Corrective Action Plans

GRHC Response & Corrective Action Plan The GRHC does not dispute the finding and acknowledges the deficiencies identified. Due to staff shortages and turnover, GRHC experienced challenges in maintaining consistent file management, eligibility determinations, and recertifications in strict compliance with HUD requirements. However, prior to the auditor’s testing that resulted in this finding, the GRHC had already begun discussing strategies to address these issues. Recognizing the need for stronger internal controls and process improvements, the GRHC initiated a plan to enhance file management, compliance monitoring, and process reviews. This plan includes: Process Mapping of Critical Functions to standardize workflows, ensure consistency, and eliminate inefficiencies. Digitization of forms to improve efficiency and reduce errors. Electronic document signing to streamline tenant file processing. Internal control checklists to ensure completeness and accuracy before file submission. Quality control (QC) review of all files by a manager before final submission to ensure compliance with HUD regulations. Strategies for these improvements began in August 2024 and are scheduled for full implementation by July 2025. GRHC leadership has been actively monitoring these efforts and meeting regularly to ensure progress toward compliance. Corrective Actions & Implementation Plan Corrective Action Responsible Group Completion Date Status Process mapping of critical workflows to ensure standardized procedures for eligibility and recertifications. Policy and Program Feb 2025 Completed Implement digitization of forms to streamline eligibility and recertification processes. Policy and Program 30-Apr-25 In Progress Introduce electronic document signing to enhance efficiency and reduce processing time. Policy and Program /IT 30-Apr-25 In Progress Develop and enforce internal control checklists for eligibility and recertifications. Policy and Program/IT 31-May In Progress Provide staff training on new processes and HUD compliance requirements. Policy and Program 30-Apr-25 Planned Conduct internal audits to evaluate the effectiveness of the new controls before manager QC begins. Policy and Program 30-Jun-25 Planned Require manager-level QC review of all tenant files before submission. Program Managers 01-Jul-25 Planned Implement a formal backup plan to ensure timely eligibility processing during staff absences or workload surges. ED/Program Directors 01-July-25 Planned Regular reporting to GRHC leadership on the status of tenant file compliance improvements. ED/Policy and Program Ongoing Planned Expected Outcome Full compliance with HUD requirements for eligibility and recertifications. Improved internal controls to prevent future deficiencies. A sustainable QC system for ongoing compliance monitoring. Monitoring & Follow-Up The Policy and Program Implementation Manager will oversee corrective actions and provide bi-weekly progress updates. The Executive Director will present the Corrective Action Plan at the next board meeting. Contact Person: Jose L. Capeles Title: Policy and Program Planning and Implementation Manager Date: 03/28/2025

Finding 2024-001 Federal Agency: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing Number: 84.268 Federal Award Year: Funding periods between July 1, 2023 through June 30, 2024 Compliance Requirement: Eligibility Finding Type: Noncompliance and Significant Deficiency The School of Dental Medicine did not have a report to identify students with a federal loan aggregate related issue. The Office of Admissions and Financial Aid had a report for students in the undergraduate and graduate careers (excluding the Dental Medicine professional Primary Academic Program). The Office of Admissions and Financial Aid added the School of Dental Medicine staff as a recipient on this report to assist them in identifying students with an ISIR code indicating students that are approaching or have already exceeded the Federal Direct Loan aggregate limits for review. Since September 2024, the School of Dental Medicine has been receiving and reviewing the Aggregate Overpay Checklist report. Name of the contact person: Michelle Jackson Completion date: Already completed, September 2024

Recommendation: We recommend the Institute review its policies and procedures around sending entrance information to students to ensure students are receiving proper counseling and ensure entrance counseling is documented before loans disbursements are made. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SOU will review its policies and procedures for Direct Loan entrance counseling to ensure all students, including GRAD PLUS loan recipients, have completed their entrance counseling or previously completed counseling is retained within the student information system. Name(s) of the contact person(s) responsible for corrective action: Daniel M. Tramuta, Interim Director of Financial Aid Planned completion date for corrective action plan: April 2025

2024-001 Eligibility $ 0 Condition and Criteria: The Authority’s purpose for existence is providing decent, safe and affordable housing to low- income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family’s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following: a. 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. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. e. Reexamine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary. Population and Items Tested: Testing of seventy-one family files revealed the following deficiencies: 1. Two lacked documentation of rent reasonableness. 2. One file lacked an HQS inspection in the file. 3. Three files calculated an incorrect housing assistance payment. 4. One file lacked a utility allowance calculation. 5. One file lacked income verification at lease up. Auditor’s Recommendation: A thorough review of tenant files should be performed for the purpose of eliminating the deficiencies. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2025

II. Finding 2024-002 - U.S. Department of Education (USDE), TRIO Cluster Programs (material weakness): We observed the following conditions in connection with our testing of the TRIO programs: (a) UB Eligibility Test: Of the 17 students selected for testing, one (1) student’s citizenship could not be determined, two (2) students did not provide any income information on the application, ten (10) students did not provide tax returns to verify low income as reported. (b) ETS Eligibility Test: Of the 17 students selected for testing, seven (7) students' citizenship status could not be determined, documentation to support enrollment status was not provided for 17 students, one (1) student did not have any information uploaded, and one (1) student has a birthdate discrepancy. (c) Educational Opportunity Center (EOC) Eligibility Test: Of the 17 participants selected for EOC testing, 17 did not have an enrollment agreement, acceptance letter, nor tax documents uploaded to adequately test the attributes, and one (1) student did not have a signature page for the EOC application. Auditor's Recommendation – We recommend the College ensure that all required documentation is submitted prior to determining the participants' eligibility. Corrective Action – Tougaloo College Administration understands the importance of federal compliance. The Vice President for Strategic Initiatives & Social Justice has direct management oversight of the TRIO programs. The lack of internal controls related to UB Eligibility Test, ETS Eligibility Test, and EOC Eligibility Test (verification of citizenship, income information, tax refunds, documentation of enrollment status, enrollment agreement, and birthdate verification), a non-recurring finding, were largely caused by a high degree of staff turnover and lack of experience in the front-line staff directly responsible for these controls. Although it has proven difficult to hire and retain highly qualified staff due to higher salaries paid by other institutions for similar positions in our market, the Executive Director of the TRIO programs and leadership team has implemented the following actions to correct the findings: 1. Continue to recruit and develop internal protocols to more fully retain highly qualified personnel. 2. Continue to train staff and increase staff training specific to reviewing the proper documentation required for attending the programs. 3. Include an additional level of early review by the Executive Director and other senior program staff to verify compliance at multiple stages of program involvement by students, including when students are initially recruited and enrolled. 4. Internal federal compliance testing will be a required criteria for the staff annual evaluations reviewed by the Executive Director of TRIO programs and the Vice President for Strategic Initiatives & Social Justice.

1. Implement new communication channels to align process to NSLDS and the USDoE.  Engage with NSLDS: Requested an access token for the data manager to monitor and reconcile data submitted.  Reach out to NSLDS to coordinate new reconciliation reports out of NSLDS database. 2. Training  Maintain sustained training and preparation for the staff. 3. Implement a weekly review process to double­check the entries for changes in enrollment reporting in NSLDS.  Implement a Document Changes and Actions Log: Keep detailed records of all changes made to procedures and actions taken to address the audit findings. This documentation can be useful for future reviews.  The Registrar will assure that all changes (LOA, withdrawals, re­ entries, and reclassifications, completions, graduations) are entered weekly and documented across all databases (NSLDS, Jenzabar student record, SRS, others as applicable).

Finding 2024-002 – HOME Loans Affordable Period Monitoring Management’s Response or Department’s Response Management concurs with the finding. Views of Responsible Officials and Corrective Action The Department will provide training to staff on HOME monitoring requirements, updating policies and procedures, as necessary, to address all current regulatory requirements. The Department’s multifamily monitoring for all projects in the HOME period of affordability will be completed prior to June 30, 2025. As part of the monitoring process, the Department will document all records requiring annual or semi-annual oversight and review for compliance with HOME requirements. Should the monitoring result in any findings requiring corrective action, the Department will ensure all findings are addressed by September 30, 2025. Anticipated Completion Date May 2025 Contact Information of Responsible Official Name: Augustine Ramirez Title: Division Manager, DPWP Community Development Division Phone: 559-600-4266

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: We are actively addressing this issue while highlighting the Division of Vocational Rehabilitation’s (“DVR’s”) high compliance rate of 98.3 percent. The Vocational Rehabilitation Specialist (“VRS”) and the Vocational Rehabilitation Manager have been thoroughly informed about the correct data entries required for Service E (work experiences while in Service status). It’s essential to note that “competitive integrated employment” must not be selected for Service E status. Instead, staff should choose alternatives such as “internships, whether paid or unpaid,” or “transitional employment” to ensure accurate data recording and prevent the inclusion of data element 350. Additionally, “competitive integrated employment” requires the client to be actively employed in alignment with their employment goal outlined in their Individualized Plan for Employment with a stable employment value date entered in the employment record. To assist our staff in this process, the Aware-System Bulletin will include a clear reminder to verify both the employment status and the stable employment value date for each case. Instructions for using the managed layout edit checker will also be provided, equipping staff with the necessary tools to identify errors and make corrections independently. The VRS will ensure that the Service E or Employed status aligns appropriately with the appropriate employment categories. This corrective action reinforces best practices and significantly improves staff compliance with the accuracy of our data from DVR’s case management system. Completion Date: On going monitoring and training as needed. Responding Official(s): Lea Dias, Vocational Rehabilitation Administrator and R. Pascual-Kestner, Vocational Rehabilitation Assistant Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. The Supplemental Nutrition and Assistance Program office (“SNAPO”) has addressed these issues within the division to make efforts to improve our payment accuracy which include electronic case documentation and data entry accuracy. Corrective Action Taken or Planned: SNAPO has worked with Statewide Branch Administration (“SBA”) to address these types of deficiencies as Hawaii is presently under corrective action for payment error rates. A mandatory refresher training to address budgeting and household composition had been implemented starting in January 2024 to improve core eligibility fundamentals such as budgeting. SNAPO will share the findings provided from this audit to include this as a part of our broader corrective strategy being implemented across the division through the partnership of SNAPO and SBA to address root causes for these errors. Regular case reviews are planned on being conducted to address areas of concern and will be addressed accordingly through supervisory channels to improve payment accuracy and case documentation. Completion Date: This is an on going activity and started for planning purposes from December 2024. SNAPO and Statewide Branch will be implementing the inaugural training/review with the Quality Maintenance and their review of the Quality Control (“QC”) Reports from Audit, Quality Control and Research Office (“AQCRO”). The Quality Control office conduct monthly reviews of all SNAP cases to provide to USDA Food and Nutrition Services on payment errors and will notate administrative deficiencies such as incorrect data entry for both income and deduction amounts used to calculate benefits when determining SNAP eligibility. The regular review cadence is monthly for the QC reports with a tentative quarterly discussion on findings to determine further assistance that can be provided through a collaboration between SNAPO and Staff Development office with policy guidance and staff training. Responding Official(s): Ginet Hayes, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Upon further review of the case, it was determined that the caseworker processed the case in “Manual Eligibility” mode which prevented the Kauhale On Line Eligibility Assistance System (“KOLEA”) from terminating benefits. Another worker removed “Manual Eligibility” mode in January enabling KOLEA to process the case and send a termination notice. The worker should have processed the case and taken the case out of “Manual Eligibility” mode when case processing was complete. Corrective Action Taken or Planned: The “Eligibility Determination” training module will be updated to include additional instructions for Manual Actions in the Kauhale On Line Eligibility Assistance System (“KOLEA”). Workers will be instructed to seek guidance from a supervisor for next steps, before running a case manually. This training will be provided on April 30, 2025, to all supervisors and caseworkers and will include a Participant Guide and a summary of the change. To ensure that the training was effective, a query will be run of all cases that are set to “manual,” including the date in which the case was placed in manual. Med-QUEST Division (“MQD”) will review all identified cases to determine if the case should remain in manual for any legitimate eligibility reason. Completion Date: April 30, 2025 Responding Official(s): Lori Lei Aponte, Med-QUEST Division, Eligibility Branch Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Department has engaged with a vendor to implement our new online provider enrollment system HOKU on August 3, 2020 and started the process to have all providers re register their information in the new online system. Most providers were given a deadline to do this by December 31, 2023 and if missed they would be terminated in 2024. There are a few providers who did not re register by December 31, 2023, and these were primarily providers of exclusive or specific services who refused to enroll into HOKU. Not enrolling these providers will have a disruptive impact to the service delivery experience and greatly increase the costs to the program, by risking the Department having to send additional patients to the mainland to get the specialized medical care needed. The Department will be terminating these remaining providers by December 31, 2025. Additionally, the Department is planning to apply for an 1115 demonstration waiver amendment in 2025, to waive the 42 CFR 455.414 provider enrollment requirements for these few providers with exclusive services. Completion Date: December 31, 2025 Responding Official(s): Marvin Malohi, Med-QUEST Division, Supervising Contracts Specialist

Views of Responding Officials: The Department does not agree with this finding. According to 45 CFR section 205.55, it states, “…the State agency will request through the Income Eligibility and Verification System (“IEVS”)…”. However, the policy does not specify the State agency must “properly use IEVS information to evaluate benefit amounts…” as notated in this finding under “Effect.” Unless IEVS provides the necessary information for the applicable benefit month(s) used to determine a TANF applicant’s or recipient’s (“client”) eligibility, information obtained through IEVS will only validate whether a household received an income source, after the fact, but will not verify the dollar amount. Hard-copy verification is obtained from the client to verify income source and dollar amount, for the applicable benefit months, to determine eligibility in accordance with §17 676-51, Hawaii Administrative Rules. For example, if a client applied for TANF on February 28, 2025, and the department processes the application on March 20, 2025 (current month), verification of the household’s income received in February 2025 and received thus far in March 2025, must be obtained to determine eligibility for the month of application (February 2025) and subsequent months (based on projected income). Data obtained from IEVS are not current; therefore, if the information obtained from IEVS is used to determine eligibility, then we would violate our own administrative policy (i.e., §17 676-51, Hawaii Administrative Rules). For example, wage information through SWICA becomes available on a quarterly basis. The most current SWICA information available would have been for quarter ending December 31, 2024, for an application received on February 28, 2025, that was processed on March 20, 2025. Eligibility determination would have been improperly made if SWICA information from IEVS was applied. Corrective Action Taken or Planned: The department will continue to conduct IEVS check. The information obtained will only be used to validate a source of income reported by the applicant/client IF the information is applicable. Completion Date: On going Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Temporary Assistance for Needy Families (“TANF”) Program Office will collaborate with the division’s Staff Development Office to develop “refresher” training modules on the Benefit, Employment, and Support Services Division (“BESSD”) Learning Academy. Each training module will focus on a specific topic of concern. To monitor staff’s completion of the training modules and their progress, each module will include a quiz or test at the end that staff will be required to complete and pass (e.g., pass equates to a score of 80% and higher). The TANF Program Office and the Staff Development Office began discussions on February 26, 2025. Completion Date: December 31, 2025 Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Temporary Assistance for Needy Families (“TANF”) Program Office will continue to issue reminders to the eligibility staff, focusing on specific topics and common errors such as, but not limited to, incorrect calculations, policy applications, and determinations. The division has implemented a strategy to address the backlog which caused some TANF applications to be processed beyond the 45 day timeframe. The strategy includes dedicating a group of eligibility staff to the statewide call center where most applicants and recipients are requested to call to complete their eligibility interviews. Completion Date: December 31, 2025 Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. CWS recognizes that Licensing case files from neighbor islands (Maui, West Hawaii, and Kauai) came late or not at all, and this lack of ability to review the records significantly contributed to the errors. Moving forward, CWS will ensure easier records identification by geographical location and begin the neighbor island’s audits first, allowing extra time for records travel to review site. CWS also notes that additional communication and information sharing with auditors would have been helpful to ensure understanding of expectations prior to on site audit. The communications requested would resemble a pre audit information sharing call, an on site audit entry meeting with key agency staff, and an audit exit conference to discuss findings before the final report is generated. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Providing requested records in advance of the audit, B. Diligent compliance with policies and procedures, C. Supervisor coaching, support and review of records/documents for completeness, D. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staffs are securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated and ensuring filed in eligibility record. C. Locate or reprint and file missing “Certificate of Approvals.” D. Locate missing clearances in records not provided for review or re run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. E. Administrators to work with courts to ensure court orders contain the required language and are secured in a timely fashion. i. Secure missing termination of parental rights order. ii. Secure court order supporting “reasonable efforts.” iii. Secure missing police protective custody documentation or voluntary foster custody agreement for three cases. F. For young person(s) in Imua Kakou (“IK”) who turned 18 while in care. i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document (reason for) continuation of monthly subsidy payments after youth turned 18. 3. CWS has identified the Eligibility Unit (“FPPEU”) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staffs (Licensing, CWS and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit, following checklist and secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. 7. In preparation for future audits, CWS will update the file identification and secure transport process as follows: A. MICU will send a separate email for records request to each neighbor island, identifying only their records, rather than sending a joint, multi-island, records request. B. The records request email sent by MICU will include a submittal deadline that will accommodate extra time for secured travel of records between islands to ensure all records arrive on time. C. MICU and Branch will review records submitted, ensuring that all records are available to the auditors for review. Completion Date: On going Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Child Welfare Services (“CWS”) recognizes that licensing case files from neighbor islands (Maui, West Hawaii, and Kauai) came late or not at all, and this lack of ability to review the records significantly contributed to the errors. Moving forward, CWS will ensure easier records identification by geographical location and begin the neighbor island’s audits first, allowing extra time for records travel to review site. CWS also notes that additional communication and information sharing with auditors would have been helpful to ensure understanding of expectations prior to on site audit. The communications requested would resemble a pre audit information sharing call, an on site audit entry meeting with key agency staff, and an audit exit conference to discuss findings before the final report is generated. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Providing requested records in advance of the audit, B. Diligent compliance with policies and procedures, C. Supervisor coaching, support and review of records/documents for completeness, D. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staff are securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated, and ensuring it is filed in eligibility record. C. Locate or reprint and file missing “Certificate of Approvals.” D. Locate missing clearances in records not provided for review or re run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. E. Administrators to work with courts to ensure court orders contain the required language and are secured in a timely fashion. i. Secure missing termination of parental rights order. ii. Secure court order supporting “reasonable efforts.” iii. Secure missing police protective custody documentation or voluntary foster custody agreement for three cases. F. For young person(s) in Imua Kakou (“IK”) who turned 18 while in care. i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document (reason for) continuation of monthly subsidy payments after youth turned 18. 3. CWS has identified the Eligibility Unit (“FPPEU”) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staffs (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit, following checklist and secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information, and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. 7. In preparation for future audits, CWS will update the file identification and secure transport process as follows: A. MICU will send a separate email for records request to each neighbor island, identifying only their records, rather than sending a joint, multi-island, records request. B. The records request email sent by MICU will include a submittal deadline that will accommodate extra time for secured travel of records between islands to ensure all records arrive on time. C. MICU and Branch will review records submitted, ensuring that all records are available to the auditors for review. Completion Date: On going Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. CWS recognizes that Licensing case files from neighbor islands (Maui, West Hawaii, and Kauai) came late or not at all, and this lack of ability to review the records significantly contributed to the errors. Moving forward, CWS will ensure easier records identification by geographical location and begin the neighbor island’s audits first, allowing extra time for records travel to review site. CWS also notes that additional communication and information sharing with auditors would have been helpful to ensure understanding of expectations prior to on site audit. The communications requested would resemble a pre audit information sharing call, an on site audit entry meeting with key agency staff, and an audit exit conference to discuss findings before the final report is generated. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Providing requested records in advance of the audit, B. Diligent compliance with policies and procedures, C. Supervisor coaching, support and review of records/documents for completeness, D. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated and ensuring filed in eligibility record. B. Locate or reprint and file missing “Certificate of Approvals.” C. Locate missing clearances in records not provided for review or re-run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. D. Administrators to work with courts to ensure court orders contain the required language and are secured in a timely fashion. i. Secure missing termination of parental rights order. ii. Secure court order supporting “reasonable efforts.” iii. Secure missing police protective custody documentation or voluntary foster custody agreement for three cases. E. For young person(s) in Imua Kakou (“IK”) who turned 18 while in care. i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document the reason for continuation of monthly subsidy payments after youth turned 18 or discontinue payment. 3. CWS has identified the Eligibility Unit (“FPPEU”) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staffs (Licensing, CWS and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit, following checklist and secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff may be given individual training or coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given individual training or coaching/supervisory support to correctly complete documentation. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. 7. In preparation for future audits, CWS will update the file identification and secure transport process as follows: A. MICU will send a separate email for records request to each neighbor island, identifying only their records, rather than sending a joint, multi-island, records request. B. The records request email sent by MICU will include a submittal deadline that will accommodate extra time for secured travel of records between islands to ensure all records arrive on time. C. MICU and Branch will review records submitted, ensuring that all records are available to the auditors for review. Completion Date: On going Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator

Finding Reference: 2024-007 - SFA Eligibility (ASU) Responsible Official: Juanita Edwards, Director of Financial Aid Corrective Action Planned: ASU disburses aid to students’ accounts once the student has completed registration. The student was enrolled and eligible for the Pell grant. The student had not completed registration, so Pell was not disbursed. Moving forward ASU will review all student accounts to ensure students have completed the registration process. If they have not completed registration timely, they will be notified. Once notified and registration is complete, Title IV funds will be disbursed to the students’ accounts. Checks and balances have been reviewed and implemented to ensure the process is completed timely. Estimated Completion Date: June 30, 2025

Finding Reference: 2024-010 - Eligibility (Board Office) Responsible Official: Dr. Casey Prestwood, Associate Commissioner for Academic and Student Affairs Corrective Action Planned: An evaluation form was developed and implemented to be used with each applicant review as a checklist of requirements. In addition, there is a second layer of review of all approved applicants’ eligibility prior to requesting disbursement of funds. An outside CPA firm was contracted in May 2024 to perform the second layer of review of each approved applicant before disbursement, to review all disbursement prior to that date in the current grant cycle, and to provide guidance on internal controls. An additional staff person to assist with grant awarding and programmatic operations was hired in August 2024. Estimated Completion Date: August 2024

xiii. Management Response and Corrective Action Plan: One of the individuals tested was identified as not being enrolled in the audited grant during the audit period. This is correct. The individual was exited from the program in the previous audit period and written documentation was uploaded to demonstrate this. However, the case manager neglected to exit the individual from HMIS during the previous audit period. This has been corrected. No services or funds were provided to this individual following their exit from the program. Our program has a good track record of data compliance and we expect this was an exception and not the rule. Program management will review and train staff again on data compliance during a weekly staff meeting, and will also counsel the involved staff member on the error to ensure there is no similar future error. xiv. Contact Person (s) Responsible for Corrective Action: Cassie Roach, Safe Parking Program Director, croach@sbnbcc.org Joel Goforth, Homeless Services Director, jgoforth@sbnbcc.org xv. Anticipated Completion Date: The anticipated completion date is April 30, 2025.

S3800-010: Finding Reference Number 2024-001 S3800-030: Statement of Condition: Management designed Control Activities to ensure compliance with the Eligibility requirement with respect to tenant eligibility. Those Control Activities include verification and review of tenant files by an independent contractor prior to finalization of new tenant move-in. However, during our testing, we noted five (5) move-in files out of five (5) move-in files tested where tenants were approved for move-in prior to review and approval by the independent contractor, circumventing the control. S3800-080: Auditor Recommendation: We recommend that the client immediately implement corrective actions to ensure compliance with internal control procedures. Specifically: 1. The compliance specialist should be required to wait for proper approval of tenant eligibility files before processing them. 2. Review and reinforce the approval process through additional training for staff to ensure they understand the critical importance of obtaining necessary approvals before proceeding. 3. Implement stronger oversight and monitoring mechanisms to ensure that files are not processed before approval. S3800-045: Actions Taken or to be Taken: Management has reviewed the policies and procedures with the property manager, who also serves as the compliance specialist. The property manager was instructed that no tenants are to be granted occupancy until the file has been approved by the independent contractor conducting the compliance review.

Corrective Action Plan: The Authority acknowledges the finding. Corrective actions to address the deficiencies are underway and include:  Updating internal policies and procedures related to tenant file documentation and income verification requirements;  Providing targeted sta􀀳 training on proper file documentation and third-party income verification procedures;  Implementing a mandatory checklist to ensure all required documentation is obtained and verified before finalizing recertifications;  Establishing a quality control process where supervisory sta􀀳 conduct periodic file reviews to ensure compliance;  Maintaining an audit trail of verification documentation to ensure proper retention.  Hired third-party service provider, Quadel to assist with tenant file documentation compliance, annual and interim recertifications and rent calculations.  Hiring Senior Housing Manager to assist with monitoring verification documentation, income calculation, citizenship and/or legal residency documentation, and signed release documentation compliance. Anticipated Completion Date: June 30, 2025 Responsible Party: Senior Manager of Housing Operations and PH Property Managers

We have determined that the sliding fee set up in our EHR will miscalculate a patient’s sliding fee discount when a combination of particular conditions are met. A representative of the EHR company has confirmed that the system “does not behave as it should” when these circumstances occur. While it is rare that a slide patient would meet all of these conditions, it does happen from time to time. Because of this, we have begun verifying the discounts applied to every slide patient’s account to ensure accuracy. Additionally, we are restructuring the sliding fee discount program and will rebuild it within the EHR to remove the possibility of one of the conditions occurring, which should prevent the system from ever miscalculating the discount to be applied. Person(s) Responsible: Kim Wieloch, Finance Director Timing for Implementation: Verifying all SFS discounts: Currently in process and ongoing; Rebuilding SFS calculation structure in EHR: By 7/1/2025

Name ofcontactperson: Julie B. Savino, Associate Vice President of Student Financial Assistance Corrective action: The University remains committed to maintaining compliance with federal requirements and ensuring accurate Free Application for Federal Student Aid (FAFSA) verification. Staff will continue to receive verification training through internal and external means to ensure the accuracy ofthe verification requirements. To address the identified issues, the University will strengthen verification policies and procedures by adding controls to prevent data entry errors. As part ofthese improvements, a secondary review process will require a Director level staff member to evaluate any Institutional Student Information Record (ISIR) updates or changes before finalizing the Student Aid Index (SAI) (previously known as Estimated Family Contribution EFC). Proposed completion date: April 15, 2025

Corrective Action Plan for Finding 2024-004 Community Care agrees with this finding. There are four bullets in this finding. We will be making a formal request to have the HMIS 72 hour data entry removed from our contract. The HMIS system does not have the capability to measure data entry timeframes because of this we would need to design a data entry tracking process to track the timeframes. If our request is denied, we will create an entry tracking process. Bullets 2-4 are results of providing services in from the perspective of a low barrier service. Our priority is to have youth come to a safe place that is warm and where they are provided with a place to sleep, food, healthcare, and services to aid them. Staying in the program is not contingent on completing assessments or engaging in a service planning process. Each time a youth is in a program they are provided with the opportunity to participate in an assessment and are offered an organized service plan. Most participate but some do not. We will continue to offer the same level of support and opportunity for assessments and service planning to each youth. • There was no auditable evidence to test whether the participants were entered into HMIS within 72 hours. • Four participants did not have a service plan developed within 30 days. • The client was unable to provide the NavSEA for three participants. • The service plan for one participant did not have documented review. Responsible Official: David McCluskey, Executive Director Date of Corrective Action: Systems are in place and efforts will continue to encourage youth to participate in assessments and service planning practices. Regarding the HMIS data entry request will be made Friday the 21st March, 2025. If denied we will build a tracking process within 30 days.