Corrective Action Plans

Finding 2023-001: Reportable Finding Considered a Material Weakness – Eligibility Assistance Listing Number: 10.181 Agency: U.S. Department of Agriculture Program: Pandemic Relief Activities: Farm and Food Worker Relief Program (FFWR) Award Number: AM22FFWDC0002-02 Grant Years: 2023 Views of Responsible Officials – The Charity Foundation acknowledges the finding regarding the improper payment of 9,424 benefit checks to ineligible beneficiaries due to insufficient verification of employment and identity documentation. This resulted in $5,654,400 in questioned costs. We understand the seriousness of this issue and have implemented corrective actions to prevent future occurrences. Corrective Actions – Root Cause Analysis: The deficiency arose because the Foundation’s application portal, designed and managed by consultant contractors, failed to accurately verify employment and identity documentation, leading to the approval of ineligible beneficiaries. Revised Eligibility Verification Process: In November 2023, the Charity Foundation implemented updated procedures to enhance the verification of applicant eligibility under the FFWR program: • Initial In-Person Screening: Applicants must now provide proof of employment, such as a paystub or W-2, in person at their place of work (farm, meatpacking facility, or grocery store). This initial screening is intended to ensure that workers are properly verified before accessing the application portal.   • Unique Identifier Creation and Control: The Charity Foundation creates and controls unique identifier codes used for logging into the application portal. These identifiers ensure secure access and prevent duplicate applications. During the initial screening process, the consultants assisting with the sign-up process distribute these unique identifiers to each eligible worker in person at the plants. • Portal Access and Document Submission: After receiving the unique identifier, applicants log into the portal and are required to upload their identification documents. A dedicated team manually reviews each document to verify that the applicant’s identity and employment meet FFWR eligibility requirements and that the information matches the details entered by the applicant. Ongoing Monitoring and Compliance: To ensure the integrity of the process, the Foundation’s internal review team conducts regular compliance checks on the submitted documentation. This ongoing monitoring process ensures that all uploaded documentation meets program standards. Staff Training: The Foundation will continue to train team members responsible for verifying applications. This training covers FFWR program requirements, proper identification and employment records review, and how to flag potential discrepancies. Regular training ensures the team remains informed of program expectations and changes. Consultant Accountability: We have revised our contract with the consultant contractors managing the application portal to establish stricter accountability measures. This includes ongoing performance reviews and quality control checks to ensure the portal supports accurate identification and employment verification. Results: These changes were successfully implemented in November 2023 and are now the standard operating procedure for the Charity Foundation’s FFWR program. Responsible Person: The Director of Finance is responsible for overseeing the implementation of the updated eligibility verification process. The Director also ensures compliance with FFWR requirements through continuous monitoring and periodic internal audits. Completion Timeline: The corrective actions were fully implemented as of November 2023 and continue to be in effect for all FFWR program applicants moving forward.

2023-004 Eligibility Section 8 Project-Based Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 670 of tenants, 20 tenant files were tested and the following deficiencies were noted: • Nine files did not have annual recertifications performed during the year, • Eight files did not have 9886 release of information forms within 15 months of annual recertification, • Six files did not have an annual recertification performed within 12 months, • Six files did not have documentation necessary to verify the reported income, and • Three files did not have a 214 declaration form for all members of the household. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024

2022-003 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 484 of Housing Voucher Cluster tenants the following deficiencies were noted: Mainstream Voucher AL #14.879 (a total of 4 tenants selected for testing): • One file did not have an annual recertification performed during the year, • One file did not have an annual recertification performed within 12 months, • Two files did not have 9886 release of information forms within 15 month of the annual recertification, • One file did not have a 214 declaration form for all members of the household, and • One file did not have documentation necessary to verify the reported income. Emergency Housing Voucher AL #14.871 (a total of 5 tenants selected for testing): • Four files did not have an annual recertification performed within 12 months, • Three files did not have a 214 declaration form for all members of the household, • Four files did not have 9886 release of information forms within 15 month of the annual recertification, and • Five files did not have rent reasonableness form performed for the annual certification. The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024. FINDINGS - FEDERAL AWARD PROGRAMS AUDIT 2023-003 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 1,500 of Housing Voucher Cluster tenants the following deficiencies were noted: Mainstream Voucher AL #14.879 (a total of 5 tenants selected for testing): • Five files did not have supporting documents needed to determine eligibility. Emergency Housing Voucher AL #14.871 (a total of 5 tenants selected for testing): • Four files did not have supporting documents needed to determine eligibility, and • One files did not have an annual recertification performed. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.

2023-002 Eligibility Moving to Work Demonstration Program AL No. 14.881 Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 18,300 of Section 8 Housing Choice Voucher and 2,300 Low Rent Public Housing tenants the following deficiencies were noted: Section 8 Housing Choice Voucher (a total of 40 tenants selected for testing): • Thirty-five files did not have annual recertifications performed during the year, • Nine files did not have 9886 release of information forms within 15 months of annual recertification, • Four files did not have a annual recertification performed with 12 months of the previous certification, • Three file did not have an inspection performed during the year • Three files did not have documentation necessary to verify the reported income, • Two files did not have a 214 declaration for a member of the household, and • Two files did not have documentation necessary to verify custody of dependents. Low Rent Public Housing (a total of 40 tenants selected for testing): • Fourteen files did not contain flat rent options forms, • Ten files did not have documentation necessary to verify the reported income, • Seven files did not have the annual recertification performed or documented, • Five files did not have a 214 declaration for a member of the household, • Three files did not have support necessary to verify income allowances, • Two files did not have 9886 release of information form within 15 months of the annual recertification, and • One file did not have annual recertifications performed within 12 months of the previous annual certification. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected during the final quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the final quarter of 2024.

Corrective Action Plan: The Methodist College Registrar has been working with NSC to get the college relinked to the correct college in their system, which was fixed 11/2023. The registrar redeveloped database query to pull the old data that had been deleted by NSC due to FERPA and began sending accurate file submissions to NSC in June 2024. Files generated and submitted under the College’s new processes are taking roughly one week to process from initial submission, through error correction, and finalization. Contact Person(s): Justina Kirchgessner Anticipated Completion Date: End of 2024

Corrective Action Plan: In standing financial aid meetings, we will review Federal Loan limits and what our process/procedures are if a student is close to limits to insure, we don’t over award. Contact Person(s): Justina Kirchgessner Anticipated Completion Date: 2024

Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority’s management company has hired a Deputy Director who completes quality control audits on all tenant files periodically. The Deputy Director holds monthly meetings with all eligibility staff workers to ensure compliance with policies and procedures. Planned Completion Date for CAP Immediately.

We have created an eligibility checklist for the WIOA programs that lists all required documentation. Additional training will be provided to the WIOA intake team on required documentation. No later than November 1, 2024, AJCC Associate Directors will implement period spot checks to ensure all necessary documents for eligibility are completed.

1.The inspector has attended an outsourced training from a reputable company that meetsthe HUD requirements and certification criteria. HQS includes requirements for allhousing types, including single and multi-family dwelling units, as well as specificrequirements for special housing types such as manufactured homes. 2.The Housing Authority HCV supervisor will implement greater oversight over theHousing Quality Standards by reinforcing the quality controls and monitoring failedinspection to improve on the standards mandated by HUD regarding biannual inspectionsand failed inspections.

ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024

Tom Keller, Executive Director, Jill Liebelt, CFO, & Chris Brungardt, CEO Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2024

The Authority will update their internal control policies over eligibility to require a review of the tenant file from another qualified personel and have a checklist to ensure compliance.

The County will ensure that procedures are in place to ensure support is maintained on file for eligibility determinations.

Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be taken to prevent ineligible expenses from being submitted in the future: • Exclude all ineligible expenses from any future Provider Relief Fund Portal submissions. • Offset the ineligible costs with lost revenues and unreimbursed expenses attributable to Corona virus. Princeton Community Hospital was a new acquisition into West Virginia University Health System as of January 1, 2023 and had not fully integrated into our processes at the time that this portal submission was completed. Upon further review, Princeton Community Hospital had lost revenues that support a significant portion of the funding received for this reporting period. Those lost revenues, along with eligible expenses, fully support the funding received. Completion Date: 09/27/2024

Finding No. 2023-001 - Tenant Eligibility: The Milton Housing Authority will continue its implementation of increased oversight for the Housing Choice Voucher Program's tenant compliance requirements. To that end, a consultant has been contracted and continues to train Employees on procedures and documentation mandated by HUD. Additionally, the Milton Housing Authority will review each file to ensure all documentation is complete. Planned Implementation Date of Corrective Action: September 27, 2024 Person Responsible for Corrective Action: Earl Fa_y, Executive Director (617) 698-2169

FINDINGS - FINANCIAL STATEMENT AUDIT None FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2023-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all current and new staff are trained on tenants’ 90-day EIV reports and ensuring they are generated within the required time period to verify tenant information promptly and help reduce errors in subsidy payments. ACTION TAKEN The Project will be monitoring use of the EIV system for move ins and recertifications.

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. Solution: Implement a standardized process for verifying, documenting, and maintaining proof of required documents (e.g. proof of residency, insurance, etc.) in the patient's file during each visit. This will involve revising and implementing the new procedures manual to verify and document patient intake. The procedures manual will support appropriate communication from data collection to when information is uploaded into EPIC to verify if clients have insurance. Our training plan will incorporate these new methods of collecting data from the clients and outline regular internal auditing of patient files to assist the Tribal Assisters to properly verify documents and communicate with providers to assist clients in enrolling with insurance providers such as but not limited to Washington Apple Health (WAH). Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. Responsible: Kathryn Halverson, Health and Human Services CEO, Lummi Indian Business Council Anticipated completion date: 06/30/2025

All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years, allowing clients to be seen by a medical provider quickly. This practice ended in 2023. 30-day eligibility is no longer allowed.

Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent versus actual time spent. ● From a list of 244 clients, 21 client intake forms (used to determine eligibility for services) for Business Growth Services clients were unable to be produced. The auditors recommend the following: 1. Management to implement procedures to ensure all expenditures, including personnel costs, are properly reviewed, approved, and supported with documentation in accordance with federal regulations. SDA Response The SDA accepts the above findings and would like to add the following information for context: ● The requirement to collect T&E forms wasn’t initially established until the completion of the 2022 audit and after the departure of some personnel. Management attempted to collect T&E forms from prior contractors, but was not successful in securing the specific forms identified by the auditors. ● The SDA created a payroll classification document during 2023 which outlined T&E for all W-2 employees at a set rate for the year. This document, however, was not accepted by the auditors as evidence of actual hours expended on each grant, resulting in this finding. ● The SDA onboarded a new Director of Business Growth Services (BGS) in 2023, which led to changes in both the operational structure and the nature of the data collected for BGS activities. During this period, a data migration took place to a newer version of Salesforce that was built specifically for the SDA. Unfortunately, some data was either lost or unmapped during the migration process, leading to discrepancies in the completeness of historical records. SDA Corrective Actions Management is committed to continue training for personnel to ensure timely completion and compliance of hiring as well as time and effort documentation going forward. The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits.

The attorney responsible for this error has been instructed on the LSC rules for eligible income overrides and specific corrections in this case, including that the financial eligibility override reason of "client seeking to maintain government benefits for low-income is only applicable if those benefits are the subject of our legal representation in a case, and families" that a client must be marked "no" for "Income Eligible (LSC guidelines)" even if they are financially eligible for our representation under a non-LSC funding contract. She was also instructed to review the LSC Financial Eligibility Training video. Ongoing compliance trainings and financial eligibility trainings have been modified to emphasize how to use the income override categories, and that a be marked as "no" for "Income Eligible (LSC guidelines)" and "LSC Eligible" even if the case must client's income makes them eligible to be served under non-LSC funding contracts.

LSNYC's Compliance Officer spoke at length with the attorney who mistakenly failed to exclude the value of the client's primary residence from the asset total and an erroneous asset override. She now understands that the "exclude" radio button should entered have been selected for this asset, which would have put the client's assets under the asset ceiling. now understands that an asset override must be approved in writing by her supervisor and She also that the asset override must be uploaded into the case file. Ongoing compliance trainings and financial eligibility trainings have been modified to emphasize the importance of selecting the "exclude" button for assets that do not count toward the total under LSC regulations, and that asset waivers must be approved in writing by a supervisor.

The attorney responsible for failing to obtain a retainer in this case was advised that retainers must always be obtained for full representation cases, and required to review a compliance training video. Ongoing compliance trainings have been modified to emphasize the importance of completing retainers with clients, for LSC compliance purposes, professional liability protection purposes, and to ensure that clients are made aware of the scope of services that LSNYC has agreed to provide and their own responsibilities in their representation.

Finding 2023-001 –– During our current year audit, it was noted that one HCVP was not inspected during the year. In this instance, the Authority did not abate payments for this unit. It was also noted one instance of a unit failing inspection, and not passing within the 30 day window. However, the Authority never put the unit into abatement. Recommendation – We recommend that the Authority review their recertification process and their process for reporting the reinspection, and review the abatement process to ensure units are properly put into abatement when inspections are failed or incomplete. Action Taken – Chester County Housing Authority management agrees with the above recommendation and has instituted policies and procedures designed to address this finding. (Please see the list of approved policies and procedures.)

View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2022 – 6/30/2023 and 7/1/2023 – 6/30/2024 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is aware of the deficiency in internal control over compliance. Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible for Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024