Corrective Action Plans

We concer with the auditors' finding that the project did not have adequate internal controls in place over tenant eligbility determination process per HUD's guidelines. While HANDS has internal policies and procedures for review of tenant certifications, the compliance position has been vacant and never properly functioned as it should. The CEO, Matthew Good, and the Director of Community Management, Cathy Consilgio, had decided prior to the audit engagement that a third party would be contracted to review applicant files prior to move-in for all HUD subsidized properties. (We have used AJ Johnson to review/approve LIHTC/HOME files for several years.) Employee training had been put on hold due to the upcoming HOTMA changes, and as the dates for HOTMA were pushed, training lagged. Our policy is as follows: once a new hire Property Manager or Assistant Property Manager completes the initial 90-day probationary period, they will be scheduled for formal HUD occupany training, and formal LIHTC training if it applies to their portfolio. Current employes will receive training bi-annually, which may include training that occures during the PAHMA conferences. All employes receive Fair Housing Training at least bi-annually, with new employees being scheduled for the first available training after their initial 90-day probationary period. The tracking sheet will be updated as training occurs, and any certificates earned will be kept on file.

Finding 2024-001 – Child Nutrition Cluster – Eligibility Context: During sample testing of 60 students for eligibility, we noted 7 instances where there was no documented review by someone other than the individual making the eligibility determination. The lack of review was isolated to paper applications. Contact Person Responsible for Corrective Action: Mr. Patrick Culp Contact Phone Number: 219-279-2418 Views of Responsible Official: We concur with the finding. Of note, this is a new finding as we have never experienced this problem before. For this audit period, the Tri-County Food Service Director suffered a serious foot injury, requiring her to miss an extended period of time. When the accident with the Food Service Director occurred, one of the first actions the corporation took was to contact IDOE about our situation. The IDOE was aware how the review the process would look during that time. While the Food Service Director was recovering, student eligibility was not reviewed properly. Description of Corrective Action Plan: The Tri-County School Corporation food service director will complete all initial reviews of student eligibility. The initial review will be for both electronic and paper applications. Once the initial review is complete, the Tri-County central office secretary will complete a second review. The secretary works in a different building and does not have a role in eligibility determinations. Anticipated Completion Date: Our corrective action plan began in August 2024, upon the return of our food service director, and this is the plan moving forward.

2024-001 – 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, 2025

Corrective Action Plan: Immediate action for correcting the error was taken August 29, 2024. The error occurred when the WIC Program Assistant entered income in the GA-WIC system. The correct income amounts were entered in GA-WIC for the required four weeks of pay, however, the GA-WIC system defaults to five rows for income entries and the WIC Program Assistant failed to remove the fifth row. This oversight resulted in GA-WIC producing an incorrect income calculation. The error was brought to the attention of the WIC Program Assistant. The employee was knowledgeable of the requirement to remove the fifth row and acknowledged the error. The WIC participant was contacted, informed of the error, and was issued a Notice of Termination. Record reviews, including income eligibility, are monitored by district WIC staff in clinic reviews at least annually. An email was sent to GA WIC requesting a system change to decrease the default income rows and allow staff to add rows as needed. Anticipated Completion Date: Completed August 29, 2024.

12/11/2024 LifeLong Medical Care Corrective Action Plan For the year ended June 30, 2024 2024-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Brent Copen, CFO Corrective Action: LifeLong Medical Care will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions. Proposed Completion Date: June 30, 2025

As of November 27, 2024, the EIV was fixed for Stoneman Village II and I (Administrator) now have access to printing reports.

Finding 2024-002 Responsible Party Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedures to ensure tenant eligibility and establishing and maintaining security deposits for tenants moving out and we will review the accuracy / completeness of the documentation being processed in the tenant files on a periodic basis. Anticipated Completion Date December 31, 2024

Finding Reference Number: 2024-001 Statement of Concurrence or Nonconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2024-001. Corrective Action: LMHA implemented in March of 2024, a comprehensive plan to resolve the backlog of recertifications that necessitated the roll forward of tenant’s prior year form HUD-50058 family report without updating family income and composition. First and foremost, representing the rolling forward of the tenant’s HUD-50058 as a biennial recertification has been discontinued. Housing Choice Voucher Department staff has implemented training of Housing Specialists and other staff to ensure biennial recertification and use of HUD-50058 Type 2 (“Annual Recertification”) will now be compliant. LMHA continues it’s contractual relationship with Nan McKay & Associates to assist with the recertification process and resolve the backlog of 50058 recertifications. LMHA has restructured workflows to provide efficiencies and accountability that will promote compliance. LMHA continues to work with various HUD departments and personnel to assess noncompliance and how to move forward. LMHA engaged its Financial Auditor, Cherry Bekaert, to review the Housing Choice Voucher Program for process, compliance, and internal control. From that collaborative process, in July 2024, LMHA was provided a comprehensive report including recommendations to improve the HCV program processes in all phases which LMHA is actively incorporating into everyday procedures. Name of Contact Person: Sarah Galloway, Chief Policy Officer, 502-569-3422, galloway@lmha1.org and Camille Robinson, Deputy Executive Director of Leased Housing, 502-569-6245, crobinson@lmha1.org Projected Completion Date: Louisville Metro Housing Authority implemented the corrective action measure in March 2024. LMHA will monitor the issue on a monthly basis to ensure compliance with the HCV program. QUESTIONED COSTS Undeterminable per Cherry Bekaert If the (Office of Policy and Management and/or Oversight Agency) has questions regarding this Plan, please call Jeff Ralph at 502-569-4372.

FINDING 2024-001 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): 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 the testing of internal controls over eligibility determinations for free and reduced meals, we noted there was no formal review control in place. There is no documented, secondary review for the applications entered in the food service software which determines eligibility. Additionally, there was no documented review by School Corporation personnel of the Income Eligibility Guidelines used by the food service software which are updated on annual basis. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will formally sign off on the Mosaic income guidelines annually prior to each school year. Responsible Party and Timeline for Completion: Shane Hacker, Assistant Superintendent of Operations; Corey Ebert, Director of Finance; Jordan Ryan, Director of Nutrition Services Anticipated Completion Date: February 1, 2025

Corrective Action Plan Year Ended June 30, 2024 Covington Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2024. Responsible Official: Ms. Christi Billings, Executive Director Name and address of independent public accounting firm: Miller & Rose, PA 1309 East Race Searcy, AR 72143 Audit period: Year ended June 30, 2024 Oversight Agency: U.S. Department of Housing and Urban Development The finding from June 30, 2024, audit is discussed below. The finding is numbered to correspond to the auditing findings disclosed in Sections B and C of the Schedule of Findings and Questioned Costs. C. FINDINGS AND QUESTIONED COSTS-MAJOR FEDERAL AWARD PROGRAMS AUDIT 2024-001 – Family File Deficiencies • Federal Program: Public and Indian Housing, Federal Assistance Listing No. 14.850 • Criteria or specific requirement: The Authority’s purpose for existence is to provide decent, safe, and affordable housing for low-income people. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent to be charged to eligible families. HUD regulations prescribe the content of these family files. These requirements consist of the following: o As a condition of admission or continued occupancy, the tenant and other family members provide necessary information, documentation, and releases for the PHA to verify income eligibility. o For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. o Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. o Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. o Re-examine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary. • Context: Our review of 23 family files revealed nine files with delinquent annual reexaminations. • Effect: The errors noted are due to lack of supporting documentation. • Cause: Proper scheduling and lack of other procedural control have resulted in untimely performed annual reexaminations. • Recommendation for Corrective Actions: The Authority should establish a master calendar to ensure all tenants are scheduled for their annual reexaminations. The Authority should also establish benchmarks for timing of certain annual reexaminations functions such as notice to tenants of the pending reexam and others as applicable. • Views of Responsible Officials and Planned Corrective Actions: We will review tenant’s files for the deficiencies identified above and implement new internal control procedures to correct these conditions. We will also provide increased supervision and training over this area. We anticipate a complete resolution of this type of error by February 29, 2025.

2024-004 Contact Person David Klein, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP June 30, 2025

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A new Registrar was hired in late May of 2024. A new process was implemented for the Fall semester of 2024 to ensure timely and accurate processing of official and unofficial withdrawals. Outcome: All student withdrawal requests both official and unofficial are processed daily and tracked in a shared workbook. This allows information about each individual withdrawal request to be captured and available for both the Business Office and Financial Aid. Date of Determination, Last Date of Attendance, Processed Date, withdrawal type, withdrawal reason, and credits impacted are all captured in the workbook to aid with R2T4 calculations. This workbook also serves as a document that can be audited in real-time to ensure accuracy of each student’s record. A Standard Operating Procedure was developed and used to train the team members effective on 8/12/2024. Person Responsible for Corrective Action Plan: Tonya Troka, University Registrar & Assistant Provost Anticipated Date of Completion: Completed and implemented for Fall 2024 Semester

Finding: 2024-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2025

Lack of documentation surrounding TEFAP eligibility. Responsible Individuals: Barbara Prather, Executive Director Corrective Action Plan: The Food Bank has implemented procedures to ensure TEFAP forms are updated annually and proper documentation is kept. Date of Completion: December 31, 2024

Catholic Charities respectfully submits the following corrective action plan for the year ended June 30, 2024. Name & address of public accounting firm: Kernutt Stokes 1600 Executive Parkway, Suite 110 Eugene OR 97401 Audit Period: June 30, 2024 Major Federal Award Findings: Finding Reference #: 2024-001 Significant deficiency Recommendation: We recommend management design and implement internal controls over compliance to ensure tenant recertification is performed within the timeframe specified by HUD. Corrective Action: Renaissance Court has contracted with a new property management company, effective April 1, 2024. Due to the transition, certain tenant recertifications were completed late. Management will work with Guardian Management to improve the procedures and ensure tenant recertifications are completed in a timely manner, as specified by HUD. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.

Subrecipient Monitoring Material Weakness in Internal Control Over Compliance and Material Noncompliance Federal Agency Name: Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Finding Summary: The subrecipient agreement requires the submission of quarterly performance reports by the subrecipient within fifteen days of quarter end. However, no quarterly performance reports were submitted by the subrecipient for the year ended June 30, 2024, as of August 1, 2024. Responsible Individuals: Stella Runde, Budget Director Corrective Action Planned: Dubuque County acknowledges the comment and has implemented a process to receive and review quarterly performance reports from the subrecipient. Anticipated Completion Date: June 30, 2025

2024-001 Federal Program - Federal Program AL # 93.224 and 93.527 Health Center Cluster Recommendation – Along with providing proper training to employees , we recommend that the Center develop a tool the eliminates manual calculations for the front desk staff to use in determining which fees to apply to vision patients. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.

Finding 2024-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster - Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Vouchers Programs Assistance Listing Number: 14.871, 14.879 and 14.EHV Noncompliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority's files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 9,051 units. Of a sample size of eighty-nine (89) tenant files, the following was noted: • HUD-9886 Authorization for Release of lnformation was missing in 4 files Our sample size is statistically valid. Known Questioned Costs: $24,363 Cause: There is significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: Of the Eighty Nine (89) tenant files audited, four (4) tenant files contained a deficiency in the same indicator---the Authorization for the Release of lnformation/ Privacy Act Notice (HUD Form 9886) retained in the tenant file was executed after the audit date range, not within the audit period (4/1/23- 3/31/24) or within the three months prior. The HACCC discovered two contributing factors for this deficiency and identified a plan to ensure compliance with this requirement which is detailed below. First, the HACCC's Housing Choice Voucher program entered into a partnership with Paul Edwards Management and Consulting (PEM) on May 1st 2024. This partnership provides the HACCC's Housing Choice Voucher program with technical assistance and coverage of vacant positions within the Housing Choice Voucher program Continued Eligibility team. The PEM team members assigned to Continued Eligibility are responsible for completing timely Annual Recertifications for all assigned Housing Choice Voucher program participants---including the collection of any signature documents required by HUD annually. To ensure compliance with this requirement, contract performance indicators related to those positions temporarily assigned to PEM (including the timeliness of Annual Recertifications and a consolidated report of findings within the Electronic File Protocol Quality Control Audit Checklists) will be included in a corrective action plan. The enhanced monitoring provided by the corrective action plan will a) ensure the continued collection of the performance indicator data and b) provide timely feedback regarding the partnerships ability to mediate the deficiency. Second, HUD removed the expiration date from the 9886 form. Effective 01/01/2024, HUD requires Housing Authorities to collect a signature on the 9886 form once throughout the course of participation instead of requiring Housing Authorities to collect a signature on the form annually (or every 15 months). HUD issued PIH Notice 2023-27 on 09/29/2023. The notice indicated "In accordance with the final rule, all applicants must sign the consent form at admission, and participants must sign the consent form no later than their next interim or regularly scheduled income reexamination. After an applicant or participant has signed and submitted a consent form either on or after January 1, 2024 (regardless of the PHA/MFH Owner's compliance date), they do not need to sign and submit subsequent consent forms at the next interim or regularly scheduled income examination ... ". The HACCC' s Housing Choice Voucher program began to request tenant signatures on the updated 9886 form effective 1/1/2024 (within our online recertification workflows) and effective 3/29/24 (within our paper recertification packets). Internal procedures for the storage of electronic documents ("HACCC Electronic File Protocol") related to the 9886 form were updated in accordance with the change, to in effect, retain the 9886 document as any other "vital document" or one-time verification would be stored and retained (ex. birth certificate, social security card, etc)--- storing and retaining only the most recent version of the document. The HACCC agrees that the requirement to retain a 9886 executed within the audit date range for these 4 files was not fulfilled despite the above-mentioned updates taking place within the audit date range. To ensure compliance with this requirement, Electronic File Protocol QC Checklist Procedure Training will be included in a corrective action plan. The training requirement will a) ensure the continued collection and review of the Electronic File Protocol Quality Control reports and b) provide timely feedback regarding whether having a single retention requirement applied throughout an entire fiscal year will effectively mediate this deficiency. We agree with the Auditor's observations on the inspection of the tenant files and will implement internal control procedures that will ensure compliance of federal regulations. Ingrid Layne, Director of Assisted Housing, will be responsible to implement this corrective action by March 31, 2025.

Corrective Actions Taken or Planned: In March 2024, the Program Executive Director implemented a formal written signature process on the access database check request sheets as written evidence of the review and approval process for housing payments. Person Responsible for Corrective Action: Rachel Erpelding, Executive Director, the Kim Wilson Housing Team, and Accounts Payable Specialist.

2024-002: Eligibility Cause: During our testing, we identified that the College’s internal control policies were not effectively designed to ensure funds are disbursed to eligible students. Context: During inquiries with management, the College identified four students that were awarded and disbursed Pell, SEOG, and Direct Loans, who were subsequently determined to be ineligible for the programs. View of the responsible official: MACC does not agree with this finding. MACC has many measures in place to ensure funds are disbursed to eligible students, including verifying identity when enrolling degree seeking students in classes each semester and reviewing high school completion status with a high school transcript, as well as reviewing ISIRs, and other documentation to determine eligibility for federal student aid. While preparing disbursements for fall 2024, the Financial Aid Office identified some odd entries on some ISIRs, which prompted us to review various patterns in admissions documents. MACC believes the students in question may be cases of stolen identities. However, this is only suspicion at this time because when the students in question enrolled in the summer 2024 semester they provided identification, submitted high school transcripts from valid high schools, completed FAFSAs which resulted with valid ISIRs (in one case the student submitted Verification (V4) documentation), submitted loan data sheets and completed entrance counseling via Zoom. The students in question were referred to the Office of Inspector General at the U. S. Department of Education on 10/15/2024; no follow-up has been received from OIG as of 01/15/2025. MACC has also discussed this case with Kathy Feith, Region 7 Branch Chief, of the U. S. Department of Education, Federal Student Aid. During an interview with an auditor from CLA, MACC disclosed the situation described above to the auditor when questioned about any potential fraud cases. MACC firmly believes all internal control policies were followed to ensure funds were disbursed to eligible students. At the time of disbursement, there was no indication these students were not eligible. As noted above, the OIG has not determined that these are in fact ineligible students; therefore, MACC does not believe it should return funds based on suspicion of ineligibility. As a result of these findings, MACC has added new steps to provide an additional layer of protection, including verifying images of state drivers licenses or other forms of identity, and development of guidelines for staff to follow if they have any suspicion of fraud. Name(s) of the contact person(s) responsible for corrective action: Amy Hager Planned completion date for corrective action plan: We expect the plan will be an ongoing effort to ensure compliance.

The City's Department of Housing has an established policy in place for determination of initial program eligibility as well as determination of continued program eligibility. The City's Department of Housing will review its procedures for executing Housing Assistance Payment (HAP) contracts and amendments and make any necessary procedural adjustments to ensure that ineligible families do not receive program assistance. The City's Department of Housing will enhance its quality control review in this area and provide additional guidance to staff as necessary.

Management agrees with the auditors’ recommendation and will evaluate process improvements and additional employee training to ensure the youth intake file audit review process is fully implemented and executed going forward. The organization has already begun to train staff with the Contracts and Compliance Manager attending quarterly Program Director Meetings to report out on file compliance status. In addition, in the first quarter of Fiscal Year 2025, the Director of Practice Development incorporated the training curriculum for program file management into onboarding for new staff. Moving forward, the Director of Development and Compliance Manager will provide specific trainings during the agency-wide Intake Specialist meeting and the Program Manager meeting. These trainings will take place before the end of the calendar year.

Child Nutrition implemented a new policy/procedure for handling free and reduced applications effective July 1, 2024.

Finding 2024-001 – Child Nutrition Cluster – Eligibility 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. Contact Person Responsible for Corrective Action: Tracy Wilson Contact Phone Number:317-408-1388 ext. 407 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will review and provide proof that multiple parties reviewed and confirmed the correct income eligibility guidelines in our software each year prior to making the applications available to parents. Anticipated Completion Date: Immediate