Corrective Action Plans

2025-001 - Child and Adult Care Food Program - Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. A seventh provider did not have the proper documentation on file to support their Tier determination. Recommendation Controls should be reviewed and updated to ensure that reimbursements are only requested for complete and accurate meals counts at the correct rate of reimbursement, and that only eligible participants are submitted to the State for reimbursement. Comments on the Finding Recommendation The CACFP at The Russell Child Development Center acknowledges the findings and understands the importance of ensuring that all meal reimbursements are based on complete, accurate meal counts and correct reimbursement rates, and that Tier determinations are fully supported by proper documentation. Action Taken: As of October 31 , 2025, Russell Child Development Center, has ceased participation in the Child and Adult Care Food Program. During the final grant award year, CACFP staff reviewed and updated Tier Determination forms and supporting documentation when it was identified that documentation was missing or incomplete. In addition, staff corrected provider license types within the CACFP files when discrepancies were identified to ensure accurate reimbursement rates. No further claims have been submitted since the program's closure. All CACFP-related records, including Tier documentation, meal count records, and reimbursement data, will be retained for the required record-keeping timeframe in accordance with federal and state regulations.

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to a lack of verification of whether the patient had active eligibility or not. Steps have been implemented to remedy the issue in FY 2026. The Director of Financial Services-IAT reporting team is enhancing training and communication to improve understanding of eligibility and documentation requirements. Furthermore, procedures will be implemented to systematically monitor all medications billed to Ryan White and State HIV Services Programs, as well as verify participants' current eligibility status on a biweekly basis. The organization expects these processes to run efficiently by April 30th, 2026.

The Family Health Centers of Clark County, Inc. dba The Family Health Centers of Southern Indiana will institute a further refined 2nd review of all newly assigned or changed sliding fee assignments. This review will be completed by individuals who are briefed on all related sliding fee policies and procedures. Any discrepancies will be sent to the billing manager for updates and aggregation of discrepancy type for further personnel training. The Accounting department will also institute a monthly internal audit process and review a random sample of patients with claims in each particular month that has a sliding fee profile and forwarding to billing manager for correction and aggregation of discrepancy type for further personnel education and possible process changes to ease issues. The Family Health Centers of Clark County, Inc., doing business as The Family Health Centers of Southern Indiana, will adjust secondary review of all newly assigned or modified sliding fee scale determinations, assigning this review to designated staff members who are trained and knowledgeable in all applicable sliding fee scale policies and procedures. Any discrepancies found during the secondary review will be sent to the Billing Manager for timely correction. The Billing Manager will document, categorize, and aggregate discrepancies by type to identify trends and support targeted staff education and retraining efforts. This corrective action will be maintained on an ongoing basis to ensure continued compliance with sliding fee scale requirements and to strengthen internal controls.

Board of Commissioners Administration Building Jason R. Jones, Chairman 406 Craven Street Dennis Bucher, Vice Chairman New Bern, NC 28560 Thomas F. Mark George S. Liner Fax 252-637-0526 Theron L. McCabe jveit@cravencountync.gov Ettienne “E.T.” Mitchell Beatrice R. Smith Administrative Staff Jack B. Veit III, County Manager Commissioners 252-636-6601 Gene Hodges, Assistant County Manager Manager 252-636-6600 Nan Holton, Clerk to the Board Finance 252-636-6603 Amber M. Parker, Human Resources Director Human Resources 252-636-6602 Craig Warren, Finance Director None Reported. Finding 2025-001 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed completion date: April Rollins, Medicaid Program Manager Policy refresher training will be held by December 31, 2025. Refresher training for staff that files should be reviewed internally to ensure proper documentation is in place for eligibility determination. Workers will receive refresher training what files should contain and the importance of complete and accurate record keeping. Staff will have refresher training that all files include online verifications; documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Second party reviews of at least or in excess of the state’s mandated 98 cases will be conducted quarterly. The second party review threshold for staff is 90%. Any errors will be discussed one on one by the supervisor with the employee to ensure the employee has a full understanding of policies and procedures. Supervisors will review error trends every quarter to determine if further group training is needed. The Learning Gateway trainings have also been completed in the past 180 days for all Medicaid staff will further assist with retaining staff. 12/31/2025 Corrective Action Plan For the Year Ended June 30, 2025 Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs 188

Finding 2025-004 Title I Grants to Local Educational Agencies – Eligibility Contact Person Responsible for Corrective Action: Superintendent and Title I Program Director Mr. Todd Tanksley Contact Phone Number and Email Address: 812-849-4481 – tanksleyto@mitchell.k12.in.us Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan The School Corporation has established and implemented written internal control procedures to ensure that enrollment and poverty data reported in the October Real Time Reports are reviewed for accuracy and compared to the Title I application prior to submission. Beginning with the current grant cycle, the School Corporation will: 1. Obtain and retain copies of the October Real Time Report data used for each Title I application year. 2. Perform and document a detailed review of enrollment and poverty counts by school utilizing a worksheet that itemizes total enrollment at each school within the district, compares the low-income count according to the Real Time report, the utilized lunch software, and the counts indicated on the Title I application, and indicates a match (or variance in the event of data discrepancy) of the data among those three data sources. INDIANA STATE BOARD OF ACCOUNTS 32 3. Compare the poverty and enrollment data from the October Real Time Reports to the Eligible School Summary within the Title I application. 4. Verify poverty data using source documentation from the school lunch software system. 5. Investigate and resolve any discrepancies identified prior to submission. 6. Maintain documentation supporting the review, comparison, and verification process in accordance with federal record retention requirements under 2 CFR 200.334. Planned Evidence of Correction The School Corporation will maintain the following documentation as evidence of corrective action: ● October Real Time Reports ● Poverty and enrollment comparison worksheets ● School lunch software reports ● Signed and dated review checklists ● Copies of submitted Title I application Anticipated Completion Date Implemented and ongoing beginning with the 2026 Title I application.

Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review their awarding procedures and implement procedures to ensure the Stafford loans are awarded within the annual and aggregate limits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: At the time the Subsidized Direct Loan was initially awarded, the student was classified as grade level one and was correctly awarded $3,500. Subsequently, the student’s grade level increased; however, the Direct Loan award was not adjusted accordingly. The Office of Financial Aid relies on email notifications to identify students with grade-level changes, and the notification for this student was inadvertently missed. In response to this error, the Office of Financial Aid implemented additional monitoring controls. A report was developed to identify all students with changes in grade level and is now generated and provided weekly by the Office of the Registrar to the Office of Financial Aid. A designated Financial Aid Advisor has been assigned responsibility for reviewing this report and adjusting Direct Loan awards as necessary to ensure accuracy. As an additional preventative measure, the Director of Financial Aid will verify student grade level and corresponding Direct Loan eligibility prior to disbursement. The Office of Financial Aid will also conduct periodic reviews to confirm that Direct Loan awards consistently and accurately align with students’ grade levels.

Finding Reference: 2025-001 Description of Finding: HUD regulations require certifications to be completed and entered timely to ensure accurate calculation of Housing Assistance Payments (HAP), Total Tenant Payment (TTP) and utility reimbursements. Per 24 CFR section 982.516, the Authority must reexamine family income and composition at least once every two years and adjust the tenant rent and housing assistance payment as necessary using the documentation from third party verification. Of the 60 Moving to Work files tested, the following items were noted: • 40 instances of certifications not completed timely • 6 instances where the file did not contain income support • 3 instances where housing quality standards inspections were not completed within the last 2 years • 1 instance in which a rent comparison was not completed for a new move in Statement of Concurrence or Nonconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2025-001. Corrective Action: LMHA continues to work through issues around the proper and timely processing of program certifications to support accurate Housing Assistance Payments, Total Tenant Payments and utility reimbursements. Currently, recertifications are processed on a biennial basis schedule, through a three-tiered system outlined in our updated MTW plan. This will address timeliness of recertification while also ensuring compliance and review of supporting documentation. Please note the following rules tied to LMHA’s three-tiered recertification system: 1) When the family is zero income, they will go to an annual recertification. 2) When family is working, (enrolling in KTAP (Kentucky Transitional Assistance Program), receiving Child Support, and other similar sources of income) they will go to a biennial recertification. 3) When a family has fixed income, (receiving Social Security, Supplemental Security Income, and/or Pension payments), they will go to a triennial recertification. The HCV Team is also working with Yardi (ERP system) to maximize the reporting and monitoring of the recertification schedule. The manager initiates the tracking for needed processing and possible termination of participants. With the three-tiered system, staff will be able to review all tenant information closely during recertifications to ensure proper housing assistance payments. Additionally, to improve sufficient controls and internal monitoring, the HCV Team is partnering with the Compliance Team to review tenant files for errors and improper supporting documentation.

Corrective Action Plan: The School District is committed and will be diligent in preparing meals with high quality products. Regular cooked meals and expanded menu choices will be prepared which will result in an increase in expenses. There has been unpredictability with the increase of certain goods, and we expect this to continue into the 2025-2026 fiscal year as well. The School District also participates in the Community Eligibility Provision (CEP) which provides free breakfast and lunch to every student within the School District. Salaries for School Lunch employees have also been increasing year after year due to the increase of minimum wage in New York State. The minimum wage is expected to increase to $16.00 per hour and entry level wages have increased per contract. The School District does have a practice of transferring BOCES aid gained from the cost of the BOCES management contract to the School Lunch Fund; the aid will not be transferred in upcoming years. The School District has devised a NYSED approved plan to expend the excess funds in the School Lunch Fund through appropriating a substantial amount of fund balance to be planned for and used for the cafeteria and kitchen within the next planned capital project. We are currently in the planning phase of our next capital project with a vote anticipated during the 2025-2026 fiscal year. If needed, we will examine other avenues to ensure we do not exceed the allowable limit of cash at year end.

2025-001 – Significant Deficiency in Internal Controls over Compliance – Eligibility

Responsible Party: Dr. Donald Heseman, Superintendent

Corrective Action Plan: The District will implement procedures to require adequate supervision and formal review documentation on all applications.

Expected Completion Date: November 2025

Management will monitor tenant recertifications to ensure that they are being completed in a timely manner. The following measures will be implemented: • Centralized tracking by the Housing Manager on a monthly basis to monitor the recertification timeline for each unit. This will include tracking the 120, 90, 60, and 30 day reminders to be sent to tenants in advance of the recertification effective dates. • Automated reminders will be provided on a monthly basis by the third party vendor that processes HAP billings to the Housing Manager and site managers, in order to ensure that they are aware of any recertification deadlines. • Additional training will be provided for all staff members involved in the recertification process.

CFDA 10.565 Commodity Supplemental Food Program Name of Contact Person: Shelly Neeley, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a top priority in the program’s operation. There are currently 1,800 applications processed through WOFB and 43 site locations for CSFP. These include those applicants on the active list and the wait list as well as those who may not qualify for the program. During the auditing process, there were 11 participants that did not have a current/updated application on file yet received a distribution. To ensure that all applications are renewed within a twelve-month period, and that the recipients without a valid application on file do not receive distributions until a valid, up-to-date application has been obtained, WOFB has begun to implement and will continue implementing the following internal control procedures. WOFB will continue to update/renew all applications each March to have all expiration dates within the same month each year. The master spreadsheet has also been updated to include parameters that will flag an upcoming expiration date. This will assist the senior sites in knowing more timely who needs a renewal application at their location. In addition, Pantry Trak/Fresh Trak is being updated and revised. I have been working closely with Mid-Ohio in revising the CSFP portion to better meet the needs of the program at WOFB. The ultimate goal is to use the Pantry Trak system to log and track all CSFP information electronically. This too will increase the accuracy of the data. As an additional audit of accuracy WOFB will conduct an internal audit monthly by randomly pulling a sampling of 3 percent (48) of the 1,600 CSFP recipients to verify the accuracy of the applications on file. Proposed Completion Date: The processes implemented will be ongoing. As the Pantry Trak program tool continues to improve its use for tracking and logging, use for CSFP will increase.

November 21, 2025 FINDING 2025-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Otis College of Art and Design agrees with the finding. Upon review of the finding, Financial Aid administration met with Registrar’s staff to create a new procedure whereby immediate reporting of withdrawals are made directly to NSLDS in addition to the regularly scheduled monthly reports to NSLDS through the National Student Clearinghouse (NSC). This immediate reporting should eliminate any timing issues with the monthly reports through NSC. In addition, a joint effort to streamline the routing of withdrawal forms to the appropriate departments for faster processing is underway. This reprocessing of the withdrawal forms will be implemented in the next 120 days. Responsible Office and Individuals The Executive Director of Financial Aid and The One Stop, Michaela Matsumoto and Registrar, Nicole Raef are the responsible individuals for implementation of the corrective action plan. Corrective Action Plan The Registrar implemented a centralized tracking system that is now used for every withdrawal and graduation status change at all points in the semester. Registration reviews the withdrawal list weekly to ensure each change is accurately reflected in both NSC and NSLDS. To address graduation status updates, we are adjusting the timeline of our final spring enrollment report to NSC so it is submitted at the end of May. This allows NSC to transmit the data to NSLDS at the beginning of June resulting in fewer manual updates in NSLDS. Registration will then review all graduated students to confirm accurate NSLDS reporting rather than relying solely on Clearinghouse submissions. In addition, the Registration office will review and correct the NSC error report on a monthly basis. The Financial Aid and Registration offices will also initiate quarterly meetings to ensure timely submissions and address any emerging issues.

Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective actions have been taken: During the 2023-2024 academic year, EngageKY implemented a new process for recordkeeping related to the recruitment and selection of Kentucky College Coaches. As part of the implementation, site supervisors and program staff began to use Salesforce to maintain notes from screening interviews and general interviews. The missing documentation referenced in this finding was for individuals hired prior to the new process. EngageKY will continue to use Salesforce to document the recruitment and selection of Kentucky College Coaches.

Finding 2025-001 Budget Violations Name of contact person: Jen Waterhouse, Chief Financial Officer Corrective Action: Proposed completion date: Finding 2025-002 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: Corrective Actions for Finding 2025-002 also apply to State Award Findings. Corrective Action Plan For the Year Ended June 30, 2025 Section II - Financial Statement Findings Training for understanding Subscription Based Information Technology Agreements (SBITA) is a priority and will be conducted immediately. In FY26, SBITA’s will be reviewed and recorded quarterly via a budgeting worksheet to capture payments throughout the year for GASB 96 agreements. In May, the list will be monitored closely, and Finance staff will follow up with departments to confirm anticipated expenditures falling under GASB 96 are taken into consideration. Reports will be reviewed by the Chief Financial Officer for correctness, and the budget amendment will be in place in the first Board of Commissioner’s meeting in June 2026. In addition to the Budget Amendment taking place in early June; staff will also reconcile debt book GASB 96 reports to ensure complete records and agreement with prior year balances are intact. 6/8/2026 Section III - Federal Award Findings and Questioned Costs Training will be conducted with staff specifically concerning the finding areas , ensuring all required request for information and electronic verification sources are used, ensuring all verified information is appropriately updated in NC FAST evidence and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review verify that proper procedures are being followed with regard to these policies. Section IV - State Award Findings and Questioned Costs 12/5/2025 􀀔􀀚􀀕

The financial aid office is under new leadership as of January 1, 2025. During 2025, department leadership began its review of departmental policies and procedures, focusing on remediating compliance weaknesses within the department while moving toward best practice in federal and state aid delivery. Department leadership has put structures in place at multiple points of potential failure to prevent inaccurate aid calculations. These structures include new policy and procedure documentation, enhanced optimization in the Banner system, staff training in multiple modalities including intradepartmental training, asynchronous independent training, off-site training, and a monthly reconciliation program with AVC’s fiscal office. We have also begun a system of cross training to ensure that expertise persists within the department during times of staffing changes, extended leaves of absence, and vacancies.

Lack of Review Documentation (Significant Deficiency) Condition: Four participants were selected for eligibility test work for the Upward Bound Math and Science (UBMS) program. All four of these participants applications did not have any indication that they were reviewed or approved by the appropriate program director before receiving services from the program. Criteria: Based on the clients controls over TRIO eligibility, the program directors obtain various documents from the participant in order to make a determination of eligibility prior to the participant receiving services from the program. It was noted during the testing of the Talent Search – Upward Bound Math and Science program (UBMS) program eligibility that there is no documentation to indicate that applications were formally reviewed or approved by the program director. Cause: Required internal control review procedures were not documented and hence, no evidence was available to support that such review was performed. Effect: Although the students tested appear to be eligible to receive program services, this lack of program director review could’ve led to students that weren’t eligible receiving program services. Identification of repeat finding: No. Recommendation: The University should increase in efforts through training to ensure that all controls related to eligibility for all TRIO programs are properly followed. Views of Responsible Officials: As noted in the audit finding, auditor sample testing disclosed no instances of noncompliance related to participant eligibility to receive program services. While the University’s internal controls over compliance were not fully documented (lack of support proving eligibility review), at a minimum, University staff were aware of program eligibility requirements and first level internal controls functioned properly (no compliance sample errors). Going forward, the University will more stringently adhere to its procedures that include documentation of program eligibility review. Corrective Action: To strengthen internal controls, the TRIO program has implemented a corrective action plan requiring that all application forms be thoroughly reviewed for completion and proper authorization prior to submission. Each form must now include a verified approval signature from the designated supervisor or administrator. Furthermore, all approved TRIO application forms are securely uploaded and stored in the University's OneDrive system, allowing authorized personnel to view, track and confirm approvals in real time. This corrective action ensures documentation integrity, promotes transparency, and supports continuous program readiness for internal and external review. The following documentation protocols will ensure full compliance and transparency for all application forms. *Be thoroughly completed with no missing fields or attachments. *Include a verified approval signature from the designated supervisor or authorized administrator before acceptance. *Be uploaded immediately to the University's secure OneDrive system for real-time viewing, tracking and audit accesss by authorized personnel by the 15th of every month. This process creates a standardized worflow that ensures every TRIO form is accurately documented, authorized, and available for verification at all stages of the review cycle. Responsible Person(s): Stephanie White, AVP/Comptroller swhite@vuu.edu 804 257-5745 Linda Jackson, VP Sponsored Research and Innovation lrjackson@vuu.edu 804 257-5807 Gloria Foote, Grant Accountant gjfoote@vuu.ed 804 257-5781. Planned date of Completion of Corrective Action: December 31, 2025

Finding No: 2025-004 Condition: The District receives Title I funding and determines eligibility for schoolwide programs based on attendance numbers derived from free and reduced lunch counts. During the audit, we noted that the district’s process for compiling these attendance numbers involves the grant manager obtaining a report from the Business Office, which is generated from the food service platform as of a specific day. However, the district was unable to reproduce the report used to complete the Title I application and supporting documentation for the reported figures was not available for review. Plan: The District will maintain all reports used to compile attendance figures for the Title I grant. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Mark Orszula, CSBO

U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.568 All Awards Federal Financial Assistance Listing # 10.569 All Awards Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations and reviews for The Emergency Food Assistance Programs. Responsible Individuals: Kate Molbert, COO David Stachon, CFO Corrective Action Plan: The GPFB will ensure all documents for TEFAP programs have proper signatures by necessary parties going forward. An electronic signature process has been implemented to make the dissemination, review and storage of this process easier. Also, additional staffing has been hired to manage this process in the form of a Programs and Operations Compliance Manager with substantial compliance experience. Anticipated Completion Date: Immediate

Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses attended and fees incurred. Corrective Action: The Financial Aid Department now verifies actual course enrollment prior to disbursement for specialized programs, ensuring accuracy and compliance. Beginning Winter term 2026, mid-term audits for the aviation program have been implemented to strengthen oversight. Additionally, policy updates now require real-time cost of attendance adjustments for all individualized programs to maintain consistency and alignment with federal regulations. Responsible Person: Director of Financial Aid, with support from Aviation Program Director. Anticipated Completion Date: Begin implementation immediately and accomplish full implementation by Spring 2026; ongoing monitoring.

The District will implement additional internal controls to ensure that all household income is properly included in the eligibility determination process for free and reduced-price meals. The Food Service Director (or authorized designee) will perform a second-level review of all applications prior to final approval, focusing on verification that all sources of income - including income earned by students - are included in the total household calculation. The District will update its internal checklist and train staff responsible for reviewing meal applications to verify that each application is complete, income sources are clearly identified, and supporting documentation (if applicable) has been properly considered. The Food Service Director will conduct a mid-year self-audit of eligibility determinations to confirm accuracy and compliance with 7 CFR 245.6 requirements. The District will maintain documentation of reviews and training to support compliance efforts in furter audits.

2025-001 – ALN 14.850 – Public Housing Operating Fund – Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Tony Webster, Executive Director Projected Completion Date: June 30, 2026

A. Finding Finding 2025-001 – Moving to Work Resident Files – Eligibility – Rent Calculations & HAP Disbursements Noncompliance & Material Weakness – ALN #14.881 B. Condition and Cause The auditor reviewed fifteen (15) Housing Choice Voucher (HCV) project-based voucher (PBV) participant files and twenty (20) HCV tenant-based voucher (TBV) participant files for a total of thirty-five (35) participant files. It was noted that fourteen (14) TBV files were non-compliant. C. Background Information The HCV Department has had numerous staff turnover in recent years. Due to organizational restructuring, Shannon Walters was moved from HCV Manager to Multi-Family Housing Director in March 2024 and Todd James was promoted to Interim HCV Manager in March 2024. Todd was moved to the HCV Operations Administrator position in February 2025, and Charlotte Bowen was hired as HCV Manager in March 2025. Mary Cameron was hired as HCV Caseworker (TBV) in December 2023 and received extensive one-on-one training. Due to performance concerns, she was given a Performance Improvement Plan. Upon completion, her performance was found to be unsatisfactory. Mary was transferred to Property Manager at the LaFayette Housing Authority site in October 2025. D. Controls to Correct the Deficiency To correct the finding noted above, the Auburn Housing Authority (AHA) will proceed as follows: a. The HCV Manager will perform a comprehensive audit of all TBV files and correct appliable deficiencies. b. Implement other internal control measures to eliminate future audit findings. E. Person Responsible: Sharon N. Tolbert, CEO F. Anticipated Completion Date: June 30, 2026