Corrective Action Plans

Finding Number: 2025-003 Finding Title: Eligibility - MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality controls specific to the Medicaid program, will be reviewed and updated. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether documentation is sufficient, along with examples of acceptable support. At a minimum, required documentation will include: • Documentation verifying citizenship. • Examples of properly completed applications. • Reconciliation of the income verification in MAXIS and the documentation in the case file. • Reconciliation of the asset verification in MAXIS and the documentation in the case file. The Quality Assurance review process and Corrective Action Plan have been documented and communicated to provide guidance for new staff, serve as refresher training for existing staff, and ensure that appropriate actions are consistently followed. This documentation will be reviewed and revised as necessary to maintain compliance and consistency across the department. Supervisory review has been implemented for new hires. When issues are identified with current staff, enhanced review strategies and procedures will be applied to ensure required documentation is properly reviewed prior to case approval. In addition, supervisors will review the audited cases to look for any trends in errors with specific staff. Anticipated Completion Date: December 31, 2026

Finding Number: 2025-002 Finding Title: Special Tests and Provisions – Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality controls specific to the Child Support program, will be reviewed and updated. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether documentation is sufficient, along with examples of acceptable support. At a minimum, required documentation will include: • Documentation supporting non-cooperation. • Verification of sanction implementation and removal timelines. • Reviewing files for completeness. Supervisory review has been implemented for new hires. When issues are identified with current staff, enhanced review strategies and procedures will be applied to ensure required documentation is properly reviewed prior to case approval. In addition, supervisors will review the audited cases to look for any trends in errors with specific staff. Anticipated Completion Date: December 31, 2026

Finding Number: 2025-001 Finding Title: Eligibility-MAXIS Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality control review checklists, specific to each program area, will be reviewed and updated, and additional controls will be developed to ensure that required documentation is obtained and maintained. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether supporting documentation is sufficient, along with examples of acceptable documentation. At a minimum, required documentation will include: • Documentation verifying client eligibility for the key eligibility-determining factors. • Evidence of the verification process recorded in MAXIS. Supervisors will continue to conduct periodic reviews of case files to ensure that all required documentation is on file. In addition, supervisors will review the audited cases to look for any trends in errors with specific staff. Anticipated Completion Date: December 31, 2026

Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Alissa Collington, Executive Director Corrective Action:Mangement will review the recertification process and plan to monitor recertifications. Proposed Completion Date: Immediately

Name of Auditee: County of Delaware, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2025 CAP Prepared by: Roxanne Ellsworth, Director of Fiscal Affairs Phone: (607) 832-5090 (1) Audit Finding 2025-001 - Program Eligibility - Noncompliance (a) Implementation Plan of Actions - The County will determine eligibility over its programs. (b) Implementation Date - This will be implemented by December 31, 2026. (c) Persons Responsible for Implementation - The Director of Fiscal Affairs.

Management Response and Actions Taken: Incorrect Utility Allowance • MHA will expand its system’s bedroom count to include 6-bedroom units. This will eliminate the need to manually calculate Utility Allowances above 5-bedrooms. Additionally, management will review all 5+ bedroom unit files to ensure Utility Allowances are correctly reflected. • MHA will confirm the validation report is properly identifying any conflicts in the Utility Allowance selected versus voucher size and household composition to ensure errors are properly captured and corrected. Incorrect Payment Standard • MHA will review with all staff procedures for: o Requesting Payment Standard overrides; o Administrative Plan policies for application of a decrease in payment standards; o We have affirmed that the Yardi system settings accurately reflect MHA Administrative Plan policies regarding the handling of year-over-year Payment Standard decreases; and o MHA will add system validation checks to compare selected payment standards against household composition for each file and to evaluate if the current year selected payment standard has decreased from the prior year payment standard. Missing 9886 Form • Management will work with its software provider to develop a new system report to identify all minors whose date of birth would result in them turning 18 (becoming adults) after the effective date of the family’s annual recertification. This report will be run monthly and will identify all minors who have turned 18 during the month. Staff can then send appropriate notice and paperwork to the “new adult” to have them complete Form 9886a. Name of Responsible Person(s): Paul Watkins, HCV Program Administrator Projected Completion Date: December 31, 2026

Department of Health and Human Services Dirne Health Centers, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: 01/1/25 – 12/31/25 The findings from the 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 There were no financial statement findings in the audit period. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2025-01 Health Center Cluster– Assistance Listing No. 93.224 and 93.527 Recommendation: CLA recommends that the Clinic strengthen its review process over sliding fee discount determinations by implementing procedures to verify that each patient application is evaluated using current eligibility information and that the corresponding sliding fee scale level is accurately applied. CLA further recommends that the Clinic document evidence of review and approval before discounts are applied to patient encounters and establish a process for timely identification and correction of any discrepancies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing and strengthening Heritage Health’s Sliding Fee Discount Program procedures to ensure that sliding fee eligibility determinations are completed and documented consistently in accordance with the organization’s board-approved policies. Management will clarify procedures related to eligibility and income verification, the application of the appropriate sliding fee scale, and documentation of the review and approval process. Staff responsible for sliding fee determinations will receive training on the updated procedures. Management will also review system configuration and workflows related to the application of sliding fee discounts and establish a periodic internal monitoring process to verify that eligibility determinations are appropriately documented, the correct sliding fee level is applied, and identified discrepancies are investigated and corrected in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Sonya Zhang Planned completion date for corrective action plan: December 31, 2026 If the Department of Health and Human Services has questions regarding this plan, please call Sonya Zhang at 520-667-6333.

Finding 2025-002 Finding Number: 2025-002 Finding Title: Documentation of Procurement and Suspension and Debarment Control Procedures Corrective Action Planned: Management believes this finding resulted from the Organization’s assessment that compliance procedures implemented through the Construction Manager were sufficient to address the suspension and debarment requirements associated with direct vendor payments. The Organization incorporated applicable federal compliance requirements into its agreement with the Construction Manager and the related subcontractor arrangements and documented its rationale regarding whether additional verification was required for vendors paid directly to preserve the Organization's sales tax exemption. The Organization has subsequently confirmed that none of the material vendors paid directly by RMHC were listed as suspended, debarred, or otherwise excluded from participation in federal programs. Therefore, management believes the finding relates to compliance documentation and retention requirements rather than the engagement of ineligible vendors. To strengthen compliance documentation in this area, management will update its procurement and federal award compliance procedures to clearly address situations in which the Organization makes direct payments to vendors using federal funds, including circumstances where the Organization does not have a direct contractual relationship with those vendors and where project procurement activities are administered through a Construction Manager or other third party. Management will update applicable checklists and written guidance, provide training to personnel responsible for federal award compliance, and implement supervisory review of covered-transaction evaluations involving direct vendor payments. Management will also ensure that documentation supporting suspension and debarment determinations and related compliance conclusions is retained in the applicable procurement and payment files. In addition, management notes that the circumstances giving rise to this finding were unique to the capital project and the Organization's previous practice of paying certain material vendors directly in order to preserve its sales tax exemption. Pursuant to Oklahoma Senate Bill 44, effective in 2026, sales tax exemptions were expanded to expressly apply to contractors and subcontractors performing work for qualified tax-exempt entities. As a result, the Organization does not anticipate the need to make direct payments to material vendors for future construction projects solely to preserve sales tax-exempt treatment, thereby significantly reducing the likelihood of similar circumstances occurring in the future. Management further notes that no federal funds were expended by the Organization during 2026. Nevertheless, management has implemented procedural revisions described above so that controls will be in place for any future federally funded activities. Responsible Person: Jenna Morey, President Anticipated Completion Date: December 31, 2026

Finding 2025-003 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testing the Federal Poverty Guideline (FPG), thirteen files did not contain verification that the patient had no income. Also, 5 files did not contain evidence of review by the Health Center’s staff. Action Planned in Response to the Finding: In 2025, the collection and retention of sliding fee discount qualifying documents were integrated and the calculation performed by the clinic’s electronic medical record system so the prior paper system of documentation was replaced by the EMR’s audit trail reporting. Since HRSA chapter 9 Demonstrating Compliance section G states patients refusing to provide income or family size is an exception to the need for records, this input cell was left blank. Going forward, if a patient declines to provide proof requested, we will request patient sign a form and will add a comment that patient declines to provide this information. To address the evidence of review issue, this was a potential issue when we had the paper process but now that we are electronic, all access to determine sliding fee discount is captured with name of employee and a time stamp. Official Responsible for Ensuring the CAP: Darian Davis Planned Completion Date: December 2026

Finding 2025-001: CFDA #93.658 Foster Care, Title IV-E CFDA #93.659 Adoption Assistance Corrective Action: Management intends to implement procedures to improve document retention, electronic record storage, supervisory review, and overall monitoring controls for the Foster Care and Adoption Assistance programs. Contact: Randy Lozier, County Treasurer Anticipated Completion Date: By December 31, 2026

2025-001 Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been created along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2026

Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Gary Jones, Executive Director Corrective Action: Mangement will review the recertification process and plan to monitor recertifications. Proposed Completion Date: Immediately

CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The County will reinforce procedures requiring eligibility workers to maintain adequate documentation supporting all income sources used in Medical Assistance eligibility determinations. Supervisory reviews will be performed periodically to ensure case files contain the necessary supporting documentation and that eligibility calculations agree to information maintained in the case record. 3. Official Responsible for Ensuring CAP: Lisa Herges, County Administrator, is the official responsible for ensuring corrective action of the compliance finding. 4. Planned Completion Date for CAP: December 31, 2026 5. Plan to Monitor Completion of CAP: The County Board will be monitoring this corrective action plan. Sincerely, Lisa Herges County Administrator

Finding Number: 2025-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Michael Pooler, Economic Supports Division Director Corrective Action Planned: The County will continue to implement TANF quality control review measures and hold weekly unit meetings to address case-specific questions and policy clarifications with program experts. These practices support ongoing learning, reduce knowledge gaps, and reinforce the importance of consistent documentation and attention to detail across the unit. Anticipated Completion Date: March 31, 2027

# 1 A revised case review sheet will include a section for caseworkers to document their calculation confirming that verified electronic income and self-attested income are within the 25% guideline. This will show that the comparison was completed and the income used in the eligibility determination is accurate. An additional section will be added on to the case review sheet in the event the client is self-employed and provided tax returns to determine eligibility. The section will require staff to confirm they used the corrected Adjusted Gross Income (AGI) from the federal tax return when determining eligibility. # 2 All MAGI employees will attend MAGI Policy training and application processing offered through the state. # 3 Renewals will continue to be reviewed by a specialist, supervisor, or administrator. Cases will be returned and corrected when there are errors.

ELIGIBILITY Recommendation: It is recommended that the County start reviewing casefiles. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will start printing a coversheet for the Fiscal Supervisor to sign and retain physical evidence of the review being done. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2026

Finding Number: 2025‐002 Program Name/Assistance Listing Title: Tribal Self Determination Assistance Listing Number: 93.441 Contact Person: Tahnee Brown, Controller Anticipated Completion Date: Implemented ‐ Effective Immediately Planned Corrective Action: Pine Hill Health Center has instructed Patient Registration staff to obtain and retain documentation supporting patient eligibility. If documentation is not available, the patient will be classified as “Pending Verification” or “Ineligible” until the required documentation is provided. The Billing Manager will monitor the process and ensure eligibility documentation is retained in the patient's health record.

Finding 2025-002 U.S. Department of Housing and Urban Development Housing Voucher Cluster: Section 8 Housing Choice Vouchers and Mainstream VouchersALNs 14.871 & amp; 14.879 Eligibility and Reporting Maher Duessel Finding Condition: During our review of 40 tenant files prepared by the Authority as part of the biennial reexamination process, we noted a lack of functioning internal controls, evidenced by 4 of the Authority’s internal control checklists not being completed or unable to be provided for audit, which led to the below exceptions in our testing. We noted one instance where a tenant recertification using the Form HUD-50058, Family Report (Form) (which provides eligibility and reporting information) was not completed on a timely basis. We also noted three instances where other documentation to support the reporting and eligibility assessment as part of completion of the HUD-50058 was not provided. This includes items such as support for income calculation and medical deductions. These exceptions indicate a lack of functioning internal controls and oversight to ensure compliance with HUD requirements related to timely and accurate tenant recertifications. HACP Management Response/Action Taken: Finding 2025-001 - Eligibility and Reporting Finding 2025-002 - U.S. Department of Housing and Urban Development Housing Voucher Cluster: Section 8 Housing Choice Vouchers and Mainstream Vouchers- ALNs 14.871 & 14.879 Eligibility and Reporting Summary and Corrective Action Plan: The audit identified continued, internal control weaknesses related to timely recertifications, completion of required internal control checklists, and documentation supporting income calculations and medical deductions. This is a repeat finding from 2021-2024. To address these deficiencies, the HACP plans to go live on October 1st, 2026, with BOB.ai, an artificial intelligence software solution platform built for Public Housing Authorities (PHAs) to assist with tasks to include rent calculations, recertifications, and case management. BOB.ai will support the timely processing and tracking of recertifications, helping to prevent late recertifications and identify outstanding actions before deadlines are missed. The system will also help ensure required forms and supporting documentation are submitted in full before the recertification is processed, reducing the risk of incomplete files and missing eligibility documentation. The HACP Housing Choice Voucher (HCV) Department is evaluating an additional workflow in DocuClass that will include a finalized checklist as part of the recertification is finalized. The HACP will utilize system-generated reports to monitor upcoming and overdue recertifications, with management regularly reviewing the reports and addressing outstanding items. Staff must complete all applicable internal control checklists, and supervisors will review files to confirm that required documentation and checklists are complete.tification workflow. The HCV management will perform the following actions to assist with ensuring internal compliance to include the following: • Conduct ongoing quality-control reviews and provide staff training on HUD-50058 requirements, documentation standards, and timeliness expectations. • Address recurring deficiencies through documented coaching and corrective action, as appropriate. • Continue to monitor recertification timeliness, documentation completeness, and internal control compliance through monthly reports and file reviews to ensure the corrective actions are effective and prevent recurrence of the finding. • Monitor control functions, staff productivity, work completion, and compliance with established processing timelines. These enhanced monitoring practices have increased management’s ability to identify work that is incomplete, delayed, or otherwise not meeting established performance expectations. • Holding staff accountable through documented coaching, performance management, and disciplinary action, when appropriate, in accordance with applicable HACP policies and procedures. Unfortunately, in some instances, the time required to identify, document, address, and monitor recurring performance deficiencies through the applicable disciplinary process results in work becoming overdue before the HACP can complete the personnel action or otherwise resolve the underlying staffing issue. The HACP recognizes the operational impact of these circumstances and is continuing to strengthen workload monitoring, supervisory oversight, and system-generated alerts. Also, workflow controls are being utilized to identify and address deficiencies as early as possible and minimize the impact of staff turnover and performance-related delays on program operations.

Finding 2025-001 U.S. Department of Housing and Urban Development Moving to Work Demonstration Program - ALN 14.881 Eligibility and Reporting Repeat Finding from 2021 (2021-001), 2022 (2022-001), 2023 (2023-001), and 2024 (2024-001) Maher Duessel Finding Condition: During our review of 40 tenant files prepared by the Housing Authority of the City of Pittsburgh (Authority) as part of the biennial reexamination process, we noted a lack of functioning internal controls, evidenced by 4 of the Authority’s internal control checklists not being completed or unable to be provided for audit, which led to the below exceptions in our testing. We noted two instances where a tenant recertification using the Form HUD-50058, Family Report (Form) (which provides eligibility and reporting information) was not completed on a timely basis. We also noted three instances where other documentation to support the reporting and eligibility assessment as part of completion of the HUD- 50058 was not provided. This includes items such as support for income calculation and medical deductions. These exceptions indicate a lack of functioning internal controls and oversight to ensure compliance with HUD requirements related to timely and accurate tenant recertifications. HACP Management Response/Action Taken: Finding 2025-001 - Eligibility and Reporting Finding 2025-002 - U.S. Department of Housing and Urban Development Housing Voucher Cluster: Section 8 Housing Choice Vouchers and Mainstream Vouchers- ALNs 14.871 & 14.879 Eligibility and Reporting Summary and Corrective Action Plan: The audit identified continued, internal control weaknesses related to timely recertifications, completion of required internal control checklists, and documentation supporting income calculations and medical deductions. This is a repeat finding from 2021-2024. To address these deficiencies, the HACP plans to go live on October 1st, 2026, with BOB.ai, an artificial intelligence software solution platform built for Public Housing Authorities (PHAs) to assist with tasks to include rent calculations, recertifications, and case management. BOB.ai will support the timely processing and tracking of recertifications, helping to prevent late recertifications and identify outstanding actions before deadlines are missed. The system will also help ensure required forms and supporting documentation are submitted in full before the recertification is processed, reducing the risk of incomplete files and missing eligibility documentation. The HACP Housing Choice Voucher (HCV) Department is evaluating an additional workflow in DocuClass that will include a finalized checklist as part of the recertification workflow. The checklist will confirm that all required documents, eligibility information, and supporting documentation have been received and reviewed before the recertification is finalized. The HACP will utilize system-generated reports to monitor upcoming and overdue recertifications, with management regularly reviewing the reports and addressing outstanding items. Staff must complete all applicable internal control checklists, and supervisors will review files to confirm that required documentation and checklists are complete. The HCV management will perform the following actions to assist with ensuring internal compliance to include the following: Conduct ongoing quality-control reviews and provide staff training on HUD-50058 requirements, documentation standards, and timeliness expectations. • Address recurring deficiencies through documented coaching and corrective action, as appropriate. • Continue to monitor recertification timeliness, documentation completeness, and internal control compliance through monthly reports and file reviews to ensure the corrective actions are effective and prevent recurrence of the finding. • Monitor control functions, staff productivity, work completion, and compliance with established processing timelines. These enhanced monitoring practices have increased management’s ability to identify work that is incomplete, delayed, or otherwise not meeting established performance expectations. • Holding staff accountable through documented coaching, performance management, and disciplinary action, when appropriate, in accordance with applicable HACP policies and procedures. Unfortunately, in some instances, the time required to identify, document, address, and monitor recurring performance deficiencies through the applicable disciplinary process results in work becoming overdue before the HACP can complete the personnel action or otherwise resolve the underlying staffing issue.The HACP recognizes the operational impact of these circumstances and is continuing to strengthen workload monitoring, supervisory oversight, and system-generated alerts. Also, workflow controls are being utilized to identify and address deficiencies as early as possible and minimize the impact of staff turnover and performance-related delays on program operations.

Housing Division staff at Economic Development will complete monitoring of owner records related to tenant income eligibility and on-site monitoring for the 24 developments that are behind schedule. These 24 will be in addition to those that are scheduled to be monitored in the 2026 fiscal year (7/01/2026-6/30/2027), for a total of 40 properties in all. One property in question is in litigation at this moment so that visit may depend on advice of counsel on how to proceed. Timetable of dates for performance of planned corrective action steps including completion date: All of the above-noted properties will be monitored between this date and the end of the fiscal year – June 30, 2027. Staff will prioritize those properties that are behind schedule for completion by September 30, 2026. Description of monitoring to be performed to ensure corrective action steps are taken: Staff will prioritize those properties that are behind schedule with the goal of completion by the end of the 3rd calendar quarter (September 30, 2026). The Housing Division Manager will require staff to provide on a bi-weekly basis a list of properties that have been scheduled for visits as well as results of those recently completed (both for the 24 properties and regularly scheduled visits). Unlike in past years, the monitoring visits will be spread throughout the year so that they can be completed in an orderly fashion and staff will have more flexibility to adjust to the property managers’ schedules for the visits. Once this fiscal year is complete, all of the properties should be back on a triennial basis for monitoring.

Greenwich Communities accepts the audit finding that electronic income verification was not performed timely in twenty-nine instances, and we have already implemented corrective actions to resolve the issue. Corrective Actions Completed: • Targeted Training was provided to the manager responsible for income verifications. • Process Review sessions ensured that the manager fully understands the correct verification workflow and strict compliance deadlines. • Updated Tracking mechanisms were put in place to flag pending verifications before they become overdue. Preventive Measures: • Regular Monitoring by supervisors will catch any delayed verifications immediately. • Monthly Checks will ensure staff continue to follow the correct timeline for electronic income verification.

Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Marisol Aponte, Acting Director of Housing Choice Voucher Program, is responsible for ensuring the deficiencies have been rectified by December 31, 2026.

There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that controls intended to ensure annual renewal of sliding fee discount applications were not consistently operating as intended. Management is strengthening monitoring procedures by implementing tracking mechanisms to identify expiring applications and requiring verification of eligibility documentation prior to continued application of discounts, consistent with the requirement under Section 330(k)(3)(G) of the Public Health Service Act (42 U.S.C. 254b(k)(3)(G)) that health centers establish systems for sliding fee eligibility determination. In addition, management will provide additional training to all billing and front-desk staff on the sliding fee discount program, including eligibility determination, income and household-size documentation requirements, application renewal procedures, and the proper application of discounts in the practice management system. Periodic supervisory reviews will be performed to ensure compliance with the Board-approved sliding fee discount policy, consistent with the internal control requirements of the Uniform Guidance (2 CFR 200.303). Management will also review the sliding fee discount schedule on a regular basis, no less than annually, and will update it in a timely manner whenever necessary, including upon publication of the annual Federal Poverty Guidelines, so that discounts continue to be adjusted on the basis of each patient’s ability to pay as required by 42 CFR 51c.303(f), with all updates presented to the Board of Directors for approval and communicated promptly to billing staff. Documentation of staff training, schedule reviews, and Board approvals will be retained to demonstrate compliance with HRSA Health Center Program requirements, including Chapter 9 (Sliding Fee Discount Program) of the HRSA Health Center Program Compliance Manual. Name(s) of the contact person(s) responsible for corrective action: Edward Murphy, Asante Muyungga, Charity Gutierrez, Anthony Parker, Bennett Baber, Jannell Robinson. Planned completion date for corrective action plan: December 31st, 2026

CORRECTIVE ACTION PLAN September 25, 2026 U.S. Department of Health and Human Services Park DuValle Community Health Center, Inc. respectively submits the following corrective action plan for the yearended December 31, 2025. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Pkwy., Suite 300 Louisville, Kentucky 40223 Audit period: December 31, 2025. The findings from the schedule of findings and questioned costs for the year ended December 31, 2025, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT 2025-001 Condition: During our audit procedures, we noted that bank reconciliations were not performed as part of close procedures. The absence of bank reconciliations increases the risk that cash could be materially misstated. Action: Management will implement policies and procedures by December 31, 2026, to ensure proper reconciliation of bank accounts. FINDINGS- FEDERAL AWARD PROGRAM AUDITS 2025-002 Condition: Sliding fee scale: There were several instances noted where the incorrect sliding fee discount was given to patients based on their verified incomes and household sizes, as well as instances in which patients were not evaluated for sliding fee discounts based on patient income and family size. Action: Managementwill implement internal control procedures by December 31, 2026, to ensure that sliding fee discounts are properly applied and posted to patient accounts for eligible encounters and that patients are evaluated for eligibility for sliding fee discounts.

MEDICAL ASSISTANCE - LACK OF CASEFILE CONTROLS Recommendation: It is recommended the County implement formal internal review procedures over casefiles to ensure required procedures are completed and adequately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures over casefiles to ensure required procedures are completed and adequately documented. Name of the contact person responsible for corrective action plan: Kathleen Ryan, County: Auditor Planned completion date for corrective action plan: December 31, 2026