Corrective Action Plans

2025-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Daphne Chan, Interim Head of Finance Corrective Action: Management implemented staff training and periodic internal reviews in response to the prior year finding related to the Sliding Fee Discount Program. While these actions improved awareness of requirements, management identified the need for additional controls to ensure consistent application and documentation going forward. To address the remaining gaps, management will implement the following actions: - Strengthen intake and documentation controls by reinforcing procedures to ensure proof of income documentation is obtained and retained. - Train site staff to ensure consistency in applying sliding fee discount. - Routine spot checks with timely escalation to Site Directors and Operations leadership when issues or variances are identified. - Refine internal monitoring activities to focus on higher risk transactions, such as new patient registrations, income re-certifications, etc. for final eligibility determination. Management will continue to monitor the effectiveness of these controls and make adjustments as needed to ensure ongoing compliance with Health Center Program requirements. Estimated Completion Date: June 30, 2026 Signed by Daphne Chan Interim Head of Finance

Views from Responsible Officials and Corrective Action Plan BCFS Health and Human Services For the Year Ended August 31, 2025 Finding Number: 2025‑001 and 2025-002Federal Program: Crime Victim Assistance – AL 16.575 (Common Thread – Texas) Pass‑Through Entity: Texas Office of the Governor Award Number: 3853406 Questioned Costs: $853,982 Responsible Person: Rosa Baez, President BCFS Health and Human Services Views of Responsible Officials: Management concurs with the finding. BCFS Health and Human Services’ (BCFS HHS) in-kind match plan includes the use of exempt personnel performing after-hours "on-call" volunteer duties, such as answering phones or undertaking responsibilities outside their standard work roles. BCFS HHS did not meet the in-kind match requirements, as the former Program Executive Director deviated from the in-kind match plan, as approved by the funder. The former Program Executive Director did so by hiring full-time personnel to perform the same duties as the on-call volunteers and including them as part of the in-kind match. In 2022, during the COVID pandemic, the funder waived match requirements; during this period, the prior Program Executive Director hired full-time overnight on-call personnel, in response to increased call volume driven by restrictions on face-to-face services due to concerns of exposure. The match waiver was discontinued with the grant awarded for October 2024 through September 2025, and BCFS HHS was required to meet their match obligations. The former Program Executive Director failed to reassign the On-Call workers resulting in a significant deviation from the approved match plan and contributed to the noncompliance of in-kind match requirements. Immediately upon the issuance of the monitoring report regarding match requirements, BCFS HHS’ President has been actively working with Office of the Governor (OOG) to rectify the match requirements per the grant. Management has recorded an accrual for the estimated adjustment and has implemented the corrective action plan outlined below. Page 2 of 3 Corrective Action Plan Upon receiving the preliminary monitoring report from the OOG, management promptly initiated an internal review with the OOG and began collaborating with OOG to address and resolve the findings identified. Effective immediately, BCFS HHS has established new protocols to ensure compliance with match requirements for the Common Thread Texas program. BCFS HHS will undertake the following corrective actions: 1. Revised In-Kind Volunteer Hotline Process A protocol has been implemented to manage the volunteer hotline for the Common Thread Program during after-hour operations. The hotline provides callers with program information, resources, referrals, and transfers calls as appropriate, including crisis response or intake services. The volunteer hotline is managed by volunteers that include exempt employees (working outside their regular duties), interns, and other approved community volunteers. Volunteers must complete training prior to being scheduled. The protocol guidelines include: •A designated volunteer timesheet. •A signed attestation certifying that hours listed are an accurate record ofvolunteer service. •Confirmation that the volunteer work is not required by their employment andis different and separate from their regular job duties. These measures provide robust supporting documentation and ensure that match activities are voluntary, allowable, and compliant. The Volunteer Hotline Protocol was reviewed and approved by the Office of the Governor (Public Safety Office and Office of Compliance and Monitoring). Target completion: Completed January 2026 2. Strengthen Match Documentation Processes Volunteer Attestation and Timesheet- Volunteers are required to sign a timesheet and an attestation affirming that the recorded hours accurately reflect their service with the Common Thread Volunteer Hotline. Additionally, if applicable, volunteers must confirm that this service is not mandated by their employment and is distinct from their regular job responsibilities. Monthly Match Meetings: These meetings will review the reported match activities against the approved match plan. Additionally, the meetings provide an opportunity to evaluate current needs and trends, and to ensure match obligations are met. Page 3 of 3 Target completion: Completed January 2026. 3. Correct and Reclassify Previously Reported Match BCFS HHS excluded the disallowed match activities and included permissible methods such as unrecovered indirect costs, reductions in billed expenditures, including personnel and training—and additional adjustments approved by OOG. All necessary changes are incorporated in the final Financial Status Report (FSR) submitted on January 29, 2026. Target completion: Completed. 4. Staff Training and Ongoing Compliance Monitoring BCFS HHS will provide Common Thread leadership training on uniform guidance match requirements, OOG-specific guidance, and the Volunteer Hotline Protocols. Weekly Audits- The BCFS HHS Director of Support Services, or designee, will conduct weekly audits to ensure protocol adherence. This will encompass a review of the hotline volunteers’ timesheets, and schedules. Results will be discussed in the monthly match meetings. Use of U.S. Bureau of Labor Statistics wage data- All volunteer and intern hours are valued using OOG‑approved labor categories. Target completion: Training will be completed by February 28, 2026; monitoring process will be implemented February 1, 2026. Sincerely, Rosa Baez, President BCFS Health and Human Services

Condition: During review of 40 eligibility determinations and redeterminations, we identified two exceptions: one case lacked documentation of IEVS reports required to verify income and eligibility information, and another case had a redetermination completed more than 12 months prior to the active eligibility date, which does not comply with the annual redetermination requirement under 42 CFR 435.916. Recommendation: CLA recommends that the County strengthen monitoring procedures to ensure that Income and Eligibility Verification System (IEVS) reports are obtained and retained for all eligibility determinations, implement controls to verify that redeterminations are completed within the required 12-month timeframe prior to the active eligibility date, and provide staff training on compliance requirements and proper documentation standards to reinforce adherence to established policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: All eligibility units will review the updated CP 25- 01 “EFAS IEVS Process” by 2/27/26 and annually thereafter. Supervisors will monitor CalSAWS reports/tasks for assigned staff to ensure compliance with processing standards. Supervisors will also monitor CalSAWS Monthly Productivity reports for their units to ensure that Redeterminations are completed timely and include Medi-Cal redeterminations in the case review process for new and journey-level staff. Eligibility Specialists will review the memo MC 25-016 “Updated Medi-Cal Annual and Change in Circumstance RE Guidance” by 2/27/2026. To avoid late redeterminations, staff will be offered overtime opportunities to ensure compliance until such time as the units have enough staff to meet the workload. The Department will complete minimally two eligibility induction training classes and two journey level refresher trainings per year. Name(s) of the contact person(s) responsible for corrective action: Rachel Ebel-Elliott, Social Services Deputy Director Planned completion date for corrective action plan: 6/30/2026

Incorrect Loan Disbursement Amount Corrective Action Plan: The Financial Aid Services office, in collaboration with IT, has implemented an exception report. This report is received daily, and designed to identify any students whose subsidized and unsubsidized loan awards may not align with their enrollment status, need, and annual loan limit. The goal is to proactivety identify and correct any discrepancies before disbursement to ensure accuracy. Responsible Person for Correction Action Plan: Marlon Jones Jr., Director of Financial Aid Services Implementation Date of Corrective Action Plan: 9/18/2025

Incorrect Pell Disbursement Corrective Action Plan: The Financial Aid Services office, in collaboration with IT, has implemented an exception report. This report is received, daily, and designed to identify any students whose Pell Grant awards may not align with their enrollment status or need. The goal is to proactively identify and correct discrepancies before disbursement to ensure accuracy. Responsible Person for Corrective Action Plan: Erika Guzman, Associate Di rector of Financial Aid Services Implementation Date of Corrective Action Plan: 6/23/2025

The District bookkeeper, along with food service staff, will thoroughly review applications in for completeness.

The local agency’s internal second party worksheet has been updated according to policy and includes a weighted score for monitoring error trends and patterns for individual staff and the unit. Supervisors complete second party reviews monthly for all staff, hold individual worker conferences monthly to review discrepancies discovered providing instruction as needed. NCFAST Learning Gateway will be utilized if a specified training is available. Targeted training/instruction is provided during monthly team meetings to review errors and provide guidance and instruction to staff for policy and NC FAST functionality updates. Restructure of the units/staff responsible for administration of the Food and Nutrition Services program will be implemented to separate the required functions for case management. The goal will be to streamline workflow processes with managing all three functions (application, processing, case recertification), promote more efficient time management with respect to interviewing and case processing and increase productivity while decreasing errors.

Utilizing the State provided DHB-7078 - 2nd Party Review Worksheet, which separated evaluation for applications and recertifications, to complete targeted case reviews on error prone areas. These areas include the areas identified during the audit and include sections surrounding income, resources and documentation. Supervisors complete second party reviews monthly for all staff and continue to hold individual worker conferences monthly to review discrepancies discovered providing instruction as needed. NCFAST Learning Gateway will be utilized if a specified training is available. Targeted training/instruction is provided during monthly team meetings to review errors and provide guidance and instruction to staff for policy and NC FAST functionality updates.

Controls have been strengthened to ensure that the front desk accurately enters applicants’ income and family size into the ECW system when determining eligibility for the sliding fee schedule. A member of the Finance Department is reviewing all sliding fee applications. These policies and procedures have been implemented to improve accuracy and compliance. Policy 01-03-029 – Sliding Fee Audit Policy was implemented on June 1, 2025. This policy includes the following: The Compliance Officer conducts a monthly audit, with audit results submitted to the Risk Manager on a quarterly basis. The Front Desk Trainer provides additional training to any employee who receives a failing score on an audit. This training is documented and signed off by the employee, the Front Desk Trainer, and the employee’s supervisor. Disciplinary actions are as follows: 1. First occurrence – One-on-one training 2. Second occurrence – Verbal warning and additional training 3. Third occurrence – Written warning 4. Fourth occurrence – Up to and including termination Mandatory training was conducted on January 14th and 15th and included all site managers, operations managers, the CFO, and the COO. Additional Controls Implemented: Effective July 1, 2025, all sliding fee applications are reviewed by a member of the Finance Department. The front desk is required to make any corrections or changes identified during the finance review. In addition, a task force has been formed to ensure appropriate follow-up is completed and to identify new opportunities to improve accuracy and compliance for all sliding fee patients. The front desk has also been provided with an Excel-based tool to assist with accurately entering patient income.

The College’s Vice President for Academic Affairs and Dean of the College concurred with the finding identified. The College has revised its policies and procedures as follows: Historically, Student Affairs coded only those students who took a Leave of Absence during the semester (“L”) or withdrew during the semester (“W”). Student Affairs has created a new code (“N”) to track students who inform the college of their intent to withdraw at the end of a given semester. At the end of each semester, Student Affairs provides the Registrar’s Office with a report of all students who informed the college of their intent to unenroll (“L”, “W”, and “N”). Using the report, the Registrar’s Office confirms that all students have been accurately exited with the appropriate exit date and exit reason prior to submitting the final “end of term” report to the National Student Clearinghouse. This new process was implemented beginning in the Fall 2025 semester. The corrective actions will be implemented by Dr. Kristen M. Amick, Registrar. Dr. Amick’s email address is: amickkm@westminster.edu.

Americorps Seniors Senior Companion Program – Assistance Listing No. 94.016 Recommendation: We recommend that additional review procedures are put in place to ensure the volunteer type is accurate based on their income review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program leadership will review and update existing policies and procedure manuals to ensure provide clear and accurate steps to adhere to funding guidance. The supporting technology will be updated in a manner that will require program coordinators/managers to actively complete a required field to verify current income eligibility. In addition, the program will develop and implement an active review process to monitor and support compliance and accurate record keeping. Name(s) of the contact person(s) responsible for corrective action: Drew Erickson Planned completion date for corrective action plan: 02/28/2026

Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College implement a review process that compares enrolled credits to Pell awards to ensure all students receive the correct Pell Grant amounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: There was one student in Fall 2024 who was under-awarded Pell Grant funds due to an error related to the student’s withdrawal status and the number of credits attempted. The Pell award was manually processed incorrectly based on this enrollment change. Beginning in Spring 2025, the Financial Aid team implemented a new process requiring a formal review of enrollment intensity for all students prior to determining and disbursing Pell Grant funds. This ensures that Pell awards are calculated and adjusted accurately. Additionally, the team now utilizes enrollment and Pell related reports to help identify potential changes in student enrollment and support timely, accurate award reviews. Name(s) of the contact person(s) responsible for corrective action: Dr. Carla Dirkshneider, VP of Enrollment and Retention Planned completion date for corrective action plan: Corrective action was implemented January, 2025.

Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend the College review the R2T4 requirements and implement procedures to ensure that calculations use the correct number of break days and are completed accurately and within the required timeframes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the review period, two students did not receive their Return to Title IV (R2T4) calculations within the required 45-day timeframe. The delay occurred because the Financial Aid Office did not receive the corresponding change of registration forms from the Registrar’s Office, which is necessary to initiate the R2T4 process. To prevent recurrence, the Financial Aid Office has implemented the following corrective actions: 1. Monitoring Reports: The team now runs a student status change report to independently identify potential R2T4 cases, even if documentation has not yet been forwarded. 2. Improved Communication Workflow: Financial Aid has been added to the Registrar’s change of registration email distribution list to ensure timely notification of withdrawals, drops, and status changes. These measures strengthen internal controls, improve cross departmental communication, and ensure that all future R2T4 calculations are completed within federal timelines. Name(s) of the contact person(s) responsible for corrective action: Dr. Carla Dirkshneider, VP of Enrollment and Retention Planned completion date for corrective action plan: Corrective action was implemented in June 2025.

Corrective Action Plan

Action:

1. To Provide Mandatory training to accounting personnel on certain accounting principles regarding

HUD Multifamily Housing. This includes taking accounting continuing education classes in accounting

for HUD Projects. Create an Internal Auditing function. Management provide a structure and process

to review and monitor the processing of monthly financial statements and transactions. Management

must also review and monitor the processing of monthly bank reconciliations. By providing these

processes it will reduce the risk of material misstatements and increase the likelihood that financial

statements will be produced at a reasonable period after year end.

2. Management utilizing the Internal Audit Function should revise its internal control system as follows:

a. Identify major areas of risk of material misstatement and/or fraud. As an example, the areas may

include; late Audit reporting, identifying areas of risk of material misstatement such as making