Corrective Action Plans

Finding Reference: 2024-010 - Eligibility (Board Office) Responsible Official: Dr. Casey Prestwood, Associate Commissioner for Academic and Student Affairs Corrective Action Planned: An evaluation form was developed and implemented to be used with each applicant review as a checklist of requirements. In addition, there is a second layer of review of all approved applicants’ eligibility prior to requesting disbursement of funds. An outside CPA firm was contracted in May 2024 to perform the second layer of review of each approved applicant before disbursement, to review all disbursement prior to that date in the current grant cycle, and to provide guidance on internal controls. An additional staff person to assist with grant awarding and programmatic operations was hired in August 2024. Estimated Completion Date: August 2024

xiii. Management Response and Corrective Action Plan: One of the individuals tested was identified as not being enrolled in the audited grant during the audit period. This is correct. The individual was exited from the program in the previous audit period and written documentation was uploaded to demonstrate this. However, the case manager neglected to exit the individual from HMIS during the previous audit period. This has been corrected. No services or funds were provided to this individual following their exit from the program. Our program has a good track record of data compliance and we expect this was an exception and not the rule. Program management will review and train staff again on data compliance during a weekly staff meeting, and will also counsel the involved staff member on the error to ensure there is no similar future error. xiv. Contact Person (s) Responsible for Corrective Action: Cassie Roach, Safe Parking Program Director, croach@sbnbcc.org Joel Goforth, Homeless Services Director, jgoforth@sbnbcc.org xv. Anticipated Completion Date: The anticipated completion date is April 30, 2025.

S3800-010: Finding Reference Number 2024-001 S3800-030: Statement of Condition: Management designed Control Activities to ensure compliance with the Eligibility requirement with respect to tenant eligibility. Those Control Activities include verification and review of tenant files by an independent contractor prior to finalization of new tenant move-in. However, during our testing, we noted five (5) move-in files out of five (5) move-in files tested where tenants were approved for move-in prior to review and approval by the independent contractor, circumventing the control. S3800-080: Auditor Recommendation: We recommend that the client immediately implement corrective actions to ensure compliance with internal control procedures. Specifically: 1. The compliance specialist should be required to wait for proper approval of tenant eligibility files before processing them. 2. Review and reinforce the approval process through additional training for staff to ensure they understand the critical importance of obtaining necessary approvals before proceeding. 3. Implement stronger oversight and monitoring mechanisms to ensure that files are not processed before approval. S3800-045: Actions Taken or to be Taken: Management has reviewed the policies and procedures with the property manager, who also serves as the compliance specialist. The property manager was instructed that no tenants are to be granted occupancy until the file has been approved by the independent contractor conducting the compliance review.

Corrective Action Plan: The Authority acknowledges the finding. Corrective actions to address the deficiencies are underway and include:  Updating internal policies and procedures related to tenant file documentation and income verification requirements;  Providing targeted sta􀀳 training on proper file documentation and third-party income verification procedures;  Implementing a mandatory checklist to ensure all required documentation is obtained and verified before finalizing recertifications;  Establishing a quality control process where supervisory sta􀀳 conduct periodic file reviews to ensure compliance;  Maintaining an audit trail of verification documentation to ensure proper retention.  Hired third-party service provider, Quadel to assist with tenant file documentation compliance, annual and interim recertifications and rent calculations.  Hiring Senior Housing Manager to assist with monitoring verification documentation, income calculation, citizenship and/or legal residency documentation, and signed release documentation compliance. Anticipated Completion Date: June 30, 2025 Responsible Party: Senior Manager of Housing Operations and PH Property Managers

We have determined that the sliding fee set up in our EHR will miscalculate a patient’s sliding fee discount when a combination of particular conditions are met. A representative of the EHR company has confirmed that the system “does not behave as it should” when these circumstances occur. While it is rare that a slide patient would meet all of these conditions, it does happen from time to time. Because of this, we have begun verifying the discounts applied to every slide patient’s account to ensure accuracy. Additionally, we are restructuring the sliding fee discount program and will rebuild it within the EHR to remove the possibility of one of the conditions occurring, which should prevent the system from ever miscalculating the discount to be applied. Person(s) Responsible: Kim Wieloch, Finance Director Timing for Implementation: Verifying all SFS discounts: Currently in process and ongoing; Rebuilding SFS calculation structure in EHR: By 7/1/2025

Name ofcontactperson: Julie B. Savino, Associate Vice President of Student Financial Assistance Corrective action: The University remains committed to maintaining compliance with federal requirements and ensuring accurate Free Application for Federal Student Aid (FAFSA) verification. Staff will continue to receive verification training through internal and external means to ensure the accuracy ofthe verification requirements. To address the identified issues, the University will strengthen verification policies and procedures by adding controls to prevent data entry errors. As part ofthese improvements, a secondary review process will require a Director level staff member to evaluate any Institutional Student Information Record (ISIR) updates or changes before finalizing the Student Aid Index (SAI) (previously known as Estimated Family Contribution EFC). Proposed completion date: April 15, 2025

Corrective Action Plan for Finding 2024-004 Community Care agrees with this finding. There are four bullets in this finding. We will be making a formal request to have the HMIS 72 hour data entry removed from our contract. The HMIS system does not have the capability to measure data entry timeframes because of this we would need to design a data entry tracking process to track the timeframes. If our request is denied, we will create an entry tracking process. Bullets 2-4 are results of providing services in from the perspective of a low barrier service. Our priority is to have youth come to a safe place that is warm and where they are provided with a place to sleep, food, healthcare, and services to aid them. Staying in the program is not contingent on completing assessments or engaging in a service planning process. Each time a youth is in a program they are provided with the opportunity to participate in an assessment and are offered an organized service plan. Most participate but some do not. We will continue to offer the same level of support and opportunity for assessments and service planning to each youth. • There was no auditable evidence to test whether the participants were entered into HMIS within 72 hours. • Four participants did not have a service plan developed within 30 days. • The client was unable to provide the NavSEA for three participants. • The service plan for one participant did not have documented review. Responsible Official: David McCluskey, Executive Director Date of Corrective Action: Systems are in place and efforts will continue to encourage youth to participate in assessments and service planning practices. Regarding the HMIS data entry request will be made Friday the 21st March, 2025. If denied we will build a tracking process within 30 days.

2024-004 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth Activities participants. Action Taken: The Board has established policies and procedures to strengthen eligibility verification for the Youth program participants. These policies outline clear documentation requirements, verification steps, and staff responsibilities. Staff involved in eligibility determination have been trained on the new procedures to ensure consistency and compliance with federal and state guidelines and will receive ongoing training and technical assistance. The Board has implemented internal controls, including multi-level verification and supervisory review to ensure the accuracy and completeness of participant eligibility determinations.

Health Resources and Services Administration Jacquelyn Kilmer, Harlem United Community AIDS Center, Inc.’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024 The findings from the June 30, 2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT Material Weakness Item 2024-001 - Accounting for Leases The Organization adopted Financial Accounting Standards Board ("FASB") Accounting Standards Update ("ASU") 2016-02 (as amended), Leases (Topic 842), on July 1, 2020. Topic 842 required lessees to recognize a right-of-use asset and a corresponding lease liability for virtually all leases. The Organization did not apply Topic 842 for approximately 300 lease agreements for scatter sites that are part of the Organization's Housing Assistance Program. Recommendation We recommend that the Organization read and review all of its lease agreements to ensure that they are properly accounted for under Topic 842. Action Taken We agree with the finding. Management has already implemented a review of all of its existing lease agreements to ensure that we are accounting for them properly under Topic 842. We are also in the process of reviewing our accounting policies in relation to leases. Effectivity Date: July 2024 FINDINGS FEDERAL AWARD PROGRAM AUDITS Significant Deficiency Item 2024-002 - Procurement, Suspension and Debarment - U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Projects of Regional and National Significance (Assistance Listing Number 93.243) Notice of Award Number 1H79SP082826 for 2023-2025 and Notice of Award Number 5H79TI085189 for 2023 to 2024 The Center did not maintain documentation of its verification of two sample employees and two sample vendors to ascertain if they are suspended or debarred. Recommendation: We recommend that the Organization implement a policy requiring proper documentation of their verification of employees and vendors for suspension and debarment. Action Taken: Management agrees that evidence of exclusion search was not maintained or kept on file. Management has already established a policy in relation to performing verification for suspension and debarment and the Organization will be training all the personnel involved to ensure that proper documentation is kept on file. Effectivity Date: March 2025 Sincerely yours, Signature:  Jacquelyn Kilmer, CEO Harlem United Community AIDS Center, Inc.

Finding 2024-002 – Low Income Public Housing Tenant Files – Eligibility – Noncompliance & Material Weakness – Public and Indian Housing – ALN #14.850 Corrective Action Plan: The Housing Authority has contracted with US Inspections to continue pre-inspecting units in preparation for NSPIRE inspections. Additionally, staff is coordinating Income Calculation training with Zeffert University. Lastly, the Housing Authority has implemented a 100% file compliance review, which took effect on January 1, 2025. Person Responsible: Tammy Bradshaw, Admissions & Compliance Manager Anticipated Completion Date: June 2025

Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office will be implementing an SOP which will document a review process of work done by the third-party processor, to include COD reporting, and Verification procedures. We will also be implementing a process to review students who need to complete their exit counseling. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025

The sliding fee schedule has been updated several times in the last 24 months with subsequent staff training. Beginning in December 2024 our organization will begin charging a nominal fee then accurately utilizing sliding discounts based on income levels/family size. The organization has also increased training in processing and entering the collected patient income forms and sliding fee schedule packet of forms needed to accurately account for providing the patient with the sliding fee schedule adjustment.

Management agrees with the finding and recommendations, but also has determined that this finding will not be repeated in future years, as the arrearages program has come to a close.

Interim corrective actions: These cases involved situations where students dropped courses before withdrawing (officially or unofficially) from all courses. UW-River Falls did not have a system in place to review course participation for courses which students dropped prior to withdrawal, although it has procedures in place to review course participation for enrolled courses at the time of withdrawal and when students are assigned failing grades. For Fall Semester 2024: Existing procedures: 1. Official withdrawals: Students officially withdrawing from the University must complete an electronic form which collects instructor verification of course participation. The Financial Aid office receives this form once it has been processed by the Registrar’s office. Students reported as not having participated in courses have their financial aid adjusted prior to calculating a return to Title IV funds. 2. Unofficial withdrawals: Instructors assigning failing grades to students must report student’s course participation or non-participation and, if available, a last date of course participation. Following the grading deadline, a report listing all students who never participated in classes is run and students found to have failed courses due to non-participation have their financial aid adjusted prior to calculating a return to Title IV funds. Additional procedure instituted: 3. Learning management system review: Students who withdraw (officially or unofficially) and who dropped courses prior to withdrawing had their dropped courses reviewed in the Learning Management System (LMS). Students who submitted assignments as recorded in the system were determined to have begun participation in the course. Students who submitted no assignments were determined to not have participated in the course and financial aid was adjusted prior to calculating a return to Title IV funds. For Spring Semester 2025: Existing procedures: 1. Procedures 1,2, and 3 from Fall Semester 2024 continue to be employed for Spring semester 2025. Additional procedures: 2. Expanding the LMS review to Pell grant students with dropped courses: Students with disbursed Pell Grants who drop courses after the Pell grant census date now have these courses reviewed to determine if the student began attendance before dropping the course, using the same procedure as #3 above.Instructor course participation verification: After the 3rd week of classes for Spring 2025, UWRiver Fall requested that instructors report students who had not begun participation in their courses. This report is currently being reviewed and students with Pell grants will be evaluated to determine if an adjustment to the student’s enrollment intensity is needed to ensure that the disbursed Pell grant is accurate. Student who have begun participation in no enrolled courses will be reviewed for possible return of all Title IV funds. Future additional corrective actions: 1. UW-River Falls will pursue making course participation verification by instructors during the first month of the semester an administrative policy and develop formal procedures for surveying instructors and reporting students found to not have begun participation in a course or courses to the Financial Aid office for adjustments to their disbursed Title IV aid. 2. UW-River Falls will pursue adding an instructor course participation step to the course drop form currently in use by the Registrar’s office. Anticipated Completion Date: Interim actions were implemented in September 2024 and February 2025. Permanent action expected by Spring 2026. Person(s) responsible for corrective action: Cindy Holbrook, Executive Director of Enrollment Management Cindy.Holbrook@uwrf.edu 715-425-3500 Robert Bode, Director of Financial Aid and Military/Veterans Resource Center Robert.Bode@uwrf.edu 715-425-3141 Kelly Browning, University Registrar Kelly.Browning@uwrf.edu 715-425-3342 Responsible Unit Division of Enrollment Mangagement

Wisconsin Department of Health Services Planned Corrective Action: This FY 2022-23 finding continued through SFY 2023-24 because the public health emergency unwinding was completed after June 30, 2024, for this population. No new concerns were identified by LAB during their FY 2023-24 audit. Corrective actions began during SFY 2023-24, and DHS completed a final analysis in November 2024. As part of this process, all outstanding cases were resolved. After the analysis was completed, DHS implemented an ongoing monthly monitoring plan with the IM agencies, which was outlined in the CARES Coordinator Notice (CCN) dated January 27, 2025. Anticipated Completion Date: January 27, 2025Persons responsible for corrective action: Autumn Arnold, Director Bureau of Eligibility and Enrollment Policy, Division of Medicaid Services autumn.arnold@dhs.wisconsin.gov Jonelle Brom, Director Bureau of Eligibility Operations and Training, Division of Medicaid Services Jonellem.Brom@dhs.wisconsin.gov Dave Varana, Director Bureau of Fiscal Accountability and Management, Division of Medicaid Services Dave2.Varana@dhs.wisconsin.gov

Planned Corrective Action: The Office of the Commissioner of Insurance accepts the Legislative Audit Bureau’s recommendation to ensure claims meet eligibility requirements and include appropriate documentation. The following corrective actions are planned: • A spreadsheet is used to collect claims service and payment dates. A formula will be applied to either restrict or flag dates outside the allowable period. • Insurance carriers will be notified of the formula change and reminded to only include claims that were paid within the allowable period. Anticipated Completion Date: The PY 2025 spreadsheet will be updated by February 2025 and insurance carriers notified when provided the updated spreadsheet for PY 2025 reporting. Reporting for 1st quarter 2025 is due in May 2025. Person responsible for corrective action: Rebecca Easland, Deputy Commissioner of Insurance Rebecca.easland@wisconsin

Planned Corrective Action: As the auditors noted, the Department of Administration implemented the policies and procedures it developed to review and assess the service organization audit report for the Homeowner Assistance Fund to establish and maintain effective internal control over federal awards. Anticipated Completion Date: October 2, 2024 Person responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.

Description of Corrective Action Plan: Shoals Community School Corporation’s Director of School Nutrition, Tamara Florio, will ensure that all time cards are signed by the employee and by herself before submitting to the Payroll Administrator, Darla Holt. Responsible Party and Time and Timeline for Completion: Tamara Florio, Director of School Nutrition-this will be implemented immediately, this 2024-2025 school year.

2024-001 Notification of Disbursements (Significant Deficiency) Criteria: Prior to making a disbursement, the school must notify students of the amount and type of Title IV funds they are expected to receive, and how and when those disbursements will be made (often referred to as an award letter or college financing plan) (34 CFR 668.165(a)(1)). Condition: One out of twenty-five undergraduate students selected for disbursement testing for the 2023-2024 academic year was not documented as having been notified prior to the disbursement of Title IV funds. Notification failed to occur after the student's enrollment status changed from half-time to three-fourths time enrollment, making them eligible for additional Pell Grant awards. Action Taken: The University will request assistance from the software provider and consultants to develop a notification process for when a student’s enrollment status changes from half-time to three-fourths time enrollment. Responsible Party: Emily Williamson, Financial Aid Director Point of contact: Emily Williamson, Financial Aid Director Williamson_e@lynchburg.edu (434) 993-8253 Expected date of correction: June 1, 2025

View of Responsible Officials: A policy for notifying applicants of changes to Expected Family Contribution (EFC) or financial assistance resulting from the verification process is contained in the Delaware College of Art and Design (DCAD) Approval, Delivery, and Disbursement of Title IV Funds Policies and Procedures in Section III Item d. (previously submitted). Should any of the students’ financial aid change or increase, FAO emails the student Updated Financial Aid Award Letters reflecting the changes. A copy of the student’s Need Analysis/Award Updates is also given to the Bursar. The two other omissions in the finding were correctly noted as not written in DCAD’s policy. No planned corrective action is necessary due to the College’s closure.

Department of Justice 2024-001 Crime Victim Assistance Program Auditor’s Recommendation: We recommend Community Crisis Center, Inc. continue to review its files to ensure that all client files contain the required confidentiality and intake forms. We also recommend Community Crisis Center, Inc. implement and enforce a policy to obtain the signed forms for all new clients and get any signed forms as soon as possible for any current clients. Additionally, Community Crisis Center, Inc. should conduct regular training and monitoring of employees to ensure confidentiality best practices are followed. Action Taken: Community Crisis center, Inc. will review files to ensure that confidentiality forms and intakes are present on a daily, monthly and quarterly basis for accuracy. In Addtiion, training will be provided to all new staff upon hiring, with quarterly reviews thereafter. If the funding agency has questions regarding this plan, please call me at 847-742-4088.

Boston Public Schools has revised its’ eligibility record keeping process to ensure that records are accurate and complete. This adjustment to record keeping practice has been instituted beginning with the FY25 grant application cycle. Anticipated Completion Date: June 30, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov