Corrective Action Plans

Finding 2024-003 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals, semi-annual review of privileged users, and annual review for all users. Security management and access control processes will continue to be a standing agenda item for ongoing quarterly training sessions with Local Office Security Coordinators (LOSCs). For parts a., c., and d., the Access Management Section began conducting quarterly reconciliations of DSA to the Bridges Integrated Automated Eligibility Determination System (Bridges) during the first quarter of fiscal year 2025. For part b., MDHHS is currently evaluating the feasibility of establishing a quarterly review process to help ensure documentation is maintained for a sample of LOSC monitoring reports. MDHHS anticipates completing the evaluation by September 30, 2025, and will determine an anticipated completion date for implementation, if necessary, at that time. For part e., MDHHS Local Office Directors, District Managers, or designees review a monthly sample of high-risk Bridges transactions to ensure documentation was properly maintained. Beginning September 2024, MDHHS Business Service Centers (BSC) implemented a monitoring process to ensure monthly reviews are completed by the local offices timely and that the documentation is properly maintained. Anticipated Completion Date a., c., d., and e. Completed b. September 30, 2025 Responsible Individual(s) a., b., c., and d. Jim Bowen, MDHHS e. Veronica Maxson, MDHHS

Finding 2024-002 Bridges Interface Controls Management Views DTMB disagrees with the condition and the effect of the OAG’s finding. The OAG sampled 85 total files across eight interfaces. Of these, seven appeared to present issues. For five of the sampled files, detailed exception results no longer existed. DTMB maintains summary tables for 10 years and purges detailed exception records at the beginning of each calendar year for anything older than 12 months. This purge process was communicated to the OAG during the fiscal year 2022 audit, and sampling was performed prior to purging for the fiscal year 2023 audit. When informed that the sample included files for which the detailed exception records had been purged, the OAG requested DTMB run a simulation processing of the original interface file in a testing environment to recreate detailed exception records. DTMB’s technical teams informed the OAG that rerunning in the current test environment would likely differ from the original results due to code changes that occurred in the test environment subsequent to when the original interface files were run in production. The OAG requested DTMB to proceed with rerunning the files in the current test environment. As a result, the OAG identified five instances where the detailed exception records from the simulation in the test environment did not exactly match the summary table from the original production interface results. For the 2 remaining files out of 85 (2.4 percent) that were cited, it should be clarified that the reconciliation being discussed is not data that was lost or misplaced between systems, but reconciliation of two exceptions correctly logged and correctly not counted in a summary report because they were alerts during processing, not errors that would be forwarded for review. These results do not present a significant deficiency in the ability of MDHHS to review the detailed exceptions. Also, these 2 records are insignificant when compared to the 11.6 million records processed in the 85 sampled files (0.000001 percent). Therefore, the current controls are reasonable to ensure that data processed from the source system to the receiving system is processed accurately, completely, and timely. Planned Corrective Action DTMB disagrees with the finding and does not intend to take further action. Anticipated Completion Date Not applicable Responsible Individual(s) Nathan Buckwalter, DTMB

Finding-002 Eligibility – Significant deficiency in internal control over compliance (Unit Inspection Documentation) Management Response Management acknowledges that this finding resulted in part from an over-reliance on partner organizations for performing initial and annual unit inspections, without ensuring that full inspection documentation was consistently maintained in internal records. To address this, the following corrective actions have been implemented: •The Leasing Department and Support Services teams are now required to collect and retain copies of all unit inspection documentation (both initial move-in inspections and annual reinspection), even when performed by partner organizations. •A centralized tracking log for unit inspections has been created and will be maintained by the Program Director to monitor inspection status and ensure document retention for each client. •Program staff are required to upload inspection documents to a secure central drive and log inspection completion in the client case management database. •Quarterly reviews will be conducted by the Compliance team to ensure all required inspection documentation is properly retained and accessible. Training on these updated procedures will be conducted on June 10, 2025, with quarterly refresher trainings planned. Responsible Staff: Program Directors and Leasing Manager Implementation Date: June 2, 2025

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2024 Finding Reference Number: 2024-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of expenditures to support activities allowed or unallowed, allowable costs/cost principles, reporting and special tests and provisions related to amounts reimbursed for the project worksheet as it relates to the FEMA disposition requirements for COVID-19 related supplies. As a result, Management was reimbursed by FEMA for expenditures that were not in compliance with the FEMA disposition requirements which resulted in a questioned costs of $480,606. Corrective Action Plan: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reporting for reimbursement in the FEMA project worksheet comply with the FEMA disposition requirements. Management will work with FEMA to refund the questioned costs and discuss the extent of the additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: June 30, 2025

Views of Responsible Officials: HIAS management accepts the recommendation and is implementing procedures to ensure that FFATA reports are submitted in a timely manner.

Finding 2024-005 The Authority has hired a new Executive Director in April of 2025. She is undertaking the process of learning the systems in place and adjusting them to meet the requirements of the program. The Authority has hired a consultant that has significant experience in HUD regulations to help guide them to implement the appropriate systems. Planned corrective actions are to be implemented immediately.

Name of Contact Person: Wendy Ellis, Executive Director We will implement proper internal control procedures for the Low Rent Public Housing program eligibility requirements. Immediately.

Name of Contact Person: Sherry Joyner, Executive Director. We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Immediately.

Name of Contact Person: Sherry Joyner, Executive Director. We will implement proper internal control procedures for the Section 8 New Construction program eligibility requirements. Immediately.

Recommendation: It is recommended that a supervisor or peer perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to complete casefile reviews over all Medical Assistance casefiles. Name of the contact person responsible for corrective action plan: Kayla Matter, HHS Deputy Director Planned completion date for corrective action plan: December 31, 2025

2024-010 - ALN 14.850 - Public Housing Operating Fund - Special Tests and Provisions - Declaration of Trust Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor's recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action plan is in place to address these weaknesses and deficiencies. Person Responsible for Correction of Finding: Christy Amacher, Executive Director Anticipated Completion Date: September 30, 2025

Name of Contact Person: Lynn Alligood, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. Immediately.

Name of Contact Person: Lynn Alligood, Executive Director Corrective Action: We will implement proper internal control procedures for the Section 8 New Construction program eligibility requirements. Immediately.

Recommendation: The Commission should consider reviewing its current policy regarding rent certifications. The Commission should ensure all persons involved in the certification process are properly trained and understand regulations in order to accurately identify errors. Additionally, the Commission should implement a thorough second party review of annual certifications to verify accuracy. Action Taken: Management will implement stronger controls over tenant files including a more thorough second party review. Anticipated Completion Date of Action: August 31, 2025.

Finding Number: 2024-004 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: QC Team (Lead ES): Whitney VonDeLinde, Megan Howard, Melissa Hoeft Kellie Tienter, Public Assistance Manager Jessica Leth, Economic Assistance Director Corrective Action Planned: • Training TANF employees: o Distribution of Lead ES Newsletter – monthly training communication (includes updates to forms, bulletins from the state, policy & procedural changes, and technical tips) o Supervisor’s will review mandatory verifications at unit meetings by the end of Q3 2025. o Child Support Income Budgeting Guide  Includes how to budget, case noting, etc. o Move In Checklist  We have made clarifying updates to this document regarding requesting a case file from a previous county if not already received. o April 2025 PSU News  QC team shared information and tips from what they noticed while going through the audit • MFIP case reviews conducted by supervisors in Q2 and Q3. 15 per ES per year. • Per Hennepin County we were only transferring the last year of case file documents when clients moved from Anoka County to Hennepin County. Beginning in Q2 of 2025 Anoka County began transferring the entire case file to ensure the complete retention of case files. Anticipated Completion Date: • Completion by end of Q3 2025

NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS, AIRPORT IMPROVEMENT PROGRAM, CFDA NO. 20.106, CONTRACT NO. AIP-3-30-0068-014-2022 Name of contact person: Board of County Commissioners Corrective Action: The Board will take a more active role in insuring that all grant terms and conditions are being adhered to. Proposed Completion Date: Immediately.

Contact Person Larissa Deedrich, Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all files are accurate and follow all local, state and federal compliance guidelines. Planned Completion Date for CAP September 30, 2025

ALLOWABLE COSTS AND ALLOWABLE ACTIVITIES – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County has a supervisor review the random moment studies wages in detail to ensure costs are accurate by report line. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to ensure all expenditures reported are accurate. Name of the contact person responsible for corrective action plan: Kara Terry, Community Services Director Planned completion date for corrective action plan: December 31, 2025

REPORTING – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: It is recommended that the County review their policies and federal requirements to ensure all costs incurred are reported accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to ensure that all costs incurred are reported accurately. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2025

2024-003 Housing Choice Voucher Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (ALN #14.871) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters This is a repeat finding of 2023-002 from September 30, 2023 (Originally reported as Material non-compliance and Material Weakness in Internal Control over Compliance under finding 2019-001 from September 30, 2019) Statement of Condition: Out of a total tenant population of approximately 1,118 vouchers, 25 files were selected for testing, and the following errors were discovered. • 2 tenant files had the following error: o The HAP contract in the tenants’ file was not signed by a representative of Ocala Housing Authority. • 1 tenant file had the following error: o The tenant's utility allowance was incorrectly calculated using the 2023 utility allowance rates. The 2024 utility allowance rates should have been used. Correcting this error will decrease the Housing Assistance Payment by $4. • 1 tenant file had the following error: o The tenant's utility allowance was incorrectly calculated using the 2023 utility allowance rates. The 2024 utility allowance rates should have been used. Correcting this error will increase the Housing Assistance Payment by $23. • 1 tenant file had the following error: o The tenant's utility allowance was incorrectly calculated using the 2023 utility allowance rates. The 2024 utility allowance rates should have been used. Correcting this error will increase the Housing Assistance Payment by $7. • 1 tenant file had the following error: o The tenant's utility allowance was incorrectly calculated using the 2023 utility allowance rates for a 1-bedroom unit. The 2024 utility allowance rates for a 2-bedroom unit should have been used. Correcting this error will increase the Housing Assistance Payment by $20. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income, and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an “Other Adult” packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant's file. The Counselor's caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors' strength and weaknesses and to determine if additional training and/or monitoring is needed. A Counselor has been assigned to only handle specialty vouchers (EHV, VASH, Homeownership, and FUP). The FSS Coordinator is responsible for the full management of HCV FSS participants. The Authority has hired an Intake Housing Counselor/Portability Specialist to focus on determining eligibility of new applicants pulled from the waitlist and to manage the waitlist. This Counselor also determines eligibility and compiles document packet for portability clients. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor's processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. All new admissions move-in files are now being sent to the Compliance Director for review prior to approval. A sample size of 15% is now being reviewed at the end of month by the Compliance Director and Housing Programs Director for compliance. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV Counselors, except the Counselor handling specialty vouchers, will attend Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training and successfully passed the certification exam during the next 24 months, as budget permits.

2024-002 Public Housing Tenant Files: Eligibility Program: U.S. Department of HUD: Public and Indian Housing Program (ALN #14.850) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Statement of Condition: We tested 19 out of approximately 181 tenant files and discovered the following errors: • 1 tenant file had the following error: o A dependent of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the dependent’s birth certificate, the dependent is a U.S. citizen. • 1 tenant file had the following error: o The tenant’s childcare income was calculated and reported incorrectly on the 50058 form in the amount of $2,472. Correcting the tenant’s childcare income to $2,237 would decrease the tenant’s rent by $6. • 1 tenant file had the following error: o Support for the tenant’s wage income could not be located. It’s unknown as to whether the tenant’s wage income is calculated and reported correctly on the 50058 form and whether the tenant’s rent is calculated correctly. • 1 tenant file had the following error: o The tenant’s social security income was carried forward from the prior year in the amount of $11,172. Correcting the tenant’s social security income to $12,144 for the annual recertification period tested, would increase the tenant’s rent by $25. • 1 tenant file had the following error: o The tenant’s social security income was carried forward from the prior year in the amount of $12,456. Correcting the tenant’s social security income to $13,548 for the annual recertification period tested, would increase the tenant’s rent by $27. • 1 tenant file had the following error: o The tenant’s other source income of $720 was carried forward from the prior year. The tenant’s income was not updated for the annual recertification and it’s unknown as to whether the tenant’s other source income is calculated and reported correctly on the 50058 form and whether the tenant’s rent is calculated correctly. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income, and assistance is determined. The agency has created a Family Worksheet and a PH Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an “Other Adult” packet to ensure 214 forms and other pertinent are completed for all adult household members. Management will monitor and review counselor’s strength and weaknesses and determine if additional training and/or monitoring is needed.

Corrective Action – GYAC has purchased an electronic system that assists with the tracking of meal count sheets and attendance rosters. This system compares the names on the roll with the number of meals being claimed, ensuring that participant rosters are accurately maintained and matched with meal delivery records, thereby preventing discrepancies and reducing the error rate in submissions. Responsible for Corrective Action: Rosman T. Randle, Executive Director Date of Implementation: June 2025

Views of Responsible Officials and Planned Corrective Action: Global Communities experienced staff turnover in the positions responsible for FFATA reporting. Management will ensure those staff now responsible for maintaining compliance with FFATA reporting requirements have received adequate training and that supporting documentation of the review and approval of FFATA reports prior to submission are retained in our files.

Finding 2024- 001: Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: To reinforce compliance and ensure consistent adherence to policies a specialized team­ including a Compliance & Training Administrator, a Trainer, and two Senior Occupancy Specialists-has been established to oversee all Housing Choice Voucher (HCV) program training and compliance. This team is responsible for: ■ New hire training to ensure foundational competency. • Refresher trainings to address knowledge gaps and reinforce standards. • Policy & procedure update trainings to keep staff informed of changes. Quality Control: We conduct 100% quality control on all new hires', completed action files and 100% quality control on all contract files. Twenty-five percent (25%) of all Non-provisional employees work product is quality controlled by the compliance team. Department Structure: The entire leadership team completed Nan McKay's HOTMA training to ensure full alignment with the latest Housing Opportunity Through Modernization Act {HOTMA) requirements. This top-down approach guarantees that policy Interpretations and training materials are consistent and up to date. To ensure all required documents are properly retained and accessible, the agency has expedited the transition to a fully digital file system. This will Include standardized naming conventions, centralized storage with access controls, and a documented retention protocol to prevent future discrepancies. Additionally, any staff that falls below the 80 % success rate will be required to actively engage in all mandated trainings and utilize the compliance team as a resource for clarification. Furthermore, staff requiring further reinforcement will be promptly addressed through one-on­ one coaching or additional training sessions with their immediate supervisor. Anticipated Completion Date: The current staff is attending monthly trainings on the Administrative Plan, best practices and HOTMA policy changes. We anticipate completion of the plan by 12/31/2025. Person Responsible: Ms. Rhonda Jackson, Housing Program Manager II, Ms. Malandria Watson, Housing Program Manager I, -and Ebony Bell, Compliance and Training Administrator will be responsible for reviewing the Quality Control Report and error ratios monthly.

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