Corrective Action Plans

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2024-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2024-010 Inadequate Request for Information Name of contact: Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Section III - Federal Award Findings and Question Costs Family and Children's Medicaid Supervisor will be randomly checking at least 10 cases a month to ensure if accurate information is being entered. Also, prior to submitting work, cases will be randomly check by supervisor and/or lead work to ensure the correct information is being entered. Supervisor will be implement refresher training in the Learning Gateway. Adult Medicaid Supervisor will be meeting with staff to put into place that prior to case termination, case be reviewed by supervisor and/or lead-worker to ensure that all proper procedures have been followed before terminating a case. Supervisor will also implement refresher training for all caseworkers thru Learning Gateway. Supervisor will continue to randomly check at least 10 cases to track any error trends and then discuss any errors or trends with worker and/or unit. These procedures will be implemented November 2024. Also a program manager will be hired in the month of November 2024 as an additional source in helping with reports and providing additional training to staff who may be needing additional help. Supervisor will be checking at least 10 records a month with focus on IV-D entry and documentation. Meeting with staff to ensure child support information is being obtained, documented and entered if needed. Supervisor will be implementing Learning Gateway training for the staff and/or one on one training. These procedures will be implemented in November 2024. Also, a Program Manager will be hired in November 2024 to assist with trainings and any other additional help staff may be needing. 149

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2024-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2024-010 Inadequate Request for Information Name of contact: Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Section III - Federal Award Findings and Question Costs Family and Children's Medicaid Supervisor will be randomly checking at least 10 cases a month to ensure if accurate information is being entered. Also, prior to submitting work, cases will be randomly check by supervisor and/or lead work to ensure the correct information is being entered. Supervisor will be implement refresher training in the Learning Gateway. Adult Medicaid Supervisor will be meeting with staff to put into place that prior to case termination, case be reviewed by supervisor and/or lead-worker to ensure that all proper procedures have been followed before terminating a case. Supervisor will also implement refresher training for all caseworkers thru Learning Gateway. Supervisor will continue to randomly check at least 10 cases to track any error trends and then discuss any errors or trends with worker and/or unit. These procedures will be implemented November 2024. Also a program manager will be hired in the month of November 2024 as an additional source in helping with reports and providing additional training to staff who may be needing additional help. Supervisor will be checking at least 10 records a month with focus on IV-D entry and documentation. Meeting with staff to ensure child support information is being obtained, documented and entered if needed. Supervisor will be implementing Learning Gateway training for the staff and/or one on one training. These procedures will be implemented in November 2024. Also, a Program Manager will be hired in November 2024 to assist with trainings and any other additional help staff may be needing. 149

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2024-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2024-010 Inadequate Request for Information Name of contact: Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Section III - Federal Award Findings and Question Costs Family and Children's Medicaid Supervisor will be randomly checking at least 10 cases a month to ensure if accurate information is being entered. Also, prior to submitting work, cases will be randomly check by supervisor and/or lead work to ensure the correct information is being entered. Supervisor will be implement refresher training in the Learning Gateway. Adult Medicaid Supervisor will be meeting with staff to put into place that prior to case termination, case be reviewed by supervisor and/or lead-worker to ensure that all proper procedures have been followed before terminating a case. Supervisor will also implement refresher training for all caseworkers thru Learning Gateway. Supervisor will continue to randomly check at least 10 cases to track any error trends and then discuss any errors or trends with worker and/or unit. These procedures will be implemented November 2024. Also a program manager will be hired in the month of November 2024 as an additional source in helping with reports and providing additional training to staff who may be needing additional help. Supervisor will be checking at least 10 records a month with focus on IV-D entry and documentation. Meeting with staff to ensure child support information is being obtained, documented and entered if needed. Supervisor will be implementing Learning Gateway training for the staff and/or one on one training. These procedures will be implemented in November 2024. Also, a Program Manager will be hired in November 2024 to assist with trainings and any other additional help staff may be needing. 149

Finding 2024-005 Inadequate Request for Information Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-006 FNS Eligibility Determinations Name of Contact Person: Alice Wilson, FNS Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs (continued) The county will conduct refresher training on how and when to request information needed that includes when to request The Work Number, OVS,AVS, Property checks and Register of Deeds checks. The county will conduct a targeted second party of cases to check the effectiveness of the refresher training provided. 4/1/2025 Section IV - State Award Findings and Questioned Costs Corrective Action Plan for Finding 2024-002, 2024-003, 2024-004, 2024-005 also apply to State Award Findings. All FNS staff will attend a refresher training where sections 435, 505 and 510 will be reviewed. This training will be conducted by Supervision in FNS with the support of the FNS lead staff. This training will include an outline of the requirement for supporting documentation of eligibility and benefit determinations to include verifications used to support such determination at application and recertification where appropriate. All relatable NC FAST job aids will be reviewed with staff to ensure that functionality within the NCFAST system is followed. 3/1/2025

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-004 Inaccurate Resources Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: The County recognizes that through our transition in software we have fully reconciled all fixed asset transactions. Going forward, County finance staff will thoroughly track and reconcile all fixed assets annually. Along with reconciliation, the process of purchasing and recoding asset transactions has been modified, to include various checks and balances. Completed 7/1/2024 Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings 4/1/2025 Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and continues to demonstrate the successfullness as the error for 2024 was one error. For the Year Ended June 30, 2024 Corrective Action Plan Staff will receive refresher training on updating the evidence dashboard at redetermination of eligibility that will be conducted by Supervision. The documentation template for Recertifications will also be updated to include a line item for caseworkers to document that the evidence dashboard has been updated. Lead staff will also complete two targeted Quality review checks on a case sampling to gauge if staff are appropriately updating the dashboard. 4/1/2025 All staff will receive refresher training on determining Household size and countable income, including checking the determinations tab on the activated PDC to ensure that all required income and household members are counted. Lead staff will conduct a targeted QC sample to track progress of lowering this error finding over the first quarter of 2025. 4/1/2025

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-004 Inaccurate Resources Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: The County recognizes that through our transition in software we have fully reconciled all fixed asset transactions. Going forward, County finance staff will thoroughly track and reconcile all fixed assets annually. Along with reconciliation, the process of purchasing and recoding asset transactions has been modified, to include various checks and balances. Completed 7/1/2024 Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings 4/1/2025 Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and continues to demonstrate the successfullness as the error for 2024 was one error. For the Year Ended June 30, 2024 Corrective Action Plan Staff will receive refresher training on updating the evidence dashboard at redetermination of eligibility that will be conducted by Supervision. The documentation template for Recertifications will also be updated to include a line item for caseworkers to document that the evidence dashboard has been updated. Lead staff will also complete two targeted Quality review checks on a case sampling to gauge if staff are appropriately updating the dashboard. 4/1/2025 All staff will receive refresher training on determining Household size and countable income, including checking the determinations tab on the activated PDC to ensure that all required income and household members are counted. Lead staff will conduct a targeted QC sample to track progress of lowering this error finding over the first quarter of 2025. 4/1/2025

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-004 Inaccurate Resources Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: The County recognizes that through our transition in software we have fully reconciled all fixed asset transactions. Going forward, County finance staff will thoroughly track and reconcile all fixed assets annually. Along with reconciliation, the process of purchasing and recoding asset transactions has been modified, to include various checks and balances. Completed 7/1/2024 Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings 4/1/2025 Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and continues to demonstrate the successfullness as the error for 2024 was one error. For the Year Ended June 30, 2024 Corrective Action Plan Staff will receive refresher training on updating the evidence dashboard at redetermination of eligibility that will be conducted by Supervision. The documentation template for Recertifications will also be updated to include a line item for caseworkers to document that the evidence dashboard has been updated. Lead staff will also complete two targeted Quality review checks on a case sampling to gauge if staff are appropriately updating the dashboard. 4/1/2025 All staff will receive refresher training on determining Household size and countable income, including checking the determinations tab on the activated PDC to ensure that all required income and household members are counted. Lead staff will conduct a targeted QC sample to track progress of lowering this error finding over the first quarter of 2025. 4/1/2025

Finding 2024-005 Inadequate Request for Information Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-006 FNS Eligibility Determinations Name of Contact Person: Alice Wilson, FNS Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs (continued) The county will conduct refresher training on how and when to request information needed that includes when to request The Work Number, OVS,AVS, Property checks and Register of Deeds checks. The county will conduct a targeted second party of cases to check the effectiveness of the refresher training provided. 4/1/2025 Section IV - State Award Findings and Questioned Costs Corrective Action Plan for Finding 2024-002, 2024-003, 2024-004, 2024-005 also apply to State Award Findings. All FNS staff will attend a refresher training where sections 435, 505 and 510 will be reviewed. This training will be conducted by Supervision in FNS with the support of the FNS lead staff. This training will include an outline of the requirement for supporting documentation of eligibility and benefit determinations to include verifications used to support such determination at application and recertification where appropriate. All relatable NC FAST job aids will be reviewed with staff to ensure that functionality within the NCFAST system is followed. 3/1/2025

Corrective Action Plan For the Year Ended June 30, 2024 Finding: 2024-005 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to the State Award Findings. Section IV - State Award Findings and Question Costs Section III - Federal Award Findings and Question Costs (continued) Darren Phillips, Supervisor QA/PI The Eligibility Error case will be referred to Program Integrity as an Agency Error to redo the Client's budget and to see if any money is owed back to the County and State. We have developed a training slideshow for all FNS workers to cover all errors made on the audited cases. Training will be conducted by 2/28/2025. 236

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers.This covers training for the use of OVS and the TWN and a reminder about the correct way to end-date income and add new income to NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers. A training slide shows that buildings are part of Real Property and must be added to a case. Corrective Action Plan Section III - Federal Award Findings and Question Costs Section II - Financial Statement Findings For the Year Ended June 30, 2024 Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers and a new system for tracking recertification cases has been implented in the three Recertification Units to alleviate worker errors when sending request for information to applicant/beneficiaries and completing recertifications in a timely manner. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide training to the caseworkers. Supervisors has been reminded to use the appropriate reports in NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. 235

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers.This covers training for the use of OVS and the TWN and a reminder about the correct way to end-date income and add new income to NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers. A training slide shows that buildings are part of Real Property and must be added to a case. Corrective Action Plan Section III - Federal Award Findings and Question Costs Section II - Financial Statement Findings For the Year Ended June 30, 2024 Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers and a new system for tracking recertification cases has been implented in the three Recertification Units to alleviate worker errors when sending request for information to applicant/beneficiaries and completing recertifications in a timely manner. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide training to the caseworkers. Supervisors has been reminded to use the appropriate reports in NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. 235

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers.This covers training for the use of OVS and the TWN and a reminder about the correct way to end-date income and add new income to NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers. A training slide shows that buildings are part of Real Property and must be added to a case. Corrective Action Plan Section III - Federal Award Findings and Question Costs Section II - Financial Statement Findings For the Year Ended June 30, 2024 Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers and a new system for tracking recertification cases has been implented in the three Recertification Units to alleviate worker errors when sending request for information to applicant/beneficiaries and completing recertifications in a timely manner. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide training to the caseworkers. Supervisors has been reminded to use the appropriate reports in NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. 235

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers.This covers training for the use of OVS and the TWN and a reminder about the correct way to end-date income and add new income to NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers. A training slide shows that buildings are part of Real Property and must be added to a case. Corrective Action Plan Section III - Federal Award Findings and Question Costs Section II - Financial Statement Findings For the Year Ended June 30, 2024 Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers and a new system for tracking recertification cases has been implented in the three Recertification Units to alleviate worker errors when sending request for information to applicant/beneficiaries and completing recertifications in a timely manner. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide training to the caseworkers. Supervisors has been reminded to use the appropriate reports in NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. 235

2024.02 - Eligibility Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken 1) To ensure patient eligibility is properly assigned to patients, the Director of Clinical Operations will perform random audits on a Monthly basis of patients that are assigned. 2) The Director of Clinical Operations will also ensure proper training to those that are assigning eligibility to ensure that proper documentation is obtained and properly stored. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Eric Newman, CFO at (203) 756-8021 x 3015. Sincerely yours, Eric Newman Chief Financial Officer

SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will assign random audits on a Monthly basis of patients that are assigned a sliding fee. 2) Director of Program Management as well as Program Managers will monitor Phreesia dashboard to identify self-pay patients on the schedule and work to ensure that accounts are updated accordingly. a. For any accounts that need to be updated, they will inform the PSA who checked in the patient to make the updates as necessary and provide additional training if needed. b. Provide trainings to PSAs to ensure that they are offering the Sliding Fee Discount to all patients that may need to apply, and appropriately applying those slides. 3) If a Pt has had a visit and left prior to getting sliding fee information, PSAs are to call the patient to let them know that they may have to apply for a sliding fee (or receive insurance information over the phone). 4) Practice Managers will identify Self-pay accounts via Phreesia each morning that may need attention and send a list of accounts to the PSAs at the beginning of each day. PSA will then contact the patients to remind them to bring in proof of income to apply for the sliding fee if eligilble.

2024-005 – Pell Grant Calculation. Auditor Description of Condition and Effect. One student out of the twenty five Pell grants tested was found to be under awarded based on the enrollment status and cost of attendance. As a result of this condition, the College was exposed to an increased risk that incorrect information would be used to determine students' Pell Grant award amounts. Auditor Recommendation. We recommend the College implement procedures to ensure the COA and EFC used to calculate each student's Pell Grant is updated for each academic year and reviewed by an independent official. Corrective Action. This is corrected on setup and noted to correct the COA. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. March 2025 - next set up, it was corrected for 24/25 academic year in May 2024.

Finding Summary: U.S. Department of Education Student Financial Aid Cluster (FAL # 84.268, 84.063) Eligibility Significant Deficiency in Internal Control over Compliance Responsible Individuals: Alicia Smith, Director of Financial Aid Corrective Action Plan: The process has been adjusted to ensure manual calculations are done independently by two different people. Anticipated Completion Date: July 1, 2025

For the Year Ended June 30, 2024 Corrective Action Plan Proposed completion date: Finding 2024-006 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Finding 2024-007 Inaccurate Information Entry Name of contact person: Refresher training will be held by December 31, 2024 on effective documentation and record keeping. “Vehicle Status Documentation” template will be created and implemented by December 31, 2024. Error Trends Data log was implemented October 1, 2024. Adult Medicaid Lead Workers will monitor this by conducting a random selection of second party reviews each month. Adult Income Maintenance Supervisor II (pending vacancy), Delta Elliott, Income Maintenance Lead Worker III, and Michelle Ogle, Income Maintenance Lead Worker III Error discovered where vehicle status was not clearly documented in the case record caused by ineffective record keeping and incomplete documentation. Refresher training will be held by 12/31/2024 to review appropriate documentation and record keeping in NC FAST and will be conducted by Adult Medicaid leadership. Adult Medicaid Supervisor will create a “Vehicle Status Documentation” template that will be utilized by all Adult Medicaid caseworkers at every application and recertification. Completion and uploading of this template will be required in NC FAST. Adult Medicaid Lead Caseworkers will monitor the use of the template during monthly second party reviews of each caseworker. Adult Medicaid Supervisor created and utilized an Error Trends Data log effective 10/1/2024. The Error Trends Data log captures monthly errors to identify trends among staff. This log also provides Adult Medicaid leadership with data regarding errors that are repetitive to help leadership conduct monthly or quarterly refresher training as well as individualized training for staff who continue to have repetitive errors. Staff who fail to utilize the “Vehicle Status Documentation” template and continue to have repetitive errors will be placed on a corrective action plan. Policy refresher training will be held before 12/31/2024 that will cover the IV-D Referral process with specific advisory that the policy is currently suspended until further notice per DHB (Admin Letter 13-23). The Recertification Documentation template was updated on 11/20/2024 and went into effect immediately to be used by all Family and Children’s Medicaid caseworkers. The Error Trends Data log was implemented on October 1, 2024. Family and Children’s Medicaid leadership will monitor this by conducting a random selection of second party reviews each month. Section III - Federal Award Findings and Questioned Costs (continued) Kim Grissom, Income Maintenance Supervisor II; Taylor White, Income Maintenance Supervisor II; Lisa Kornegay, Income Maintenance Lead Worker III; and Sherry Stainback, Income Maintenance Lead Worker III 176Corrective Action Plan For the Year Ended June 30, 2024 Proposed completion date: Corrective actions for Finding 2024-005, 2024-006, and 2024-007 also apply to State Award findings. Errors discovered were income and household composition was calculated incorrectly due to inaccurate information being entered into NCFAST. Family and Children’s Medicaid leadership updated the Recertification Documentation Template on 11/20/2024 to ensure that accurate income, specifically UIB, and household composition is captured and documented appropriately. All Family and Children’s Medicaid caseworkers have been advised to utilize the updated Recertification Documentation Template effective immediately. The Family and Children Medicaid Supervisors created and utilizes an Error Trends Data log effective 10/1/2024. The Error Trends Data log captures monthly errors to identify trends among staff. This log also provides Family and Children Medicaid leadership with data regarding errors that are repetitive to help leadership conduct monthly or quarterly refresher training as well as individualized trainings for staff who continue to have repetitive errors. Staff who fail to utilize the updated Recertification Documentation template and continue to have repetitive errors will be placed on a corrective action plan. Refresher policy training will be held to ensure caseworkers understand policy surrounding income, specifically UIB, and household composition before 12/31/2024. The Recertification Documentation template was updated on 11/20/2024 and went into effect immediately to be used by all Family and Children’s Medicaid caseworkers. The Error Trends Data log was implemented on October 1, 2024. Family and Children’s Medicaid leadership will monitor this by conducting a random selection of second party reviews each month. Section IV - State Award Findings and Questioned Costs Section III - Federal Award Findings and Questioned Costs (continued) 177

For the Year Ended June 30, 2024 Corrective Action Plan Proposed completion date: Finding 2024-006 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Finding 2024-007 Inaccurate Information Entry Name of contact person: Refresher training will be held by December 31, 2024 on effective documentation and record keeping. “Vehicle Status Documentation” template will be created and implemented by December 31, 2024. Error Trends Data log was implemented October 1, 2024. Adult Medicaid Lead Workers will monitor this by conducting a random selection of second party reviews each month. Adult Income Maintenance Supervisor II (pending vacancy), Delta Elliott, Income Maintenance Lead Worker III, and Michelle Ogle, Income Maintenance Lead Worker III Error discovered where vehicle status was not clearly documented in the case record caused by ineffective record keeping and incomplete documentation. Refresher training will be held by 12/31/2024 to review appropriate documentation and record keeping in NC FAST and will be conducted by Adult Medicaid leadership. Adult Medicaid Supervisor will create a “Vehicle Status Documentation” template that will be utilized by all Adult Medicaid caseworkers at every application and recertification. Completion and uploading of this template will be required in NC FAST. Adult Medicaid Lead Caseworkers will monitor the use of the template during monthly second party reviews of each caseworker. Adult Medicaid Supervisor created and utilized an Error Trends Data log effective 10/1/2024. The Error Trends Data log captures monthly errors to identify trends among staff. This log also provides Adult Medicaid leadership with data regarding errors that are repetitive to help leadership conduct monthly or quarterly refresher training as well as individualized training for staff who continue to have repetitive errors. Staff who fail to utilize the “Vehicle Status Documentation” template and continue to have repetitive errors will be placed on a corrective action plan. Policy refresher training will be held before 12/31/2024 that will cover the IV-D Referral process with specific advisory that the policy is currently suspended until further notice per DHB (Admin Letter 13-23). The Recertification Documentation template was updated on 11/20/2024 and went into effect immediately to be used by all Family and Children’s Medicaid caseworkers. The Error Trends Data log was implemented on October 1, 2024. Family and Children’s Medicaid leadership will monitor this by conducting a random selection of second party reviews each month. Section III - Federal Award Findings and Questioned Costs (continued) Kim Grissom, Income Maintenance Supervisor II; Taylor White, Income Maintenance Supervisor II; Lisa Kornegay, Income Maintenance Lead Worker III; and Sherry Stainback, Income Maintenance Lead Worker III 176

Finding 2024-005 Non-cooperation with IV-D Referrals Name of contact person: Corrective Action: July 1, 2024 Section II - Financial Statement Findings (continued) Kim Grissom, Family and Children's Medicaid Supervisor and Shelia Morton, Family and Children's Medicaid Supervisor Error discovered was that there was no IV-D Referral sent to Child Support Services. Family and Children’s Medicaid leadership updated the Recertification Documentation template on 11/20/2024 to ensure that workers are documenting the necessary IV-D Referral process (including when it is not required) on every case. The AP section of the template has been updated to allow caseworkers to provide detailed information on IV-D Referrals. All Family and Children’s Medicaid caseworkers have been advised to utilize the updated Recertification Documentation Template effective immediately. Currently, the Division of Health Benefits (DHB) have advised that during the Public Health Emergency and the Continuous Coverage Unwinding period, IV-D Referrals are not required and are only sent at the request of the client. This policy will be in effect until further notice from DHB (Admin Letter 13-23). Although IV-D Referrals are currently suspended per DHB, Family & Children’s Medicaid leadership will review this policy with staff by conducting a refresher training by 12/31/2024. The Family and Children Medicaid Supervisors created and utilizes an Error Trends Data log that went into effect on 10/1/2024. The Error Trends Data log will provide Family and Children’s Medicaid leadership with data regarding errors that are repetitive. This will help leadership conduct monthly or quarterly refresher training as well as individualized training for staff who continue to have repetitive errors. Staff who fail to utilize the updated Recertification Documentation Template and continue to have repetitive errors will be placed on a corrective action plan.For the Year Ended June 30, 2024 Corrective Action Plan Proposed completion date: Finding 2024-006 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Finding 2024-007 Inaccurate Information Entry Name of contact person: Refresher training will be held by December 31, 2024 on effective documentation and record keeping. “Vehicle Status Documentation” template will be created and implemented by December 31, 2024. Error Trends Data log was implemented October 1, 2024. Adult Medicaid Lead Workers will monitor this by conducting a random selection of second party reviews each month. Adult Income Maintenance Supervisor II (pending vacancy), Delta Elliott, Income Maintenance Lead Worker III, and Michelle Ogle, Income Maintenance Lead Worker III Error discovered where vehicle status was not clearly documented in the case record caused by ineffective record keeping and incomplete documentation. Refresher training will be held by 12/31/2024 to review appropriate documentation and record keeping in NC FAST and will be conducted by Adult Medicaid leadership. Adult Medicaid Supervisor will create a “Vehicle Status Documentation” template that will be utilized by all Adult Medicaid caseworkers at every application and recertification. Completion and uploading of this template will be required in NC FAST. Adult Medicaid Lead Caseworkers will monitor the use of the template during monthly second party reviews of each caseworker. Adult Medicaid Supervisor created and utilized an Error Trends Data log effective 10/1/2024. The Error Trends Data log captures monthly errors to identify trends among staff. This log also provides Adult Medicaid leadership with data regarding errors that are repetitive to help leadership conduct monthly or quarterly refresher training as well as individualized training for staff who continue to have repetitive errors. Staff who fail to utilize the “Vehicle Status Documentation” template and continue to have repetitive errors will be placed on a corrective action plan. Policy refresher training will be held before 12/31/2024 that will cover the IV-D Referral process with specific advisory that the policy is currently suspended until further notice per DHB (Admin Letter 13-23). The Recertification Documentation template was updated on 11/20/2024 and went into effect immediately to be used by all Family and Children’s Medicaid caseworkers. The Error Trends Data log was implemented on October 1, 2024. Family and Children’s Medicaid leadership will monitor this by conducting a random selection of second party reviews each month. Section III - Federal Award Findings and Questioned Costs (continued) Kim Grissom, Income Maintenance Supervisor II; Taylor White, Income Maintenance Supervisor II; Lisa Kornegay, Income Maintenance Lead Worker III; and Sherry Stainback, Income Maintenance Lead Worker III 176

The Director of Financial aid will update the procedure to include a report to be reviewed of credits earned to verify the amounts to be disbursed to the student is in compliance standards of the correct grade level for Direct Loans. All financial aid staff will be updated on procedures to review the Direct Loan amounts to credits earned when packaging the student and a final approval from either the Assistant Director of Financial Aid or the Director of Financial Aid before the award letter is sent to the student. Completion date 2/15/2025. Responsible staff: Crystal Hamilton, Director of Financial Aid

The Director of Financial Aid will review and verify the funds that were disbursed to the students account match the disbursement dates in COD on the date the transfer batch report is sent to the College’s Business Office. Completion date: 2/15/2025. Responsible staff: Crystal Hamilton, Director of Financial Aid

The disbursement letter that we previously had notified they had the right to decline their loan. As with the recommendation of our auditor, the letter’s wording has already been changed from the right to decline their loan to the right to cancel their loan by the Director of Financial Aid. Letter also states that the request must be received by KWC within 14 days of the date on the notice. Completion date: 9/1/2024. Responsible staff: Crystal Hamilton, Director of Financial Aid

FINDING 2024-002 􀀃 􀀃 Finding Subject: Title I Grants to Local Education Agencies – Internal Controls Over Eligibility 􀀃 Summary of Finding: Material Weakness:􀀃 Though no errors were found in the Title I application, a documented internal control plan needs to be in place to ensure that the Enrollment ad Poverty numbers inputted into the Title I Application by the IDOE matches the School Corporation’s internal records (Real Time Reports). This checks and balances for monitoring the Enrollment and Poverty numbers on the Title I application could reduce the risk of errors. 􀀃 Contact Person Responsible for Corrective Action: Kari Dyer 􀀃 Contact Phone Number and Email Address: (574)825-9425, dyerk@mcsin-k12.org Views of Responsible Officials: We concur with the finding. Though no discrepancies were found between the LEA and the Enrollment and Poverty numbers populated by the IDOE in the Title I Application, a checks and balances needs to be in place to ensure accuracy in the Title I application, reducing the risk for error and ensuring the LEA allocates funds appropriately. Description of Corrective Action Plan: The School Corporation plans to take the following action: 􀁸 Develop a dual signature page requiring verification from Title I Program Director and MCS Data Manager that IDOE Enrollment and Poverty numbers populated in the Title I Application match the LEA internal records from the October 1 count day of the previous school year. This internal control document will be titled Enrollment and Poverty Verification. 􀁸 Utilize and maintain record of the Enrollment and Poverty Verification signature form during the Title I Application period to ensure the alignment of IDOE data and LEA enrollment and poverty numbers in the Title I application. Verification from both the Title I Program Director and the MCS Data Manager will be required. o Upon submission of Oct. 1 ADM, the MCS Data Manager will supply ADM information on the Enrollment and Poverty Verification form to the Title I Program Director. o During the creation of the Title I budget application, Title I Program Director will cross-reference and verify Oct. 1 ADM data with the Enrollment and Poverty numbers populated by the IDOE in the Title I application, addressing discrepancies with the IDOE Title Grant Specialist should they occur. Anticipated Completion Date: Winter 2025: Internal Control process written for Enrollment and Poverty Verification Winter 2025: Creation of Enrollment and Poverty Verification signature form. Annually: Utilization of the Enrollment and Poverty Verification process and signature form during the October ADM process and during the Title I Application process. The first use of the form will be in winter, 2025 to document Oct.1, 2024 enrollment and poverty numbers with the first verification occurring during the fall, 2025 Title I Budget Application process for SY25-26.

Corrective Action Plan January 24, 2025 The Housing Authority City of Kennewick is submitting the following Corrective Action Plan for the year ending June 30, 2024, related to the Housing Choice Voucher Payment Standards/Rent Reasonableness. Audit period: July 1, 2023-June 30, 2024 The finding from the June 30, 2024, and Housing Choice Voucher Payment Standards/Rent calculation: Finding: Finding No. 2024-001 Condition and Context: For FYE 2023, The Housing Authority City of Kennewick’s (KHA) was approved by HUD to use 120% FMRs for the calculation of the Housing Choice Voucher Payment Standards. The actual payment standard used was incorrectly calculated. KHA mistakenly multiplied the 120% FMR twice creating an overstated calculation of 144%. The 144% FMR was not the approval payment standard by HUD. During the audit, auditors selected 40 tenants to test for eligibility and special tests and 32 out of the 40 tenants on the 50058 used the 144% payment standard. Recommendation: The Auditors recommended multiple levels of review before approving the correct payment standard. The 8 tenants tested who did not have errors were from 2024. The 2024 FMR is correct, the Housing Authority is not using the correct payment standard. The issue appears to be a one time mathematical mistake. Plan for Corrective Action: Management will obtain multiple level of reviews on future payment standard calculation to ensure that the correct FMRs are used to calculate the payment standard.Actions Taken: KHA reached out to HUD to verify whether there are any further actions to be taken to correct the incorrect payment standard. HUD will confirm the necessary actions after reviewing the audit reports. There might be no further action taken as the current FMRs have increased and the agency is currently under the correct payment standard. Hermelinda Sierra_______________ Hermelinda Sierra CFO/Deputy Director Contact Persons: Hermelinda Sierra, CFO/Deputy Director 509-586-8576 ext. 111 Matt Truman, KHA Executive Director 509-586-8576 ext. 103