Corrective Action Plans

Management Response/Corrective Action Plan: During the audit period, the City was in the process of transitioning to a virtual inspection and project management platform designed to retain inspection reports, photographs, and supporting documentation in a centralized and permanent digital file. This system is now in place and used for all HUD activity record keeping assuring records are consistently documented and readily accessible for compliance and monitoring purposes. Following the audit period, the City ultimately discontinued direct administration of housing rehabilitation programs under the CDBG entitlement. As a result, the risk of missing pre-rehabilitation inspection documentation for City-managed activities has been eliminated.

The discrepancies identified were the result of inconsistencies between internal student records and data transmitted to COD for Direct Loan origination. These errors occurred due to manual data entry and timing differences between updates made in the institution’s student information system (SIS) and those reflected in COD. Financial Aid staff received refresher training on Direct Loan data accuracy, COD reporting requirements, and verification procedures to ensure consistent documentation and communication between systems. Collaboration with IT Office is underway to establish automated data checks between the SIS and COD files to minimize the risk of future mismatches. Implementation of the corrective action plan is expected to be complete by June 30, 2026. Responsible Party Robert Rood Interim Vice President Finance and Administration

Finding Number 2024-001: Eligibility Determination Process (Material weakness in Internal Control over Compliance and Material Noncompliance – Eligibility) Program: Housing Opportunities for Persons with AIDS Assistance Listing Number: 14.241 Response and Corrective Action Plan: Management agrees with the finding that the internal controls required for this program had material weaknesses. To ensure proper program management, program staff have created appropriate procedures and processes to demonstrate internal controls. These include a manager review of potential clients, a checklist for ensuring that the program collects and maintains required records, and a procedure for collecting and storing third-party documentation for client program intake/eligibility, diagnosis, and income. Anticipated Completion Date: by September 1, 2025 Responsible Person: Tiffany Major, Deputy Director

Finding 2024-003 Significant Deficiency in Internal Control Over Compliance – Eligibility Application Review Questioned Programs ALN 84.250 American Indian Vocational Rehabilitation Services Agencies: Department of Education Award Numbers H250N210051- Year 2023 H250N210051- Year 2024 Condition The Association is not consistently following their own internal control procedures for keeping evidence of reviewing the eligibility certification form. Status In Progress Management’s Corrective Action Plan Vocational Rehabilitation (VR) will update its required document checklist to include a check for required signatures. The intake staff will utilize the checklist for its first level of application intake to ensure all supporting documents are included and the application is complete, including required signatures. Another step VR will add in the process is a second level of review. Each application that has been approved for support will be reviewed by a second reviewer before final approval. Further, each application that exceeds an award of $10,000, will be reviewed by a third approver. Since applications for services are sometimes foreword to AVCP VR by the Yukon Kuskokwim Health Corporation Audiology Department, AVCP VR will conduct regular training to Audiology staff on the correct process for completing its application. Internally, AVCP VR will continue to conduct yearly training to Village based AVCP staff, who sometimes accept and forward applications to the VR staff, on the correct process for completing its application. Lastly, AVCP VR will update its internal policies and procedures to include these four key steps to ensure applications are complete and signed

Will speak to Department Heads and make sure that the language is added to contracts in regard to suspension and debarment. Will also have a form for vendors to sign if purchasing products. If we are not able to have the first two options done will be sure to use SAM.gov to look up information prior to ordering and take screen shots showing the date. An SOP will be written up and provided to auditors to make sure we are complying with requirements.

Condition: Pell Grant disbursement data was not submitted to COD within the 15-day federal requirement due to a system error. Corrective Action: The Financial Aid Office, in collaboration with Bursar, will implement an automated alert system to flag pending COD submissions and conduct reconcilitions twice monthly. Responsible Party: Director of Financial Aid and Bursar Completion Date: January 31, 2026 Monitoring: Monthly COD reporting review with Vice President for Administration & Finance.

Congressionally Mandated Projects - Assistance Listing #66.202 Recommendation: We recommend that the City strengthen its internal controls over federal reporting requirements to ensure timely compliance with all federal reporting deadlines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Department personnel inquired, through their contact for the grant, about the reporting requirements. Multiple reimbursement requests were submitted and the all payments were received. No notification was received regarding any missing reports. As of 7/24/2025, all reporting was up to date. Name(s) of the contact person(s) responsible for corrective action: Angie Murray Planned completion date for corrective action plan: 7/24/2025

Management agrees with the finding and will evaluate expenditures of federal awards each year to ensure the filings are done timely.

United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: 2 students of the 22 students selected for eligibility did not maintain academic satisfactory progress and were on probation but did not receive notifications. Auditors’ Recommendation: We recommend that the University review its satisfactory academic progress policy to ensure that all notifications are completed as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a new SIS and Financial Aid processing system. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2025

We have changed the process so all contracts are collected at the SAU central office to ensure completeness.

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033 Recommendation: We recommend the College strengthen its internal controls to ensure timely identification of students not meeting SAP standards. Additionally, the College should work with its system administrator to resolve the SAP calculation issue or implement an alternative method for tracking SAP compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CGCC has completed a thorough review of its Satisfactory Academic Progress (SAP) policy to ensure alignment with the capabilities and limitations of our current system. We remain committed to resolving ongoing system-related issues and are actively keeping the policy and system functionality in sync as improvements are made. The issue regarding SAP not calculating correctly is still in progress. We have been working closely with Anthology to identify and implement long-term solutions. Unfortunately, the necessary fixes require significant time and manual intervention. Despite these challenges, we have made progress: as of Spring 2025, we are now able to accurately identify affected students—something that was not possible during the 2023–2024 award year. Additionally, we are in the process of hiring a Financial Aid Director. This added leadership and support will help us address the remaining issues more efficiently and continue making meaningful progress toward full resolution Name(s) of the contact person(s) responsible for corrective action: Denise Reid-Strachan Planned completion date for corrective action plan: 9/1/2025

Finding 2024-03 Insufficient Documentation Supporting Payroll Activity Condition: During testing of payroll claims, we noted that the Organization did not consistently maintain documentation of approved pay rates. Some employees had offer letters on file, while others did not. In certain cases, the offer letters on file contained pay rates that did not match the actual pay rates being paid. Although our procedures and inquiries confirmed that employees were paid the correct amounts in accordance with approved procedures, the approved documentation was not consistently retained. In addition, we noted that the Organization did not maintain properly completed and approved I-9 forms for all employees during the year. Corrective Actions Taken or Planned: The organization recognizes the importance of maintaining complete and accurate payroll documentation and acknowledges the deficiencies identified during the audit. While payroll payments were made accurately, we recognize that inconsistent retention of supporting documentation created a compliance risk. Certain documentation had been maintained in digital form by a former staff member. Due to staff turnover, these records were not readily accessible or able to be located during the audit period. Management has since initiated a process to update all employee files with current, complete, and properly executed documentation to ensure compliance and improve recordkeeping practices. Management and leadership remain committed to strengthening personnel file management, maintaining all required documentation in accordance with applicable regulations, and reinforcing oversight to prevent recurrence in future audit periods. The Organization plans to execute the following: 1. Standardization of Employee Files - The Organization has implemented a standardized checklist for all employee personnel files to ensure the presence of: + Signed offer letters with approved pay rates + Completed and verified I-9 forms + Any subsequent pay rate change approvals - Co-Executive Directors will be required to complete and sign the checklist for each employee file upon hire, and again during annual compliance reviews. 2. Offer Letter and Pay Rate Documentation - Effective immediately, all employees (existing and new) will have a signed offer letter or addendum on file reflecting their current pay rate. - For employees where discrepancies exist between historical offer letters and current pay, updated pay rate addendums will be drafted, signed by both employee and management, and placed in their personnel files. 3. I-9 Form Compliance - The organization will perform a full review of all current employee I-9 documentation to identify and correct any missing or incomplete forms. - Going forward, I-9 forms will be completed and verified on or before the employee’s first day of work, in accordance with federal requirements. - An annual HR compliance audit will be conducted to ensure all I-9’s are up to date and retained properly. 4. Training & Accountability - Administrative staff will receive refresher training on employment documentation requirements, including I-9 compliance and payroll authorization documentation. - The Co-Executive Directors will review a sample of personnel files quarterly to verify compliance and hold Co-Executive Directors accountable for maintaining accurate documentation. To ensure continued compliance, the Organization will maintain a centralized file tracking system, updated quarterly, and report results to the Board. Corrective actions will be taken immediately if gaps are identified.

Corrective Action Plan & Response: RCRHA concurs with this finding and is taking comprehensive steps to address the issue and prevent recurrence. Specifically: 1. Revisiting AMA Consulting Group Proposal:_x000B_RCRHA is in the process of revisiting a formal proposal previously received from AMA Consulting Group, LLC, which outlines a detailed "Agency Health Check" for our Public Housing program. This proposal includes: • An operational audit of tenant files and eligibility documentation • Process mapping to improve workflow and accountability • Quality control implementation • Recommendations for electronic file storage and ongoing compliance monitoring.Engaging AMA is part of our long-term strategy to modernize internal operations and improve compliance. 2. Recent Staff Training: Nan McKay Rent Calculation Course:_x000B_To immediately address gaps in eligibility documentation practices, RCRHA staff participated in the Nan McKay HCV and Public Housing Rent Calculations Course in Washington, NC._x000B_The three-day seminar provided comprehensive instruction in: • Income and asset verification under 24 CFR Part 5 • Adjusted income and allowable deductions • Total Tenant Payment (TTP) calculations for both HCV and Public Housing • Case study applications using HUD Form 50058.3. Internal File Review and Compliance Checklist Implementation:_x000B_RCRHA has initiated a review of all active Public Housing tenant files to ensure that required eligibility documents are present, accurate, and properly stored. A standardized checklist is being introduced to guide staff and ensure uniform compliance across all tenant records. 4. Electronic File System Evaluation:_x000B_In alignment with HUD best practices and our consultant's recommendation, RCRHA is evaluating the feasibility of transitioning to an electronic document management system to ensure long-term retention, audit readiness, and streamlined access to eligibility documentation. 5. Revised Calendar: RCRHA has revised their audit calendar that will begin no later than October following the fiscal year. Internal accounting has been briefed on the matter and will have additional oversight in place to monitor that audit timelines. The Board of Commissioners will monitor audit timelines and reporting schedules. 6. SEFA Preparation: There will be detailed cross walks performed by CFDA numbers that include program specific reporting requirements. Internal accounting will receive additional training in federal grant reporting and a review will be performed by the CEO and a second-level review will be performed by the external accounting consultant.RCRHA is committed to addressing the current findings with a multi-layered response that strengthens documentation procedures, promotes staff competency, and enhances our operational efficiencies.

Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertification Timeline • Annual: Start process 120 days before due date. • Interim: Complete within 30 days of household change. • Missed/Delayed: Notify Program Manager immediately and document reason. 2. Required Documentation • Income verification (pay stubs, benefits, child support). • Asset verification (bank/retirement statements). • Family composition docs (birth certificates, SSNs). • HUD-required forms. • Use EIV when available; seek third-party verification first. • All docs must be collected within 60 days of effective date. 3. File Standards • Use Resident File Checklist for each household. • Files must include all signed forms & verifications. • Store in approved secure system (electronic or paper). • Retain files 3 years after end of participation (longer if litigation/audit pending). 4. Internal Controls • Supervisory Review: 10% of files checked monthly. • Maintain clear audit trail (date notices, interviews, verifications). • Correct any deficiencies within 30 days. 5. Staff & Training • Staff handling certifications = annual HUD/HACC compliance training. • Document training completion in personnel file. 6. Monitoring • Quarterly compliance report on timeliness & file completeness. • Issues shared with Executive Director and Board. • Policies reviewed annually for updates. Roles • Housing Specialists: Complete recerts & file docs. • Supervisors: Monitor timeliness & review files. • Compliance Officer: Audit & reporting. • Executive Director: Oversight & resources. n Follow this checklist to ensure timely recertifications, complete documentation, and avoid audit findings.

Condition Found: Per 2 CFR § 200.512(a), the auditee must submit the data collection form (DCF) and reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report(s), or nine months after the end of the auditee’s fiscal year. The audit for the year ended December 31, 2023, was not submitted to the Federal Audit Clearinghouse until DATE, which is after the required submission deadline of September 30, 2024. Individual(s) Responsible for Corrective Action: Lynda P. Goldthwaite, Executive Director and Stacey Matott, Director of Finance Planned Corrective Action: With the debt work out in place, management should continue to follow procedures in place to ensure the timely completion of future audits and submission of the reporting package to the Federal Audit Clearinghouse. Anticipated Completion Date: September 30, 2025

Policy Implementation: The Town is developing and implementing a written internal policy and checklist to ensure full compliance with suspension and debarment requirements for all federally funded projects. This policy will include procedures for: o Conducting and documenting searches in the SAM.gov Exclusions system, o Requiring written certifications from all contractors and subcontractors, and o Ensuring that federal compliance clauses are incorporated in all future contracts funded with federal dollars. 2. Engineering Oversight Coordination: The Town acknowledges that coordination with its contracted engineering firm(s) is essential in maintaining federal compliance. Moving forward, we will work closely with our engineers to verify and document that all contractors and subcontractors meet federal eligibility requirements prior to award and contract execution. 3. Training and Compliance Awareness: The Town will ensure that applicable municipal personnel, as well as project managers working with federal grant funds, receive training or instruction on Uniform Guidance procurement standards, including suspension and debarment protocols.

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal requirements for allowable activities. Name, address, and telephone of District contact person: Jennifer Larson, Executive Director of Finance 124 E. Lawrence Street Mount Vernon, WA 98273 360-428-6110 Corrective action the auditee plans to take in response to the finding: The district concurs with the finding and has taken corrective action. The employee referenced in the findings is no longer employed by the district. Throughout the months-long investigation performed by OSPI, the district worked to implement changes in our internal controls to ensure strong oversight of Migrant Education Program (MEP) grant compliance, including the eligibility determination process. Changes to internal controls include: • A monthly audit of the families who were visited that month. • A trained program recruiter will conduct the eligibility interviews and home visits. • Recruiter will work with regional trained recruiter for support. • A spot check audit of students determined to be eligible district program director. • Monthly logs from staff identifying students they worked with and services provided. • Monthly meetings between MEP district director and MEP regional program manager to ensure ongoing grant compliance. • Monthly meetings with MEP Parent Advisory Committee for ongoing feedback of services provided. • Appropriate staff including the program director are required to attend Migrant grant training provided by OSPI. We thank OSPI and the Washington State Auditor’s Office for their work and collaboration. We will continue regular monitoring of the Migrant Education Program in the Mount Vernon School district to ensure compliance with all program requirements and only eligible students are being served. Anticipated date to complete the corrective action: August 31, 2025

Major Federal Award Programs Audit: Section 8 New Construction and Substantial Rehabilitation, Federal Assistance Listing Nunber 14.182 a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In connection with out lease file review, we noted the following deficiencies: 3 out of 16 existing tenants tested did not have the Enterprise Income Verification (EIV) form completed within 120 days, as required by HUD. 1 out out of 16 existing tenants tested income reported on HUD Form 50059 did not agree to income verified using the Enterprise lncome Verification (EIV). 10 out of 16 existing tenants tested did not have the annual recertifications done timely. 1 out of 2 former tenants tested did not have security deposit returned within 30 days of departure, as required by HUD.- b. Action(s) Taken or Planned on the Finding At the time of tenant file review, the current staff was not made aware of EIV documents stored in a separate area in the office. This since has been corrected and the EIV information is now in the tenant files. Management was aware due to staffing issues of the annual recertifications being behind. We have resolved the staffing issues and have a Compliance Manager that monitors this now whom help the site with any questions to bring all tenants up to date. With staffing issues being updated we are working with them to make sure to process security deposit refunds in a tinely matter.

The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.

Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creating a temporary strain on resources. The few instances of noncompliance noted in the finding were missed during this influx. Management is actively reviewing intake procedures to ensure capacity adjustments are made in response to future changes in referral patterns.

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has controls in place to properly verify assets for cases when required and ensure reviews are being performed consistently with documentation retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure casefiles are reviewed consistently and document that review. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer, Amie Gendron Administrative Services Supervisor Planned completion date for corrective action plan: December 31, 2025

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410, H8N53897, and H8L50850 for 2024 Finding 2024-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in September 2024 We agree with the auditors finding. We acknowledge that, within the current audit sample of 57 patient files, 2 were found to contain instances of noncompliance with the Sliding Fee Scale (SFS) requirements. We recognize the importance of full compliance and remain firmly to continuous improvement in this area. It is important to note that this represents a significant improvement from the prior year’s audit. The identification of only 2 errors out of 57 patients’ files selected highlights the effectiveness of the corrective actions plan we implemented in response to the previous finding. Corrective Actions and Improvements Implemented: 1. Staff Training- Following the prior audit, front desk staff received additional training emphasized accurate application of SFS policies, required documentation, and proper income verification protocols. 2. Internal Auditing- Beginning in September 2024, The CEO designated the Compliance Officer to conduct daily audits of SFS related documentation. These real time audits help identify and correct issues promptly, with findings continuously incorporated into staff training programs. While we are encourage with the progress made, we remain focused on achieving full compliance and will continue to refine our processes and training to meet that goal. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Daniel Desire, CFO

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.