Corrective Action Plans

2024-004 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth Activities participants. Action Taken: The Board has established policies and procedures to strengthen eligibility verification for the Youth program participants. These policies outline clear documentation requirements, verification steps, and staff responsibilities. Staff involved in eligibility determination have been trained on the new procedures to ensure consistency and compliance with federal and state guidelines and will receive ongoing training and technical assistance. The Board has implemented internal controls, including multi-level verification and supervisory review to ensure the accuracy and completeness of participant eligibility determinations.

Health Resources and Services Administration Jacquelyn Kilmer, Harlem United Community AIDS Center, Inc.’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024 The findings from the June 30, 2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT Material Weakness Item 2024-001 - Accounting for Leases The Organization adopted Financial Accounting Standards Board ("FASB") Accounting Standards Update ("ASU") 2016-02 (as amended), Leases (Topic 842), on July 1, 2020. Topic 842 required lessees to recognize a right-of-use asset and a corresponding lease liability for virtually all leases. The Organization did not apply Topic 842 for approximately 300 lease agreements for scatter sites that are part of the Organization's Housing Assistance Program. Recommendation We recommend that the Organization read and review all of its lease agreements to ensure that they are properly accounted for under Topic 842. Action Taken We agree with the finding. Management has already implemented a review of all of its existing lease agreements to ensure that we are accounting for them properly under Topic 842. We are also in the process of reviewing our accounting policies in relation to leases. Effectivity Date: July 2024 FINDINGS FEDERAL AWARD PROGRAM AUDITS Significant Deficiency Item 2024-002 - Procurement, Suspension and Debarment - U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Projects of Regional and National Significance (Assistance Listing Number 93.243) Notice of Award Number 1H79SP082826 for 2023-2025 and Notice of Award Number 5H79TI085189 for 2023 to 2024 The Center did not maintain documentation of its verification of two sample employees and two sample vendors to ascertain if they are suspended or debarred. Recommendation: We recommend that the Organization implement a policy requiring proper documentation of their verification of employees and vendors for suspension and debarment. Action Taken: Management agrees that evidence of exclusion search was not maintained or kept on file. Management has already established a policy in relation to performing verification for suspension and debarment and the Organization will be training all the personnel involved to ensure that proper documentation is kept on file. Effectivity Date: March 2025 Sincerely yours, Signature:  Jacquelyn Kilmer, CEO Harlem United Community AIDS Center, Inc.

Finding 2024-002 – Low Income Public Housing Tenant Files – Eligibility – Noncompliance & Material Weakness – Public and Indian Housing – ALN #14.850 Corrective Action Plan: The Housing Authority has contracted with US Inspections to continue pre-inspecting units in preparation for NSPIRE inspections. Additionally, staff is coordinating Income Calculation training with Zeffert University. Lastly, the Housing Authority has implemented a 100% file compliance review, which took effect on January 1, 2025. Person Responsible: Tammy Bradshaw, Admissions & Compliance Manager Anticipated Completion Date: June 2025

Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office will be implementing an SOP which will document a review process of work done by the third-party processor, to include COD reporting, and Verification procedures. We will also be implementing a process to review students who need to complete their exit counseling. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025

The sliding fee schedule has been updated several times in the last 24 months with subsequent staff training. Beginning in December 2024 our organization will begin charging a nominal fee then accurately utilizing sliding discounts based on income levels/family size. The organization has also increased training in processing and entering the collected patient income forms and sliding fee schedule packet of forms needed to accurately account for providing the patient with the sliding fee schedule adjustment.

Management agrees with the finding and recommendations, but also has determined that this finding will not be repeated in future years, as the arrearages program has come to a close.

Interim corrective actions: These cases involved situations where students dropped courses before withdrawing (officially or unofficially) from all courses. UW-River Falls did not have a system in place to review course participation for courses which students dropped prior to withdrawal, although it has procedures in place to review course participation for enrolled courses at the time of withdrawal and when students are assigned failing grades. For Fall Semester 2024: Existing procedures: 1. Official withdrawals: Students officially withdrawing from the University must complete an electronic form which collects instructor verification of course participation. The Financial Aid office receives this form once it has been processed by the Registrar’s office. Students reported as not having participated in courses have their financial aid adjusted prior to calculating a return to Title IV funds. 2. Unofficial withdrawals: Instructors assigning failing grades to students must report student’s course participation or non-participation and, if available, a last date of course participation. Following the grading deadline, a report listing all students who never participated in classes is run and students found to have failed courses due to non-participation have their financial aid adjusted prior to calculating a return to Title IV funds. Additional procedure instituted: 3. Learning management system review: Students who withdraw (officially or unofficially) and who dropped courses prior to withdrawing had their dropped courses reviewed in the Learning Management System (LMS). Students who submitted assignments as recorded in the system were determined to have begun participation in the course. Students who submitted no assignments were determined to not have participated in the course and financial aid was adjusted prior to calculating a return to Title IV funds. For Spring Semester 2025: Existing procedures: 1. Procedures 1,2, and 3 from Fall Semester 2024 continue to be employed for Spring semester 2025. Additional procedures: 2. Expanding the LMS review to Pell grant students with dropped courses: Students with disbursed Pell Grants who drop courses after the Pell grant census date now have these courses reviewed to determine if the student began attendance before dropping the course, using the same procedure as #3 above.Instructor course participation verification: After the 3rd week of classes for Spring 2025, UWRiver Fall requested that instructors report students who had not begun participation in their courses. This report is currently being reviewed and students with Pell grants will be evaluated to determine if an adjustment to the student’s enrollment intensity is needed to ensure that the disbursed Pell grant is accurate. Student who have begun participation in no enrolled courses will be reviewed for possible return of all Title IV funds. Future additional corrective actions: 1. UW-River Falls will pursue making course participation verification by instructors during the first month of the semester an administrative policy and develop formal procedures for surveying instructors and reporting students found to not have begun participation in a course or courses to the Financial Aid office for adjustments to their disbursed Title IV aid. 2. UW-River Falls will pursue adding an instructor course participation step to the course drop form currently in use by the Registrar’s office. Anticipated Completion Date: Interim actions were implemented in September 2024 and February 2025. Permanent action expected by Spring 2026. Person(s) responsible for corrective action: Cindy Holbrook, Executive Director of Enrollment Management Cindy.Holbrook@uwrf.edu 715-425-3500 Robert Bode, Director of Financial Aid and Military/Veterans Resource Center Robert.Bode@uwrf.edu 715-425-3141 Kelly Browning, University Registrar Kelly.Browning@uwrf.edu 715-425-3342 Responsible Unit Division of Enrollment Mangagement

Wisconsin Department of Health Services Planned Corrective Action: This FY 2022-23 finding continued through SFY 2023-24 because the public health emergency unwinding was completed after June 30, 2024, for this population. No new concerns were identified by LAB during their FY 2023-24 audit. Corrective actions began during SFY 2023-24, and DHS completed a final analysis in November 2024. As part of this process, all outstanding cases were resolved. After the analysis was completed, DHS implemented an ongoing monthly monitoring plan with the IM agencies, which was outlined in the CARES Coordinator Notice (CCN) dated January 27, 2025. Anticipated Completion Date: January 27, 2025Persons responsible for corrective action: Autumn Arnold, Director Bureau of Eligibility and Enrollment Policy, Division of Medicaid Services autumn.arnold@dhs.wisconsin.gov Jonelle Brom, Director Bureau of Eligibility Operations and Training, Division of Medicaid Services Jonellem.Brom@dhs.wisconsin.gov Dave Varana, Director Bureau of Fiscal Accountability and Management, Division of Medicaid Services Dave2.Varana@dhs.wisconsin.gov

Planned Corrective Action: The Office of the Commissioner of Insurance accepts the Legislative Audit Bureau’s recommendation to ensure claims meet eligibility requirements and include appropriate documentation. The following corrective actions are planned: • A spreadsheet is used to collect claims service and payment dates. A formula will be applied to either restrict or flag dates outside the allowable period. • Insurance carriers will be notified of the formula change and reminded to only include claims that were paid within the allowable period. Anticipated Completion Date: The PY 2025 spreadsheet will be updated by February 2025 and insurance carriers notified when provided the updated spreadsheet for PY 2025 reporting. Reporting for 1st quarter 2025 is due in May 2025. Person responsible for corrective action: Rebecca Easland, Deputy Commissioner of Insurance Rebecca.easland@wisconsin

Planned Corrective Action: As the auditors noted, the Department of Administration implemented the policies and procedures it developed to review and assess the service organization audit report for the Homeowner Assistance Fund to establish and maintain effective internal control over federal awards. Anticipated Completion Date: October 2, 2024 Person responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

Description of Corrective Action Plan: Shoals Community School Corporation’s Director of School Nutrition, Tamara Florio, will ensure that all time cards are signed by the employee and by herself before submitting to the Payroll Administrator, Darla Holt. Responsible Party and Time and Timeline for Completion: Tamara Florio, Director of School Nutrition-this will be implemented immediately, this 2024-2025 school year.

2024-001 Notification of Disbursements (Significant Deficiency) Criteria: Prior to making a disbursement, the school must notify students of the amount and type of Title IV funds they are expected to receive, and how and when those disbursements will be made (often referred to as an award letter or college financing plan) (34 CFR 668.165(a)(1)). Condition: One out of twenty-five undergraduate students selected for disbursement testing for the 2023-2024 academic year was not documented as having been notified prior to the disbursement of Title IV funds. Notification failed to occur after the student's enrollment status changed from half-time to three-fourths time enrollment, making them eligible for additional Pell Grant awards. Action Taken: The University will request assistance from the software provider and consultants to develop a notification process for when a student’s enrollment status changes from half-time to three-fourths time enrollment. Responsible Party: Emily Williamson, Financial Aid Director Point of contact: Emily Williamson, Financial Aid Director Williamson_e@lynchburg.edu (434) 993-8253 Expected date of correction: June 1, 2025

View of Responsible Officials: A policy for notifying applicants of changes to Expected Family Contribution (EFC) or financial assistance resulting from the verification process is contained in the Delaware College of Art and Design (DCAD) Approval, Delivery, and Disbursement of Title IV Funds Policies and Procedures in Section III Item d. (previously submitted). Should any of the students’ financial aid change or increase, FAO emails the student Updated Financial Aid Award Letters reflecting the changes. A copy of the student’s Need Analysis/Award Updates is also given to the Bursar. The two other omissions in the finding were correctly noted as not written in DCAD’s policy. No planned corrective action is necessary due to the College’s closure.

Department of Justice 2024-001 Crime Victim Assistance Program Auditor’s Recommendation: We recommend Community Crisis Center, Inc. continue to review its files to ensure that all client files contain the required confidentiality and intake forms. We also recommend Community Crisis Center, Inc. implement and enforce a policy to obtain the signed forms for all new clients and get any signed forms as soon as possible for any current clients. Additionally, Community Crisis Center, Inc. should conduct regular training and monitoring of employees to ensure confidentiality best practices are followed. Action Taken: Community Crisis center, Inc. will review files to ensure that confidentiality forms and intakes are present on a daily, monthly and quarterly basis for accuracy. In Addtiion, training will be provided to all new staff upon hiring, with quarterly reviews thereafter. If the funding agency has questions regarding this plan, please call me at 847-742-4088.

Boston Public Schools has revised its’ eligibility record keeping process to ensure that records are accurate and complete. This adjustment to record keeping practice has been instituted beginning with the FY25 grant application cycle. Anticipated Completion Date: June 30, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Finding: 2024-003: Significant Deficiency in Internal Control Over Compliance and Non- Material Noncompliance Responsible Person: Brian Reagan, Assistant Director, Department of Housing and Community Development Estimated Completion: April 30, 2025 Corrected Action: 1. The County will develop a solution with the software company that supports the Department of Housing and Community Development’s (DHCD) current client management to provide standardized reports that can be used by managers to monitor properties that have upcoming inspection due dates. The County will address current limitations within the software that does not allow for a fully automated workflow, which then necessitates a highly manual process and more likelihood of human error. 2. Staff will continue to utilize the monthly Section Eight Management Assessment Program (SEMAP) Indicators Report in HUD’s Public and Indian Housing Information Center (PIC) database and provide that information to the inspectors monthly so that all inspections will be planned in advance of the due date. 3. The HCV Program is currently in the process of transitioning the client management software to a new software provider and staff is diligently working to ensure that notifications and reports are available for the tracking of initial, biennial, and special inspection due dates. 4. DHCD currently employs only one full-time Inspector to conduct all initial, biennial, and special inspections for the HCV Program. The number of initial inspections increased by 180% during 2023 and 2024. As part of the Fiscal Year 2026 budget process, DHCD requested an additional full-time Inspector position that will conduct HCV inspections as well as inspections for other DHCD programs, which will further ensure that all inspections are completed in a timely manner and subject to quality control, especially during periods of program growth. 5. Additionally, the Inspector and HCV Program Manager will attend Inspection training, to enhance their knowledge of inspection requirements and compliance.

Finding 2024-002: Material Weakness in Internal Control Over Compliance and Non-Material Noncompliance Responsible Person: Chris Slagle, Program Manager; Allison Gregg, Program Manager Estimated Completion: January 31, 2026. Corrected Action: 1. The Department will conduct a thorough assessment of current redetermination reports and state policies to identify approaching deadlines and overdue items and create a structured monitoring system for supervisory staff. Standardized verification checklists will be introduced to confirm that all necessary documentation is collected, and incoming materials will be reviewed promptly to improve decision-making accuracy. The agency will collaborate with technical teams to correct the VaCMS programming error so that auto-renewals cannot occur without verification of crucial information such as social security numbers. 2. The Department will strengthen its workforce by enhancing training for new and existing employees. Requests will be submitted to the Board of Supervisors to support hiring additional staff, thereby mitigating the burden on each employee by reducing the caseload of 1,000 cases per worker to a more manageable caseload, allowing staff to process cases more efficiently. Training sessions will emphasize state and federal standards for timeliness, along with best practices for case documentation and adherence to the updated Medicaid Unwinding and Public Health Emergency guidelines. Regular professional development opportunities will be offered to ensure that all staff members remain informed about policy changes and evolving procedures. 3. The Public Benefits Unit Program leadership will conduct quarterly reviews to measure compliance with redetermination deadlines and track indicators such as workload volume, pending actions, and overdue items. Quarterly reviews will be documented and submitted to Department leadership. These reviews will highlight redetermination outcomes, caseload trends, and staffing considerations. 4. The Department will onboard the Public Benefits Program Administrator, who will be tasked with overseeing compliance across all Benefit Programs. The agency will implement a Corrective Action Plan aimed at ensuring timely and accurate completion of Medicaid redeterminations.

Corrective Action Plan We agree with the auditor’s finding as set forth above. Due to turnover in the financial aid department, there was an incorrect understanding of the maximum award process. We have updated the university’s policies and procedures to ensure they are compliant with Title IV requirements and will be assigning this responsibility to a new employee. The University has refunded, through Common Origination and Disbursement, any federal funding associated with the over-awards as noted in this finding. Timeline for Implementation of Corrective Action Plan Prior to June 30, 2025 Contact Person Vice President for Strategic Enrollment, Marketing and Communications

Information on the federal program: Subject: Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 PassThrough Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Material Noncompliance, Qualified Opinion Condition and Context: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Special Tests and Provisions - Wage Rate Requirements compliance requirements. The School Corporation had five construction and improvement projects which were funded with ESSER II (84.425D) and ESSER Ill (84.425U) grant awards. For 1 of 2 contracts selected for testing, the School Corporation did not include the Davis-Bacon wage rate requirements in the vendor contract. For this same vendor contract for floor replacement in a junior/senior high school, the School Corporation did not obtain the weekly payroll report certification from the construction vendor to monitor compliance with Davis-Bacon wage rate requirements. Therefore, no review was performed to ensure that pay rates complied with the federal wage rate requirements for this project. The total project cost disbursed for the flooring project during the audit period was $342,822 which included materials and labor. Total contract expenditures subject to Davis-Bacon wage rate requirements, including material and labor, during the audit period were $1,386,275. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: North Knox School Corporation will comply with the Davis-Bacon wage rate requirements in all future projects using federal funds. Responsible Party for Corrective Action: Darrel Bobe, Superintendent, and Terri Roesler, Treasurer, will oversee the corrective action plan. Timeline for Completion: Immediately.

Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness, Material Noncompliance, Qualified Opinion Condition and Context: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. During the testing of internal controls over eligibility determinations via the application process and related compliance, we noted the School Corporation was not able to provide the application or any documentation to support the eligibility status for 6 out of the 8 applicant students selected for tested for the 2022-2023 school year. There were no issues identified for students selected for testing whose eligibility was directly certified. Additionally, for the 2023-2024 school year, for 2 out of 30 students selected for the testing, the income eligibility determinations were not properly implemented. One student was determined to be eligible for "Free" meals per their free/reduced application but, the School Corporation incorrectly entered the eligibility as "Reduced" within the food service software. Another student was eligible for "Reduced" benefits per the direct certified download file but was entered into the food service software as eligible for "Free" benefits. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Moving forward, the corporation will take more time in reviewing free and reduced applications to ensure student free or reduced status is listed correctly and supporting documentation is maintained. Applications are now completed online limiting paper copies. A review of applications by another member of the corporation staff will also be conducted. Responsible Party for Corrective Action: Terri Roesler, Treasurer, will oversee the implementation of the corrective action plan. Timeline for Completion: Immediately.

FINDING 2024-003 Subject: Child Nutrition Cluster - Internal Controls over Eligibility Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23, FY 23-24 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. Context: During testing over controls for eligibility, we noted there was no formal, secondary review for the applications entered in the food service software determining eligibility. Additionally, there was no documented annual review by School Corporation personnel of the income eligibility guidelines used by the food service software. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Franklin County Community School Corporation has transitioned to the Community Eligibility Provision (CEP) as an alternative to collecting, approving, and verifying household eligibility applications. Responsible Party and Timeline for Completion: Jessica Defossett, September 2024 transition to CEP

Management’s View and Corrective Action Plan 2024-001 Enrollment Reporting Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Name: Pell Grant Program and Federal Direct Student Loans Award Number: Various Assistance Listing Title: Federal Pell Grants, Federal Direct Student Loans Award Year: 2023-2024 Assistance listing numbers: 84.063, 84.268 Pass-through entity: Not Applicable To whom it may concern: The Registrar’s Office has reviewed the finding and concluded the root cause to be a high volume of corrections required for graduated students as communicated by the National Student Clearinghouse (NSC). Students requiring corrections are not included in the National Student Loan Database System (NSLDS) data pulls from the NSC. When necessary, corrections were processed, the applicable students were included in a subsequent NSLDS data pull, resulting in ultimate reporting to the NSLDS outside of the required 60-day window for 31 students. To ensure reporting of graduated statuses within the compliance timeline, Dartmouth has implemented new practices based on the scheduled Degree Verify submissions to the NSC. The revised process was implemented in January 2025 and schedules an assessment of error volume and correction efforts ten days following submission to the NSC. This revised process allows enough time for degree files to be processed by the NSC, provide notification of necessary corrections to the College and result in timely acceptance by the NSLDS. Additionally, we have increased the number of staff in the Registrar's Office who are trained to make these status corrections from one to three. In performing our analysis to assess the total number of students reported outside of compliance, we identified an additional distinct population reported outside of compliance. Active students of the Master’s in Public Health (MPH) program are automatically enrolled in their next term, with an ‘EL’ (enrolled) status. Upon the Guarini Registrar’s Office’s graduation certification, the subsequent term is coded ‘CH’. The ‘CH’ term carries no credits 68 and requires no billing; however, it is reported to the NSC as a ‘Withdrawn’ status for the student. Because the ‘CH’ term is reported after the graduation term, it overrides the ‘Graduated’ status to ‘Withdrawn’ within the NSC. Upon the next NSLDS data pull, the student’s status is then updated from ‘Graduated’ to ‘Withdrawn’ in NSLDS. These statuses were corrected in February 2025 and had no impact on either the student or federal government. An additional 29 students were corrected in February 2025, resulting in a total population of 60 students reported outside of compliance with NSLDS. Per discussion with Gary Hutchins, Registrar and Assistant Dean for the Guarini School of Graduate and Advance Studies, effective immediately, future terms will be deleted for these students upon graduation certification. Deletion of the enrollment records will retain their appropriate ‘Graduated’ status. Sincerely, Eric Parsons Registrar of the College 69