Corrective Action Plans

Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.

Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for review at the time of audit. Method of Implementation: The district will improve the filing and retention of payroll timesheets and resolutions authorizing payroll expenses for federal programs. All payroll documentation will be properly maintained and made readily available for review at the time of audit.

Agency: Colorado Coalition for the Homeless Audit Period: 2025 Audit Finding Number: 2025-001 Audit Finding Title Sliding Fee Health Center Cluster Department of Health and Human Services Assistance Listing Number 93.224 Behavioral Health Services, 93.527 Bridge Access Program Award Numbers: 4 H8NCS53841-01-02 and 5 H80CS00040-24-00 Award Years: January 1, 2023-December 31, 2025 Criteria or Specific Requirement: Special Tests and Provision: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition: The Organization has a policy that includes homelessness when applying the sliding fee discount in addition to income and household size. The Health Center Compliance Manual only identifies income and household size as determining factors for the sliding fee program. Documentation to support income or household size were not maintained adequately for some patients who received sliding fee discount adjustments. Cause: The Organization's sliding fee discount policy includes homelessness, which is not specifically listed as an applicable determining factor for the sliding fee discount. The Health Center Compliance Manual specifically identifies income and household size as determining factors for the sliding fee program. Additionally, the Organization's controls did not clearly document eligibility for all patients with the sliding fee discount policy. Effect or potential effect: Other adjustments were not distinct from sliding fee adjustments applied to patient charges and, therefore, all patients received a full discount for services. Questioned Costs: None Context: A sample of 25 patients out of a population of 13,454 patients were tested.  Four of the patients sampled lacked appropriate documentation of income and/or household size. Seven of the patients sampled between 100% and 200% of the FPL were adjusted to no patient responsibility under the sliding fee discount program based on their homelessness status as identified in the Organization’s policy. The sampling methodology used is not and is not intended to be statistically valid. Identification as a repeat finding: Not a repeat finding. Recommendation: The Organization should revise its sliding fee discount policy to focus only on income and household size and further eliminate homelessness as a factor. Furthermore, the Organization should implement a process to review sliding fee discount eligibility to ensure compliance with its revised policy. Other adjustments should also be captured separately from sliding fee adjustments within the Organization's billing system. Views of responsible officials and planned corrective actions: The Organization agrees with the finding. Specific steps to be taken to correct the situation (including a timetable for performance of the CAP) or reason why corrective action is not necessary (including disagreement with the finding) NextGen, the electronic health record and practice management system CCH utilizes for revenue cycle operations has been reconfigured to separate the sliding fee adjustments from other adjustments. This was identified and corrected before the audit was completed on April 21, 2026. CCH will revise and update the Sliding Fee Discount Program policy to clarify that the only two factors for application of the sliding fee discount are family size and income. The Sliding Fee Discount Policy will no longer include ‘homelessness’ as a factor for this particular discount. CCH will review the sliding fee discount process regularly to ensure compliance with the revised policy. Additionally, appropriate documentation of self-attestation of income and family size will be collected as required. CCH will also revise and update existing policies related to Billing and Collections and for Waiving or Reducing Fees Beyond the Sliding Fee Scale to define the other discounts CCH provides to clients including those who do not provide complete data for sliding fee discount eligibility determination Finally, appropriate staff will receive updated training on the updated policies. Anticipated completion date The billing system change occurred on April 21, 2026. The policy revisions will be completed and approved by the Board by October 31, 2026 Training on the updated policies will be implemented upon final approval by the Board and be completed by November 30, 2026. Name(s) and title(s) of contact person(s) responsible for corrective action Billing system changes: Rob Plimpton, Controller /Kathy Hatfield, Interim Revenue Cycle Director Policies and Training: Andrew RobGrimm, Chief Integrated Health Operations Officer

A 100% review of applications was completed on October 10, 2025. The Food Service Supervisor will run an original direct certification before school starts and import that into Linq system. A 100% verification is completed in the fall. Each month a new direct certification is ran to catch any changes.

Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.

Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: In September 2025, the Organization began its transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. This went live in December 2025. We included mandatory eligibility fields and document upload requirements before service can begin. We developed SOPs to include a standardized eligibility checklist to be completed for all new and returning participants. Staff were trained on Pantry Soft usage, eligibility requirements and document retention stands. The Executive Team performed spot checks on these records but will begin documenting this procedure.

View of Responsible Officials and Corrective Actions: We agree with the auditor's recommendation. Although the referenced invoices were reviewed by the CEO from the vendor for eligibility and reasonableness upon receipt of the automatic e-mailed invoice, there was no procedure to print and retain this documentation in the accounting files for Instacart invoices. Effective June 1, 2026, each month the Director of Finance will compare a checklist of all credit charges to the physical copies prior to filing and obtain any missing invoices as part of the monthly closing process.

See pdf of corrective action plan

See pdf of corrective action plan

Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should provide training and education to front desk staff related to the EMR and the process for collecting and retaining family size and income information in addition to inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information and has been obtained and charges are appropriately billed in accordance with the Organization's policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the finding. To address this issue, the Organization will reinforce procedures requiring current incomeand family size documentation prior to determining sliding fee eligibility, provide additionalstaff training, and will review electronic medical record system settings to ensure properdocumentation and application of discounts. Management will conduct periodic reviews tomonitor compliance with sliding fee discount requirements. Name(s) of the contact person(s) responsible for corrective action: Chief Operations Officer or their designee. Planned completion date for corrective action plan: September 1, 2026

Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule •Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement an additional review of all sliding fee applications received and provide additional training for intake staff. Name(s) of the contact person(s) responsible for corrective action: Jennifer Smith Planned completion date for corrective action plan: 6/29/2026

During the 2025 audit, the auditors discovered that a secondary review of eligibility determinations did not occur in a timely manner. The lack of internal control opened the possibility that an individual was incorrectly determined to be eligible to receive benefits and this error would not have been identified or corrected in a timely manner. Federal Regulations establish requirements for internal control over compliance with Federal program requirements. 2 CFR Section 200.303 requires non-Federal entities to establish and maintain effective internal control over Federal awards that provides reasonable assurance the entity is managing the award in compliance with Federal statutes, regulations, and the terms and conditions of the award. These requirements include the design, implementation, and operation of control activities to ensure compliance with applicable compliance requirements, including eligibility. As eligibility is a key compliance requirement identified in the OMB Compliance Supplement, the County is required to implement a review process and system of internal controls that allows management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, errors or noncompliance in eligibility determinations on a timely basis. The Department of Human Services (DHS) has implemented a monthly review process to audit a random sample of the IV-E cases. The review includes verification of timely and accurate determinations, client information, supporting documentation, and system entries, with results documented and approved by the reviewer. DHS Division leadership will monitor compliance to ensure the reviews are conducted each month. DHS believes this additional review procedure will provide the needed internal controls over IV-E determination.

Finding #2025-007 14.239 HOME Investment Partnerships (HOME) Program Eligibility Views of Responsible Officials and Planned Corrective Action Management’s Position: #1 Management concurs and acknowledges that approving the matter without a more thorough evaluation was an oversight. #2 Management disagrees. HOME maximum subsidy per 3-bedroom unit is $338,419.00. Total HOME investment is $112,500.00. Corrective Actions: Corrective actions include strengthening internal controls and oversight. Management will implement a more comprehensive review process moving forward. This process will include additional supervisory review, verification of supporting documentation, confirmation of regulatory and policy compliance, and consultation with appropriate program and legal staff, when necessary, before approvals are granted. Management will also establish review checklists and documentation standards to ensure that all relevant factors are consistently evaluated and adequately documented. Moving forward, the Community Development Division will undergo a more rigorous evaluation process standardized review checklists and documentation requirements will be implemented to promote consistency, accountability, and proper recordkeeping. Management will monitor compliance with these enhanced procedures to reduce the risk of future deficiencies, oversights and ensure approvals are supported by adequate due diligence. Responsible Party: Jo Lyn Terlaje, Community Development Manager Anticipated Date of Completion: Final approval checklists will be implemented by August 1, 2026.

Name of Contact Person: Jill Sampson, DSS Director Corrective Action: Training will take place to reiterate the importance of properly recording the required telephonic signature and date. After reviewing the findings listed, the availability of time reserve and how to record it as well the steps following its expiration will also be discussed. All will be addressed in the upcoming training. Proposed Completion Date: April 7, 2026.

Name of Contact Person: Jill Sampson, DSS Director Corrective Action- Internal Control Error: The Auditor Report for Bladen County disclosed finding(s) of non-compliance with laws and regulations. The audit shows that we have repetitive errors from the previous year. We take these results very seriously and are committed to implementing lasting improvements. Bladen County Department of Social Services is focused on establishing protocols that will build a standard of confidence for our Income Maintenance case workers. It has been and will remain our constant goal to strengthen our Medicaid programs through knowledge and training to eradicate errors. Bladen County DSS will implement the following program policy and procedures to improve proficiency in service delivery. We do recognize that we fell short of expectations on this audit, particularly with the repeat error findings. The nucleus of the Plan of Correction will have a framework that will involve both Income Maintenance staff and Managers to set a groundwork that will empower the Medicaid teams to meet state expectations and improved audit outcomes in the future. The Second-Party Audits completed each month by Medicaid Supervisors will track our performance and upon completion of the second party of cases training will be completed to address the errors found. Staff will be given a test that will measure our performance improvement to assure accuracy on case work. Areas Needing Correction: Internal Control Errors • Failure to comply with policy requirement: Three (3) instances of failure to complete at least one compliance component. All identified missing or incomplete verification of facts or were improperly forced. • Inaccurate Resource Calculation: Three (3) instances of inaccurate resource calculations in NC FAST. The values entered in NC FAST evidence and used in the eligibility determination did not match the supporting documentation or was lacking any substantiating documentation. • Inaccurate Budget Calculation: Six (6) instances of inaccurate budget calculations in NC FAST. The values entered in NC FAST evidence and used in the eligibility determination did not match the supporting documentation or was lacking any substantiating documentation. • Failure to document/correct system issues: Four (4) instances of system errors found that were not addressed or corrected. Cases contained benefit histories that were not representative of the benefit that was issued. Goal for Correction: • Work Number Usage Administrative Letter No: 02-19 The Work Number Procedures • The Work Number (TWN) - Job Aid dated 09/21/2023; The Work Number (Fact Sheet) Dated 09/25/2023. • Manual Calculations of Income F/C MA 3300; MA 2250 • MAF-MIC-HSF Budgeting – MA 3305 • Financial Resources MA 2230 • Evidence Dashboard Relationships - Job Aid dated11/27/2018 • Acceptable use of Medical Forced Eligibility– Last updated 03/01/2023. • NC FAST Mandatory Evidence and Verifications • Adding Evidence to Case (Job Aid) • Online Verifications (Job Aid) • MA 3515 Bladen County DSS is committed to using tools listed in this Plan of Correction to assist in recognizing any areas of concern for the Medicaid Teams. Bladen County DSS is eager to assist workers to become the most efficient and productive in their daily work routine, to reach the best desired outcome for both the clients served, as well as the overall audited scores. • Training has been completed for the Medicaid staff on February 23, 2026 (Adult Department) and February 24, 2026 (Family and Children Medicaid Department). See list of Medicaid policy, Administrative letter and NC FAST job aids that were addressed during the meeting. • Medicaid Program Checklist- each Medicaid team will have a checklist that will be utilized on each application/ recertification completed. This tool will be used to ensure Income Maintenance workers have completed all necessary actions to application/recertifications. This tool will also be used in auditing each case during the second party review of the case. *Note: Item Number 18 from the Medicaid Eligibility Testing Attribute has been updated to include The Work Number for household members age 14 and above. These tools are included in the Second Party review of the record and if the worker does not complete the tool a point is deducted as being in error. • Second Party Review of Records – Will be completed monthly by the Supervisor and Lead Worker for the specific program. Each Income Maintenance worker will be monitored by monthly review of three applications and three recertifications. Any errors that are determined during the second party review will be addressed with the worker, who will be given 3 days to make the correction to the file, refute the error finding by discussing manual policy with the Supervisor/Lead worker, workers will need the policy name and section number. This internal audit will assist in determining areas of training that staff need for overall improvement in job performance. • Medicaid Spreadsheet Internal Report Card – has been created for the Medicaid team monthly utilizing the individual scores received from the Second Party review of cases. This will be the benchmark set at 96.8% for Eligibility errors and 90% for technical errors. • Monthly Audits completed by Bladen County Finance Office will continue to be completed. Each worker is given their individual errors discovered by this audit. The worker will be coached concerning the errors found and will be required to make corrections to the case. The worker will also sign the audit form indicating that the information was reviewed with them and the date recorded. • Medicaid Spreadsheet Internal Report Card reviewed by County Boards – The Medicaid Second Party Spreadsheet (Internal Accuracy Report Card) for the Adult Medicaid and the Family and Children Medicaid Department will be reviewed monthly by the Bladen County Health and Human Services Advisory Committee. A formal presentation will be sent to the committee each month via computer. This information will be sent out in the format of spreadsheets; the spreadsheets will indicate each worker (using an alphabet identification) and will indicate if the employee met the benchmark goal of 96.8% eligibility and 90% technical error rate each month. This chart will give a three-month snapshot (window of time) for notifications of error trends identified by the audits. This report will be discussed quarterly at the Health and Human Service Advisory Committee meeting offering each committee member the opportunity to address their concerns about audit scores during that quarter. • All Medicaid Program teams will staff all pending applications (by date priority) with the IMC, Supervisor, and/or Lead worker. This will help to eliminate any questions that the IMC may have in response to completion of the application. • Second Party review of cases will be completed monthly by Supervisor and Lead worker in the Medicaid programs. Upon completion of the entire team’s second party reviews, training will be created based on the errors found at the second party of work. Once the training has been completed, workers will be given a test to determine their understanding of policy, job aid and forms reviewed in the training. A test score of 90% accuracy must be maintained by each staff member to receive a passing score. A score below 90% will require additional training. • A training outline form will be utilized during training so that staff have the opportunity to give feedback as to what they feel they need additional training in. • Newly hired staff within the first (1) year of employment will receive quarterly job performance evaluations. • Newly hired and all active Income Maintenance staff will take and pass (score of 70% or above) the NC FAST Core Functions Certification and Level 1 Training Program. • Newly hired staff will be required to have work reviewed 100%. • Warning System for Persistent Errors – Implementation of a warning system for caseworkers who persistently make errors, despite corrective actions and counseling. First Warning:  When an employee repeatedly makes errors despite individual counseling and corrective actions, they will receive a First Warning.  The employee's supervisor will meet with them to discuss the errors and reinforce the importance of adhering to policies and procedures.  As per Bladen County DSS policy, employees will be given three workdays to make necessary corrections.  The First Warning will be documented in the employee's personnel file. Second Warning:  Within three months, If the employee continues to make errors after receiving a First Warning, they will be issued a Second Warning.  The supervisor will conduct another meeting with the employee to address the persistent issues.  During this meeting, a performance improvement plan will be established, outlining specific areas for improvement and a timeline for achieving them.  The Second Warning will be documented in the personnel file. • Demotion in Position – If the employee's errors persist even after receiving the Second Warning and failing to meet the goals of the Plan of Correction, they will face demotion in position. The demotion will involve a change in job responsibilities or a transfer to a lower-level position if available within the organization. This action will be taken after thorough evaluation and consultation with Human Resources. • Termination – If, despite previous warnings, the employee continues to make errors that significantly impact their performance and the effectiveness of DSS, the last step is termination. Termination is the last resort and will be considered only after the employee has received a First Warning, a Second Warning, and a demotion in position. The decision to terminate will be made in consultation with Human Resources and higher-level management. • Proposed Completion Date: This Plan of Correction will become effective April 1, 2026. The Bladen County Department of Social Services Economic Services Division for the Medicaid Programs will take an active role in ensuring work is monitored and that staff receive training throughout the year, to minimize the error rate from the Single County Audit.

Special Tests and Provisions Condition: The Organization did not maintain documentation to show that patients had been evaluated for eligibility under its sliding fee scale policy and did not apply sliding fee adjustments consistent with the sliding fee scale assigned. Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information has been obtained in accordance with TCA’s policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA Health is strengthening controls over its sliding fee discount program. Effective FY26 (April 11, 2026), Epic will require entry of family size and income and will apply the appropriate discount based on the approved sliding fee schedule, reducing the risk of missing or incorrect discounts. Staff training on sliding fee policies and Epic workflows has been reinforced and will be refreshed at least quarterly. TCA Health will also conduct monthly audits of encounters to confirm required documentation is on file and discounts are applied in accordance with the sliding fee scale, and will use results to drive targeted follow-up and process improvements. We will increase the audit to include the total population vs. a sample when reviewing. Name(s) of the contact person(s) responsible for corrective action: Samantha O. Mitchell Planned completion date for corrective action plan: 9/1/26

AUDITOR FINDING: 2025-001 Eligibility. We noted the following issues in the 25 cases tested: 1. One instance in which client income was incorrectly entered and as such, was ineligible for benefits as they were over the income limits for all of 2025. 2. Three instances in which, although case notes indicated general contact with the participant, the County did not retain sufficient documentation that a required meeting specifically addressed or confirmed engagement in an eligible work activity or was completed within required timeframe. Recommendation: We recommend that the County continue to strengthen internal controls related to eligibility determinations. This includes issuing training alerts related to the differences of subsidized and unsubsidized employment income and the impacts to eligibility. Additionally, we recommend continued periodic quality assurance reviews of TANF case files to ensure ongoing compliance with federal and state eligibility requirements and identification of employees with performance issues. Finally, we recommend the County develop monitoring reports to identify those clients who have not had a workforce contact in the required timeframe. CLIENT PLANNED ACTION: Jefferson County agrees with the findings and has taken or will take the following steps to address the errors. The findings were caused by workers on both the eligibility and workforce teams so varying measures will be implemented based on the finding and responsible team. Jefferson County will continue and implement the following actions to address and prevent future findings. • Eligibility Team Actions o Jefferson County will issue a training alert to all eligibility staff by June 20, 2026, detailing the difference between subsidized and unsubsidized employment, correct data entry, and the impact of each on TANF eligibility. o To monitor compliance, the County will continue completing Internal Quality Assurance reviews utilizing the state mandated list to assess the case and payment accuracy. • Workforce Development Team Actions o Performance concerns related to inconsistent client contact and incomplete documentation were identified during regular performance reviews in January 2026 and have been successfully addressed via the county Employee Relations coaching and disciplinary framework. •To monitor compliance, the County will continue completing Internal Quality Assurance reviews utilizing the state mandated list. In addition, Colorado Works Supervisors review at least one case per worker each month. Beginning in June 2026, the number will be increased to a minimum of 10 cases per month if a performance concern is identified. o Tableau reports have been created or enhanced to monitor compliance. • Individual case worker accuracy reports for all IQA and Supervisor reviews were released in March 2026. Progress reviews have been incorporated into monthly supervision meetings with staff. • Enhancement to report titled, Cases Needing Action, which tracks data entry of client contact and Individual Plan development in CBMS was completed on June 1, 2026. Workers will now be notified if client contact exceeds 30 days. Workers and supervisors will review the report monthly and take proactive measures for client contact prior to exceeding rule requirement of 90 days. CLIENT RESPONSIBLE PARTY: CW Eligibility Team: Julia Zoukhri (Program Manager), Brandy Brogan (Program Manager), Karen Thomas (Program Manager) and Jennifer Martinez (Quality Assurance & Systems Administrator) CW Workforce Development Team: Tara Noble (Program Manager), Kathryn Boyd-Cordova (CW Supervisor), and Erin Encinias (CW Supervisor) COMPLETION DATE: July 2026

Recommendation: Management should strengthen its tenant file review and monitoring procedures to ensure that reasonable rent determinations and utility allowance calculations are completed, documented, and reviewed in accordance with the Housing Authority’s policies and applicable program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Authority will address the identified deficiencies and prevent recurrence by strengthening file review procedures, enhancing staff training, and improving internal controls. A standardized quality control process will be implemented to ensure required tenant file elements are accurate, complete, and properly reviewed prior to approval, along with periodic monitoring to identify and correct errors in a timely manner. Staff will receive targeted and refresher training to reinforce key requirements, calculations, and documentation standards. Additionally, the Authority will evaluate opportunities to improve system controls to reduce the likelihood of errors or missed steps. Name(s) of the contact person(s) responsible for corrective action: Lowel Krueger, Executive Director. Planned completion date for corrective action plan: December 31, 2025.

Management has implemented a comprehensive continuing education program for employees who work on the SSVF program. Monthly internal audits are conducted by the Program leadership team to monitor compliance with funder guidelines.

Memo: Cause and Corrective Action Plan for Finding 2025-003 This correspondence serves as Cook County Health (CCH) and Cook County Department of Public Health (CCDPH) response to Finding 2025-003. During the FY2025 Single Audit, one audit finding was identified by Washington, Pittman & McKeever, LLC. The root cause and corrective action plan is identified below. Condition During the current audit period, the Cook County Department of Public Health (DPH) did not comply with federal regulations regarding the use and reporting of program income as it relates to funds awarded through the RWHAP Root Cause Analysis The HIV grants transitioned to CCH from an external organization in July 2025. Award amounts were granted in multiple phases, requiring four budget revisions, with the final revision approved in December 2025. The contractual period covered March 2025 through December 2025. During the transition period, CCH lacked formal operational procedures to identify, record, and track program income. Several operational and administrative challenges contributed to this issue, including: • No written internal procedures were in place to define or track program income requirements. • No formal transition teams were established to identify core grant obligations, resulting in unclear interpretation of sponsor requirements. • CCH had not yet identified the appropriate internal systems or interdepartmental collaborations necessary to retrieve and reconcile program income data. • Organizational priorities during the transition focused on maintaining existing deliverables, including vouchering, budget compliance, hiring, and onboarding of direct and administrative staff. • Staffing Shortages, CCH onboarded personnel quickly as contractual employees, direct staff transitioned onboard as CCH employees in phases upon execution of grant contracts. Corrective Action Plan CCH Director of Grants Accounting is implementing formal written processes and procedures to ensure compliance with Federal Uniform Guidance requirements related to program income. The corrective action plan includes: • Developing standardized written procedures that clearly define program income requirements and tracking responsibilities. • Establishing shared roles and responsibilities across departments to support consistent data collection, reconciliation, and reporting. • Identifying the specific data elements required to accurately record and monitor program income. • Formalizing interdepartmental collaboration processes necessary to retrieve and validate program income information. • Defining the systems and reporting tools that will be used to track and maintain program income records. • Providing staff training on program income requirements, documentation standards, and compliance expectations. These actions will strengthen internal controls and ensure timely, accurate identification and tracking of program income moving forward, official approval/implementation is expected December 2026

2025-001 Finding SDSI Housing Corporation, Inc. (SDSI Housing) received reimbursement from the reserve for replacements of $135,824 for roof repairs that were previously funded with insurance proceeds. The reserve for replacements is under funded by $135,824 due to the reimbursement of ineligible items. A reimbursement request was submitted for major roof repairs which are traditionally contemplated as eligible for draws under HUD Occupancy Handbook 4350.3 REV-1. However, management did not consider the fact that such repairs had already been funded by insurance proceeds, so the major roof repairs resulted in no cost to the Project. Comments on Finding and Recommendations Management agrees with the finding and recomendations. Actions Taken Management returned ineligible funds of $135,824 to reserve for replacements on April 16, 2026.

2025-007 Auditor’s Recommendation: The entity should strengthen internal controls over TANF benefit payments by implementing procedures to ensure payments are identifiable by participant and reconciled to eligibility records. The entity should also establish controls to verify benefit calculations and ensure assistance is discontinued when eligibility expires, and maintain sufficient documentation to demonstrate compliance with program requirements. Corrective Action: UCM will strengthen internal controls over TANF benefit payments by implementing procedures to ensure payments are clearly identifiable by participant and reconciled to approved eligibility records before assistance is provided. Each payment will be supported by participant identification, eligibility approval, assistance type, approved amount, funding source, payment date, and supporting documentation. UCM has established TANF Eligibility Determination Guidelines, a List of Acceptable Documents, and an Assistance Agreement Form to support eligibility determinations and benefit payment documentation. Per VDSS guidance, once eligibility is established at the beginning of the program, a change in status during the participant’s stay does not disqualify the participant from receiving further services. Felony record documentation is not required in the participant file as felony record status is not part of the eligibility requirement per VDSS. Evidence of review and approval will be retained in the participant file. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Case Managers Shruti Jha, Senior Director of Finance Liya Tseye & Carmen Romero, Accountants Laura D’Ambrogi, Grants Manager Anticipated Completion Date: Substantially completed as of April 6, 2026. Ongoing payment review, eligibility monitoring, reconciliation, and supervisory review will continue during the program year.

2025-006 Auditor’s Recommendation: UCM should strengthen internal controls over TANF eligibility determinations by developing and implementing written procedures that clearly define the documentation required to support all TANF eligibility criteria. These procedures should require that participant files include sufficient documentation supporting financial eligibility, citizenship or qualified alien status, TANF benefit history, household composition, compliance with applicable legal eligibility requirements, and work participation when applicable. In addition, the entity should implement a documented supervisory review and approval process to verify eligibility determinations and supporting documentation prior to the provision of assistance. The entity should also provide training to staff responsible for eligibility determinations to ensure they understand federal TANF documentation requirements and maintain complete and accurate participant files. Corrective Action: UCM will strengthen internal controls over TANF eligibility determinations by formalizing written procedures that clearly identify the documentation required to support each eligibility criterion before assistance is provided. The procedures will define required documentation for financial eligibility, citizenship or qualified alien status, TANF benefit history, household composition, applicable legal eligibility requirements, and work participation requirements when applicable. UCM reviewed and discussed the findings with the auditor, Senior Director of Finance, and Chief Program Officer. UCM also reviewed the Virginia Department of Social Services post-training materials on TANF Employment Advancement Eligibility Determination Training, and clarified identified areas of the findings with the Virginia Department of Social Services as they relate to the subrecipient signed contract. UCM designed new Screening Guidelines for incoming program participants, including a documented supervisory review and approval process, which were completed on April 16, 2026. The new screening guidelines require participant files to include sufficient documentation supporting eligibility determinations and require supervisory review before assistance is provided. A supervisor or designated reviewer will verify that the participant file contains the required eligibility documentation, that eligibility criteria have been met, and that the assistance is consistent with TANF requirements, VDSS guidance, the subrecipient contract, and program guidelines. UCM reviewed and trained staff on the new eligibility screening guidelines, acceptable documents, and income requirements on April 28, 2026. Staff responsible for TANF eligibility determinations, case management, direct assistance, and grant compliance will continue to receive training as needed to ensure they understand TANF documentation requirements and maintain complete and accurate participant files. UCM will also periodically monitor participant files to confirm continued compliance and identify any additional training or process improvements needed. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Laura D’Ambrogi, Grants Manager Case Managers VDSS Program Consultant Anticipated Completion Date: Substantially completed as of April 28, 2026. Ongoing implementation, supervisory review, staff training, and monitoring will continue during the program year.

View of Responsible Officials: Management agrees with the finding and recommendation. Corrective Action Plan: East-West Center will designate the International Programs Specialist (coordinator of the Graduate Degree Fellowships) to prepare the list of selected students to be offered scholarships demonstrating clearly that the selections meet the ratio requirement. The Dean of the Education Program will be required to sign off on the list, checking to ensure that the ratio of students meets our designated mandate. If students decline our initial offer, each alternate also will be vetted by the Dean to ensure the balance is maintained. If there is funding uncertainty up until the date required to send invitations, and a different funding source is used as an alternative or backstop, the program will bring these students on a J-visa so that they are able to shift to Federal funds at a later date to ensure that the ratio is maintained. 27 Contact Person: Director and Dean of Professional Development and Education Programs Anticipated Completion Date: May 2026 28

Description of Finding: Criteria or Specific Requirement: The lead agencies, who are subrecipients under the Federal Awards, are required to have clients sign the Form 502045-A CSFP Sub-Agency Monthly Participant Sign-in Sheet to self-declare program eligibility before food is disbursed. Issue and Cause: There were two instances out of 40 distributions tested where this signoff was not completed. Due to the hectic environment at the lead agencies during food distribution day, oversights have occurred when obtaining the required client signoff. Statement of Concurrence or Nonconcurrence: PARF management has reviewed the 2025-001 finding and concurs with the recommendations as stated. Corrective Action: PARF has an extensive training process in place for lead agencies, in relation to grant award compliance requirements, which includes the provision of training manuals and monthly phone calls to review matters. In addition, PARF provides updates to the lead agencies as new or amended requirements are enacted. Further, PARF does periodic reviews of the lead agencies and completes the biennial review Form 502035 CSFP Management Evaluation. PARF will continue to reiterate the required signoff process with the lead agencies during phone calls, training session and reviews. In addition for FY 2026 PARF will be conducting a mandatory webinar to ensure all the lead agencies are understanding the procedure and why it is important for 100 percent accuracies -https://docs.google.com/presentation/d/1YZgcq7SY4DmvhYrKZE8sp-NDhpuzn827PZDZ0xAKDw/edit?usp=sharing