for the Primary Care Clinic Managers (PCCM) meeting in September 2025. Contact person: Angela Hurley, Director of Operations Completion date for action: 12/31/2025 Implementation Controls:  Update SFDS policy to include review and verification of EHR alignment with fee schedule following any update or change approved by the Board of Directors.  Develop checklist for roll-out of changes in SFDS that prompts change management and training team to review readiness and validation procedures before going live with changes. Contact person: Angela Hurley, Director of Operations Completion date for action: 9/30/2025

Finding 2025-001- Public Housing Internal Control over Waiting List - Eligibility Noncompliance and Significant Deficiency Low Rent Public Housing - Subsidy ALN 14.850 Corrective Action Plan: The Great Falls Housing Authority printed out waiting lists on the date of the audit finding. We will keep notes on the list and at periodic times when adding or deleting applicants we will maintain all lists in a binder for historical review. Person Responsible: Donna Halbleib, Program Supervisor Anticipated Completion Date: Already implemented and will be continuously kept - March 31, 2026

Response to FY2025 Audit Finding: Impact: "Lack of policy enforcement may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries" Why: 1. Were staff not consistently collecting the required income and family size documentation? 2. Was training not comprehensive enough or did staff turnover lead to a knowledge gap? 3. Is the Organizations policy or process for documenting income unclear or not consistently enforced? 4. Was there a system in place to audit patient files internally to catch documentation errors? 5. Is the culture of compliance not strong enough to prioritize consistent documentation? Action: 1. Update/Revise sliding fee policy and procedure to clearly define acceptable documentation process for income verification and annual re-evaluation 2. Create and deliver comprehensive training to all relevant staff (front desk, enrollment specialist, and billing) 3. Implement ongoing monitoring – • Establish a new scheduled internal audit process to regularly review a sample of patient documentation for sliding fee documentation compliance. • Establish metrics to track progress, such as percentage of patient files with complete sliding fee documentation, for new and annual sliding fee applications. 4. Once all actions are complete and the issue is resolved, document these improvements to continue the cycle of compliance 5. Continue to audit files at random to ensure documentation compliance continues

Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025

Management of Miami-Cass REMC and Subsidiary will implement procedures to prevent unallowable costs. In addition, the State of Indiana Office of Community and Rural Affairs will be alerted of the questioned costs. Management agrees with this finding.

Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.

Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer

Recommendation Management should enhance and strengthen procedures to ensure tenant income certifications are completed within 90 days of the tenant being entered into the HUD TRACS system. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and recommendation and will ensure timely income verifications going forward.

Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new property manager has been hired to ensure compliance with established procedures and to oversee the continued implementation of corrective measures.

The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This will be done in conjunction with the procurement policy and be in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.

Schedule of Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-003: Significant Deficiency and Noncompliance over Eligibility Responsible Official’s Response and Corrective Action Plan: We concur with the findings related to deficiencies in Internal Controls and Noncompliance over Eligibility related to our federal grant. In response, BCI has streamlined document collection and tracking and has strengthened its onboarding and document retention procedures to ensure all member files include the required documentation, including the signed member agreements. Planned Implementation Date of Corrective Action Plan September 1, 2024 Person Responsible for Corrective Action Plan Caryn York, President & CEO

Management's Response: AMHE Tenant Occupancy Specialist's will review and adhere to AMHE's Admission and Eligibility Program Management and Occupancy Master Requirements and will attend training courses that will help strengthen their eligibility policy and procedures. Estimated Completion Date: Immediately Interim Director will review the Admission and Eligibility Program Management and Occupancy requirements per AMHE's policy and procedures. This will be addressed with AMHE staff prior to 6/30/26. Responsible Party: Comptroller and Interim Director.

Management acknowledges the need to ensure that required documentation is complete and retained in each tenant file, including executed leases, required forms, inspection documentation, and other required program documents. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that requires documented supervisory sign-off in each tenant file to ensure all required documentation is complete prior to assistance approval. Staff have completed refresher training on timing requirements, documentation standards, and calculation procedures.

Management recognizes the importance of maintaining clear, documented evidence of supervisory review of eligibility determinations, income calculations, and supporting documentation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that includes supervisory review steps requiring documented supervisory sign-off in each tenant file prior to finalizing eligibility. A standardized tracker is also being used to ensure completeness of the process.

Audit Finding: Late Issuance of the Single Audit Reporting Package. The Single Audit package for the City’s fiscal year ended June 30, 2024 was not submitted to the Federal Audit Clearinghouse by March 31, 2025. Corrective Action: Management agrees with the finding. The City is evaluating the process and design of internal controls, including the ongoing implementation of a new ERP system, in order to ensure readiness from the audit and to avoid late filing of the single audit reporting package and data collection form. Name of Contact Person and Completion Date: Leah Kagan, Interim Director of Administration, December 31, 2026 Anita Carpenter, Grants Officer, December 31, 2026

Views of Responsible Officials and Planned Corrective Actions: The Finance Department acknowledges the late submission for the 2023 fiscal year. To ensure future compliance with Uniform Guidance deadlines, year-end close and audit preparation timelines have been restructured as per the response for Finding 2024-001.

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Eligibility Questioned Costs: Unknown Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. Complete all missed annual recertifications immediately. • Method: The property manager shall immediately Identify every tenant file where an annual income recertification was not performed. Collect and verify all required documentation from the affected tenants, using third-party verification as the preferred method. • Responsible Party: Property Manager. 2. Document all eligibility factors and discrepancies. • Method: For every affected tenant file, thoroughly document the process of verifying income, assets, and eligibility. Include explanations for any missing third-party verifications and document all follow-up attempts. • Responsible Party: Property Manager. 3. Retransmit corrected HUD Form 50059 filings to the TRACS system. • Method: Submit corrections for each tenant with a file deficiency by using the "Correction/Retransmittal" (R) code on a new Form HUD-50059A. • Responsible Party: Property Manager. 4. Address any rent-related issues arising from the missing recertifications. • Method: Calculate any potential back-rent owed by tenants due to misreporting or changes in income. Based on HUD guidelines and property policy, negotiate repayment plans if necessary, but carefully follow guidance regarding tenant culpability. • Responsible Party: Property Manager. 5. Revise and formalize resident file management policies and procedures. • Method: Update internal policy and procedural documents to establish clear, step-by-step instructions for completing annual recertifications, including all documentation requirements. Incorporate a standardized checklist for each tenant file to ensure consistent application. • Responsible Party: Controller and Property Manager. 6. Implement an improved tickler and tracking system. • Method: Use property management software to automatically generate alerts and reports for upcoming recertification deadlines. Implement a double-check process where a supervisor reviews and signs off on the list of upcoming deadlines each month to ensure no file is missed. • Responsible Party: Property Manager. 7. Provide comprehensive training for all staff involved in recertifications. • Method: Conduct mandatory training for all staff on Section 811 program requirements, focusing specifically on annual income recertifications and acceptable documentation. Include regular refresher training and create a central, accessible library of HUD guidance. • Responsible Party: Third Party Training Professionals, HUD and Property Manager’s compliance officer. 8. Establish a quality control review process. • Method: Implement a desk review process where a senior staff member or third-party consultant periodically audits a sample of completed recertification files. This internal monitoring should check for accuracy, completeness, and proper documentation. • Responsible Party: Property Manager. 9. Develop a monthly compliance monitoring report. • Method: The report will summarize the status of all recertifications for the month, listing upcoming deadlines and noting any files that required a correction. This will be presented to senior management. • Responsible Party: Property Manager. 10. Conduct a follow-up review. • Method: Engage an external auditor or consultant to perform a follow-up review of recertification files after the first year of the new procedures. This independent assessment will verify that the corrective actions are working effectively. • Responsible Party: Senior Management. 11. Provide status reports to HUD. • Method: As per the notice of noncompliance, submit regular reports to the relevant HUD Hub or Program Center detailing the progress on the CAP and any specific items requested. • Responsible Party: Property Manager and Chief Financial Officer of Sponsor. Anticipated Completion Date: December 2025

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD046; AZ20Q09100 Pass-Through grantors: N/A Compliance Requirement: Eligibility Questioned Costs: Unknown Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. Complete all missed annual recertifications immediately. • Method: The property manager shall immediately Identify every tenant file where an annual income recertification was not performed. Collect and verify all required documentation from the affected tenants, using third-party verification as the preferred method. • Responsible Party: Property Manager. 2. Document all eligibility factors and discrepancies. • Method: For every affected tenant file, thoroughly document the process of verifying income, assets, and eligibility. Include explanations for any missing third-party verifications and document all follow-up attempts. • Responsible Party: Property Manager. 3. Retransmit corrected HUD Form 50059 filings to the TRACS system. • Method: Submit corrections for each tenant with a file deficiency by using the "Correction/Retransmittal" (R) code on a new Form HUD-50059A. • Responsible Party: Property Manager. 4. Address any rent-related issues arising from the missing recertifications. • Method: Calculate any potential back-rent owed by tenants due to misreporting or changes in income. Based on HUD guidelines and property policy, negotiate repayment plans if necessary, but carefully follow guidance regarding tenant culpability. • Responsible Party: Property Manager. 5. Revise and formalize resident file management policies and procedures. • Method: Update internal policy and procedural documents to establish clear, step-by-step instructions for completing annual recertifications, including all documentation requirements. Incorporate a standardized checklist for each tenant file to ensure consistent application. • Responsible Party: Controller and Property Manager. 6. Implement an improved tickler and tracking system. • Method: Use property management software to automatically generate alerts and reports for upcoming recertification deadlines. Implement a double-check process where a supervisor reviews and signs off on the list of upcoming deadlines each month to ensure no file is missed. • Responsible Party: Property Manager. 7. Provide comprehensive training for all staff involved in recertifications. • Method: Conduct mandatory training for all staff on Section 811 program requirements, focusing specifically on annual income recertifications and acceptable documentation. Include regular refresher training and create a central, accessible library of HUD guidance. • Responsible Party: Third Party Training Professionals, HUD and Property Manager’s compliance officer. 8. Establish a quality control review process. • Method: Implement a desk review process where a senior staff member or third-party consultant periodically audits a sample of completed recertification files. This internal monitoring should check for accuracy, completeness, and proper documentation. • Responsible Party: Property Manager. 9. Develop a monthly compliance monitoring report. • Method: The report will summarize the status of all recertifications for the month, listing upcoming deadlines and noting any files that required a correction. This will be presented to senior management. • Responsible Party: Property Manager. 10. Conduct a follow-up review. • Method: Engage an external auditor or consultant to perform a follow-up review of recertification files after the first year of the new procedures. This independent assessment will verify that the corrective actions are working effectively. • Responsible Party: Senior Management. 11. Provide status reports to HUD. • Method: As per the notice of noncompliance, submit regular reports to the relevant HUD Hub or Program Center detailing the progress on the CAP and any specific items requested. • Responsible Party: Property Manager and Chief Financial Officer of Sponsor. Anticipated Completion Date: December 2025