Corrective Action Plans

Finding No.: 2023-004 Federal Agency: U.S. Department of Agriculture AL Program: 10.555 Child Nutrition Cluster Federal Award No.: 7GU300GUB Area: Eligibility Questioned Costs: $0 Views of Auditee and Corrective Actions: GDOE agrees with the finding. GDOE did not published School Year 2022-2023 eligibility notifications for the community eligibility provision to the GDOE website by May 1, 2023 as required by the National School Lunch Act (NSLA). GDOE Child Nutrition Program (CNP) division is aware of the requirement and has publicly posted eligibility notifications to ensure compliance to NSLA. GDOE does not anticipate this will be an audit finding moving forward. Plan of action and completion date: The CNP Office has incorporated a calendar reminder within the CNP Office and updated the internal calendar of report due dates to facilitate the timely upload of the required information to the GDOE CNP website. Plan to monitor and responsible officials: The CNP State Administrator, Franklin Cruz, will ensure that CEP eligibility notifications are posted to the GDOE website by May 1 of every year to be in compliance with the reporting requirements of the NSLA.

CAMcare has made significant changes to the patient payment collection process. Updates were made to the Patient Payments, Refusal to Pay, Waiver/Reduction of Charges Policy, Sliding Fee Scale Policy, and Patient Payments Policy, and a Patient Payments Policy was introduced. The new EMR system allows for individual Patient Service Representatives (front desk personnel) to monitor management's adherence to collection efforts.

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will be reuqiqred to complete training courses in 2024. Property clerks and leasing specialists will be required to complete Rent Calculation courses that coorelate to their program type. HACFM is actively working on creating operation procedures and process manuals. the Procedure manaul will include the following reuqirements: Annual recertificaton packets will be sent to the resident 120 days from the houshold's annual effective date. Submission of reuqired documentation from resident will be enforced according to the lease agreements. A certification review checklist to support staff in ensuring all documnetation is in the file and all requried signatures are present. The Checklist will ensure that the submitter is verifying the file, the property manager has certified the file prior to finalizing the review in the tenant software program and uploading the file to the records. The property manager is reuqired to conduct 5% audit of the files monthly and correct any deficiencies found. An audit checklist will be created to support this required task. The management analyst position is required to audit 5 random files from each site on a quarterly basis. Ans audit checklist will be createdto support this required task.

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will be reuqiqred to complete training courses in 2024. Property clerks and leasing specialists will be required to complete Rent Calculation courses that coorelate to their program type. HACFM is actively working on creating operation procedures and process manuals. the Procedure manaul will include the following reuqirements: Annual recertificaton packets will be sent to the resident 120 days from the houshold's annual effective date. Submission of reuqired documentation from resident will be enforced according to the lease agreements. A certification review checklist to support staff in ensuring all documnetation is in the file and all requried signatures are present. The Checklist will ensure that the submitter is verifying the file, the property manager has certified the file prior to finalizing the review in the tenant software program and uploading the file to the records. The property manager is reuqired to conduct 5% audit of the files monthly and correct any deficiencies found. An audit checklist will be created to support this required task. The management analyst position is required to audit 5 random files from each site on a quarterly basis. Ans audit checklist will be createdto support this required task.

All Nations Health Center has switched EHR systems that allows for intake coordinators to suspend/pause eligibility status until all proper documentation has been obtain from the client, scanned into the system, and filed appropriately.

Management Response #2023-008: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. The Corporation also failed to provide sufficient support to verify that the applicant signed the Rights and Obligations statement. Corrective Action Plan: • All eligibility verification data, including screenshots and signed Rights and Obligations statements, will be stored in a centralized, secure shared drive maintained and managed by the WIC Director to ensure it is protected with limited access and password protection. The drive will be organized using a de-identified naming convention to ensure privacy while maintaining ease of access for authorized staff. • To maintain a robust system of checks and balances, tasks related to eligibility verification and documentation will be divided among different team members. This separation will prevent any one individual from having full control over the process, reducing the risk of oversight or potential errors. • The WIC Department’s policy and procedure manuals will be revised and updated to include the new eligibility verification process. • To ensure adherence to the new protocols, periodic audits and review sessions will be conducted by the WIC Director or designated compliance staff to verify that documentation is being properly maintained and that all procedures are followed. Staff will be required to undergo refresher training sessions as needed to reinforce the updated protocols and best practices. Responsible Party: Tracy Harrison, COO

Cluster Name: Student Financial Assistance Cluster Assistance listing numbers and names: Northern Arizona University 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins Loan Program—Federal Capital Contributions 84.063 Federal Pell Grant Programs 84.268 Federal Direct Student Loans 84.379 Teacher Education Assistance for College and Higher Education Grants (TEACH Grants) 93.364 Nursing Student Loans 93.925 Scholarships for Health Professions Students from Disadvantaged Backgrounds—Scholarships for Disadvantaged Students (SDS) Agency: Northern Arizona University (NAU) Name of contract person and title: Bradley Miner, NAU Associate Vice President and Comptroller Anticipated Completion Date June 30, 2024 Agency’s Response: Concur The University agrees with this finding and although it relies on the Federal agencies for valid identity verification, the University has already taken significant corrective action to proactively monitor and detect fraudulent student identities. The University has various internal controls, system fraud controls, and integrity measures in place as required or identified as industry best-practice to mitigate and prevent the increasing sophistication of fraudulent activity. In academic year 2023 the University had 282 online students selected for Verification by the Department of Education (ED). The 8 isolated fraud instances were the only identified fraud cases. The University receives valid identity verification checks from the Department of Education (ED) as an input for creating student profiles. Additionally, the University works with administrative agencies and leverages FAFSA checks conducted by Social Security Administration (SSA), Department of Veteran Affairs (VA), Department of Homeland Security (DHS), National Student Loan Data System (NSLDS), Department of Defense (DOD), Department of Justice (DOJ). Financial Aid does not disburse until enrollment verification is complete. 1. The University has reviewed prior fiscal years to determine if additional fraudulently enrolled students received student financial assistance, and if fraudulent loans and awards were awarded. The University conducted an in-depth analysis of multiple qualitative attributes of students receiving financial assistance. This analysis identified high risk students receiving loans and awards. Students in this population were required to complete V4 verification. 2. The University implemented anti-fraud measures as an alternative to automated student Internet Protocol (IP) verification. During the analysis to identify fraudulently enrolled students, the University identified programs at high-risk for fraudulent activity. As a proactive fraudulent activity identification measure, the University will require all students in high-risk programs, with active FAFSAs to submit and complete V4 identity verification. This anti-fraud measure will identify fraudulently enrolled students prior to the disbursement of student financial assistance including loans and awards. 3. The University has put in to place a number of additional verification measures and detective controls to validate online student identities and check for repetitive information and trends. The University is conducting feasibility studies to determine if the suggested guidance for Internet Protocol student verification abides by certain security and privacy standards and policies. Additionally, the University has concern with fraudsters ability to mask Internet Protocols by deploying Virtual Private Networks (VPNs). This renders the advanced protocols ineffective. As a compensating control, the University will begin selecting 5% of online students for V4 verification. Random sampling of online students for identity verification provides enhanced detective measures to combat the risk of identity theft for use in financial aid fraud. Additionally, the University put in place several upfront measures to detect repetitive information and trends to identify potentially fraudulent activity. Detective monitoring reporting identifies duplicate deposit information, redundant student email information, and duplicate student address information. The Department will continue to utilize these successful anti-fraud measures to proactively identify fraudulent student identities. 4. The University will continue its efforts working with law enforcement agencies to recover improper payments for fraudulent claims it paid due to identity theft, to the extent practicable. The University worked with law enforcement agencies to investigate the fraud. At the conclusion of the investigation $138,135 has been repaid. The University will continue to partner with federal, state, and local law enforcement agencies and financial institutions across the country to recover losses and aggressively pursue legal action against perpetrators of fraud.

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS concurs with the finding in this audit and would like to note this finding is related to no notice of disenrollment being mailed to a deceased member, and not related to enrollment ineligibility. AHCCCS Division of Member and Provider Services (“DMPS”) will identify the standard process for notification that should have been followed for this case. Once the root cause of the issue has been established, AHCCCS will assess current processes and procedures, as appropriate, to address this issue.

Assistance listing number and program name: 84.010 Title I Grants to Local Educational Agencies Agency: Arizona Department of Education (ADE) Name of contact person and title: Tim McCain, ADE Chief Financial Officer Chris Brown, ADE Business Officer of Education Programs Anticipated completion date: January 2025 Agency’s response: Concur • ADE is working on standardizing fiscal efficiency by adopting uniform guidelines that monitor obligations and expenditures. These guidelines outline available resources and determine allocation amounts within federal awards and earmark expiration dates within programs. • ADE is also working on standardizing how funds may be reallocated to ensure that no funds are at risk of reverting to USED. Specifically, school improvement funds are now also tracked as part of Title I allocation and reallocation process. This will ensure funds are earmarked and obligated in a timely fashion (i.e., in the period of performance). This item is planned to be completed by January 2025.

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, ADE Deputy Associate Superintendent Chris Brown, Business Officer of Education Programs Anticipated completion date: February 2025 Agency’s response: Concur • The Arizona Department of Education (ADE) has already begun to document and execute practices addressing the recommendations issued by the auditor's office. • ADE has already drafted a comprehensive policies and procedures document outlining eligibility, duties, and responsibilities with individuals who oversee and double-check the work. This document was created and refined by reviewing other states’ procedures, federal technical assistance groups, communications with the Title federal program office at the United States Department of Education, and internal procedures in other units. • The Title I unit has been restructured to have an operations team with multiple staff members overseeing data quality and internal controls for allocations. This updated structure ensures that multiple individuals are involved in the allocation process. Staffing for this should be completed by February 2025. • The updated processes include entity management to determine when charter LEAs open and operate each year. Now, other systems validate this information instead of copying the information from the prior year. As such, this item has already been completed. • Finally, the department will follow up with the United States Department of Education (USED) regarding recalculating the fiscal year 2023 and the six ineligible LEAs for Title II funds to determine feasible processes and resolutions to each audit recommendation.

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Department will review and confirm that benefits payments paid to or on the behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Follow existing policies and procedures to obtain required documentation to support requirements related to where the applicant lives and their income to ensure program applicants are eligible to receive benefit payments. The Department will abide by the existing adjudication policies and procedures that require the submission of substantiating documentation supporting the claims made by applicants regarding where they live and their household income to confirm that applicants are eligible to receive benefit payments under the program and to verify the amount of benefits they shall receive. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Department will attempt to obtain or allocate additional resources to staffing to support the program benefits application evaluation process and will provide additional training to staff on eligibility requirements and allowable benefit payment regulations. 4. Update the checklist Division personnel use to perform a post-review of eligibility determinations to include detailed guidance for verifying the determinations aligned with the Division’s written policies and procedures and supported by adequate documentation. The Department will update the checklist being used by staff to perform post-review of eligibility determinations to include detailed guidance on verifying the applicant benefits determinations in alignment with the divisional policies and procedures and evidenced by adequate substantiating documentation.

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

The County will continue to monitor supervisory and cross training processes.

Low-Income Home Energy Assistance – Assistance Listing No. 93.568 Recommendation: CLA recommends the County review controls and procedures surrounding file storage/retention to ensure files are being archived in accordance with Colorado Regulation 3.755.17 - Archiving Case Files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have completed the transfer of all our previous files and now scanning all new and current cases into a new database called Papervision. Each permanent technician will be responsible to scan their own cases into the database. Name of the contact person responsible for corrective action: Samantha Contreras Planned completion date for corrective action plan: New database has been implemented as of September 2024

2023-005 – ALN 14.871 – Housing Choice Voucher Program – Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

2023-002 – ALN 14.850 – Public & Indian Housing – Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

The CFO at TCA Health has addressed the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff were trained in the approved sliding fee scale policy and its requirements. The COO worked with the CFO and third-party billing company, and Athena to roll back the EMR update which contributed to ineffective application of the sliding fee in November 2023. TCA hired a full time Patient Services Manager in 2024 to support ongoing staff training, quality assurance monitoring, and implementation of the updated EMR and registration workflows. Staff have become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. Additionally, TCA began to undergo internal audits of records ensuring that proper documentation is maintained and a patient service manager, utilizing testing template provided by the organization’s auditor.

We have submitted the annual SAC filing as the prior year's audits have been completed. We expect the FY24 audit to be completed by the end of January 2025 and the SAC filing for the fiscal year will be completed shortly thereafter which will be prior to the deadline of nine months after the end of the audit period. Anticipated Completion Date-02/28/2025.Responsible Contact Person-Kathleen Boyce, CFAO

Finding 2023-003 Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendent will ensure MDE's approval is tangible before any obligations. We will implement a tool that allows this process to be measured daily. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Tiffany Lanier, Federal Programs Director Corrective Action Start Date: October 31, 2024

The University concurs with this finding but cannot respond why the student was awarded outside the of procedure and methodology set up for awarding HEERF Funds. The decisions were made by individuals no longer with the University and no documentation was found to determine why the student was awarded outside the policy in place. The Controller’s Office and Financial Aid Office are working together to make sure that in future funds like the HEERF will have documentation attached to secure that we follow procedure and policy and document any exceptions.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Homeland Security Passed through Cumberland County: Grant No. 39 5962 00 Grant No. ARPA R 5962 00 Emergency Food and Shelter National Board Program AL# 97.024 11/2021 12/2023 11/2021 12/2023 Passed through Salem County Board of Social Services Grant No. ARPA R 6028 00 11/2021 12/2023 Passed through Atlantic County Grant No. 39 5948 00 Grant No. ARPA R 5948 00 Passed through Cape May County Grant No. ARPA R 5960 00 Grant No. 39 5960 00 11/2021 12/2023 11/2021 12/2023 11/2021 12/2023 11/2021 4/2023 2023-006 -Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria Emergency Food and Shelter National Board Program (EFSP) funds may be used for food and related expenses (such as transporting food/food preparation and serving equipment); mass shelter; other shelter (such as hotels and motels); and rent/mortgage and/or utility assistance limited to one month. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. ,roj"':::;: Charities USt\, www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I "I'd: 856-342-4100 I Fax: 856-342-4180 Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: a W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. a Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I Tel: 856-342-4100 I Fax: 856-342-4180 Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Health and Human Services Temporary Assistance for Needy Families (TANF) - AL #93.558 Passed through Camden County Health Department: Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through Cumberland County Office on the Aging and Disabled Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through Salem County Board of Social Services Grant No. None Available 1/2022 12/2022 Grant No. None Available Passed through Gloucester County 1/2023 12/2023 Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through New Jersey Department of Human Services Division of Family Development Grant No. SF22009 10/2021 9/2022 Grant No. SF23009 10/2022 9/2023 2023-005 - Activities Allowed and Allowable Costs and Eligibility (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria TANF funds monthly cash assistance payments to low-income families with children. The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102-590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. ,,o,s::::;: C:h.1riries USA. www.catholiccharitiessouthjersey.org 1845 Haddon Avcll1le, Camden, NJ 08103 I Td: 856-342-4100 I Fax: 856-342-4180 Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. • Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I Td: 856-342-4100 I Fu.: 856-3424180 Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org stions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone ii address above.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Veterans Affairs Direct Award: Grant No. 12 NJ 053 55 Grant No. 12 NJ 053 22 VA Homeless Providers Grant and Per Diem Program AL# 64.033 9/2021 9/2023 10/2021 3/2023 Grant No. 12 NJ 053 HL 9/2021 9/2023 Grant No. 12 NJ 053 LT 8/2022 9/2026 Grant No. 12 NJ 053 23 9/2021 9/2023 2023-004 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102 590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive' assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: Theim.proper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to­ day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in Febr·uary 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB. Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Housing and Urban Development Emergency Solutions Grant Program AL# 14.231 Passed through State of New Jersey Department of Community Affairs: Grant No. 2019 02156 036106 8/2020 3/2023 Grant No. 2022 02156 0337 00 7/2021 7/2023 Grant No. 2022 02156 0339 00 4/2022 7/2023 Grant No. 2022 02156 0338 00 4/2022 9/2023 Grant No. 2022 02156 0052 08 12/2019 9/2023 Grant No. 2020 02156 0042 08 12/2019 9/2023 Grant No. 2020 02156 0042 04 12/2019 9/2023 Grant No. 2019 02156 0361OS 12/2018 9/2023 2023-003 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria ESG funds may be used for five program components: street outreach, emergency shelter, homelessness prevention, rapid re-housing assistance, and HMIS; as well as administrative activities. The five program components and the eligible activities that may be funded under each are set forth in 24 CFR 576.101 through 576.107. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. www.catholiccharitiessouthjersey.org 1845 Haddon A\-enue, Camden, NJ 08103 I Tel: 856•342-4100 I Fu: 856---3424180 Serving si.,;: counties of Southern Nev,1Jersey: Atlantic, Camden, Cape May; Cumbedand, Gloucester & Salem View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETD Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above. Robert T Waite, Controller

2023-001 – ALN 14.871 – Housing Voucher Cluster – Activities Allowed and Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024 2023-002 – Significant Deficiency in Internal Controls over Financial Reporting Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024