Corrective Action Plans

Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.

a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In connection with out lease file review, we noted the following deficiencies: The Enterprise Income Verification (EIV) form in the existing tenant's file for 5 out of 15 tenants tested did not have the EIV completed within 120 days, as required by HUD. The Enterprise Income Verification (EIV) form in the existing tenant's file for 1 out of 15 tenants tested did not have documentation in their lease file that their income was verified. The Enterprise Income Verification (EIV) form in the new tenant's file for 1 out of 2 tenants tested did not have documentation in their lease file that their income was verified. b. Action(s) Taken or Planned on the Finding Management has implemented a monthly compliance file audit that will ensure that EIV’s are pulled and tenant income verified in a timely manner.

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid real estate tax expenses in the amount of $9,400 from project cash while a tax abatement agreement was in effect. b. Action(s) Taken or Planned on the Finding Management contacted City of Middletown Tax Assessor who has agreed to reverse the bill. Management is working with the assessor to get the funds reimbursed.

SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to better capture disallowed costs getting reported. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

TIME STUDY – ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the county streamline the payroll change process between the payroll department and human services department. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

CASEFILE REVIEW (2022-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

Federal Agency: U.S. Department of Agriculture Federal Program Name: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Federal Award Identification Number and Year: 22MN004W1003, 2023 Pass-Through Agency: Minnesota Department of Health Pass-Through Number: 22MN004W1003 Award Period: Year Ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended Countryside Public Health Service implement procedures to ensure there are always two individuals involved in the determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Countryside Public Health Service will implement procedures to ensure there are always two individuals involved in the determination. Name of the contact person responsible for corrective action plan: Liz Auch, Administrator Planned completion date for corrective action plan: December 31, 2024

2023-001 ALN 14.881 – Moving to Work Demonstration Program – Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Samuel Crawford, Chief Executive Projected Completion Date: December 31, 2024

In response to the finding that Medicaid expenses could potentially be paid to ineligible individuals whose citizenship status was not documented in the IDR system, the Unit supervisor, Julie Whipple, is working with the NYS Department of Health for the correct process to receive notifications when the verification does not flag a code but instead remains blank. Following the discussion with the auditors in June 2024, Supervisors immediately began monitoring for the cases that are not verifying in the IDR system and reaching out to the individuals for proof of citizenship.

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2301MNTANF Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name(s) of the contact person(s) responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2024

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2305MN5ADM, 2305MN5MAP Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name(s) of the contact person(s) responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2024

Compliance Finding: Material Weakness U.S. Department of State - Citizen Exchanges – CFDA No. 19.415 Finding 2023-001: Timely Completion of Audit and Data Collection Form (DCF) Recommendation: Internal controls should be in place that provide reasonable assurance that the audit is engaged and completed timely and submitted to the Federal Audit Clearinghouse (now FAC.gov) by the applicable deadline (sooner of 30 days from completion of audit or 9 months from year-end). Action Taken: Management of World Link will engage the audit earlier and provide supporting documentation to the auditors based on the agreed-upon schedule for the 2023 audit to facilitate timely completion and submission of the data collection form. Completion Date: September 30, 2024

REFERENCE # 2023-003 Federal Transit Cluster - Federal Transit Formula Grant (ALN # 20.507)- Deficiency-Non-Compliance Agency: U.S. Department of Transportation Criteria: Allowable Costs––Direct - As stated in Uniform Grant Guidance - §200 Requirements for Allowable Costs: • Costs did not consist of improper payments, including (1) payments that should not have been made or that were made in incorrect amounts (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements; (2) payments that do not account for credit for applicable discounts; (3) duplicate payments; (4) payments that were made to an ineligible party or for an ineligible good or service; and (5) payments for goods or services not received (except for such payments where authorized by law). Condition/Context: The MTA has Allowable Costs procedures in place. MTA has corporate policies and procedures regarding Allowable Costs. We tested the Federal Transit Cluster- Federal Transit Formula Grant’s Allowable Costs compliance. Based on our review of sixty samples related to personnel services for this cluster , we noted that one sample related to an MTA Bus Company personnel’s hourly rate which was charged at higher rate. The correct hourly rate was $46.82 and MTA Bus Company used a rate of $60.99. Recommendation: We recommend that MTA ensure that all personnel are reviewed and should be charged at the correct hourly rates as required by §200 CFR Subpart E – Allowable Costs. Corrective Action Plan: MTA BUS worked with the project team to implement the correct rate and reparations applied. MTA returned the credit to FTA on August 12, 2024. MTA will review the files thoroughly to prevent calculation errors in the future. Action Date: August 12, 2024 Final Implementation Date: August 12, 2024 Name And Phone Number Of Person Responsible For Implementation: John Decker 718-927-7776

Corrective Action The program issues are systemic; therefore the corrective actions are identical. The MTW flexibility permits tri-annual recertification. The agency has been conducting tri-annual recertification for elderly and disabled households. Effective with February 2025 recerts, now in process, tri-annuals will be applied to all households. This significantly reduces the number of recertifications performed by each staff and permits significantly more attention to monitoring, oversight, training and correction. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the year. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. It is anticipated that TGHA files will be fully in order by July 2025.

Corrective Action The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and some at the decision of staff. Initial eligibility is currently being restructured with an emphasis on new admissions. All procedures and processes are being evaluated for accuracy, with emphasis on the noted area of noncompliance and includes a complete review and update to the Administrative Plan. There will be increased staff training and file review. In July 2024, TGHA transitioned project-based files from a property management team to the Housing Choice Voucher Department. The files had not been electronically stored. Evidence pointed to deficiencies in file maintenance. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the programs, including staff capability, training and monitoring. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. It is anticipated that TGHA files will be fully in order by July 2025.

Finding 2023-002: Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development (Repeat of Finding 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: The Operation Administrator is overall responsible the operation of Tri-County Senior Center and Housing; working together with the bookkeeping staff and Executive Director as partners to maintain financial records and budgets. The Executive Director will sporadically review tenant eligibility of new certifications and re-certifications, HAP Contracts, samples of monthly HAP Assistance Payment requests, and her presence when auditors are in-house as well any other assistance requested by Administrator. To ensure the health, safety, and well-being of the residents and staff, the Administrator oversees the responsibilities and duties of all other staff in their roles, (Administration Assistant/Program Administrator-Senior Center Activities; Administration Assistant-Membership, monthly newsletters, answer phones and any other duties requested by the Administrator), to guide them in their specific roles so they understand their duties and responsibilities as administrative staff, and ensuring the facility meets all regulatory compliance standards. If there are questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.

Management concurs with the finding and has established plans to provide additional training and review of tenant files going forward by the Director of Housing Management to ensure required tenant certifications are performed timely and completely, and all required tenant certification documentation is included in tenant files.

Finding Number: 2023-001 Planned Corrective Action: The ERA program was a temporary program as part of the American Rescue Plan Act and there will not be expenditures for this program going forward therefore corrective action is not necessary. Anticipated Completion Date: 9/23/24 Responsible Contact Person: N/A

Name of Auditee: Hazel Dell Non-Profit Housing FHA Auditee Identification Number: 126-EE027 Period Covered by the Audit: Year ended December 31, 2023 CAP provided by: Name: Andrea Bean Position: Director of Property Management Telephone Number: 360-694-2501 Finding 2023-001: 1. Statement of Condition: Four of the tenant file selected for review were charged with rental rates higher than the HAP contract. 2. Cause: Property manager error on contract rate input. 3. Actions Taken on the Finding: Property manager will be bringing the rent roll and voucher submission process to the centralized Compliance team. This team member will run the rent rolls, comparing them to the current rent schedules on file. Once this first approval is completed, the rent rolls will be sent to onsite property managers for approval.

Response: Ensure that existing filing errors are corrected and to ensure that future filing accuracy is demonstrated. Vernon Housing is implementing the following: Vernon Housing has an existing quality control program to ensure that all HCV files are complete and up to date. In addition, Vernon Housing has reorganized itself with new staff being placed during the mid-year of FY23 and current. This Housing Program Manager position centralizes Housing program oversight with expertise necessary for a successful quality control system. The Agency fiscal year 2023 audit first noted the need for improved quality control Housing Choice voucher program and filing. The sample errors pointed out during the audit have been corrected and reviewed with associated personnel. Going forward since the beginning of CY 2024 the Housing program manager has reviewed all interims along with annual certifications completed by the direct reports for compliance and filing accuracy. A structured filing system has been identified for all staff personnel to follow and be assessed during the quality control review process. A monthly quality control schedule has been implemented to report to upper management during the department closing process. Management will continue to require staff to attend training and obtain the PH/HCV Specialist Certification as a mandatory job requirement. Management will continue efforts to standardize tenant files, perform supervisory and compliance file reviews and hold staff accountable for failure to adhere to the governing rules and regulations for file compliance. HCV Program staff will continue to use file review checklists when performing Recertification procedures, which require the review of Lease Addendums to ensure that the proper documentation is in the file. These are ongoing tasks. The Housing Program Manager will be responsible for these tasks. Planned Implementation Date of Corrective Action: October 2024 Person Responsible for Corrective Action: Shenoa Steves-Housing Program Manager

Response to Finding 2023-001 The Authority generally concurs with the auditor’s findings and recommendations. To address these issues, the Authority has implemented the following corrective actions: 1. Mandatory Refresher Training: • Effective May 2024, the Authority has rolled out mandatory refresher training for all relevant staff on eligibility documentation and recertification processes. This training ensures that all staff are fully aware of the correct procedures and policies, and that they understand the importance of maintaining complete and accurate tenant files and performing recertifications in a timely manner. 2. Implementation of a New Tracking System: • A new tracking system has been implemented to ensure that all documentation is completed timely and verified by a supervisor. This system allows for real-time monitoring of the documentation process, ensuring that all required documents are included in the tenant files. 3. Utilization of Checklists: • The Authority has introduced a mandatory checklist that staff are required to use every time a file is accessed or updated. This checklist serves as a tool to ensure that all necessary steps are taken, and all required documentation is included in the tenant file. 4. Enhanced Monitoring by HCV Director and Supervisors: • The HCV Director and Supervisors will closely monitor the recertification process to ensure that all recertifications are completed in a timely manner and in accordance with policy. This includes ensuring that all participants receive and return their recertification paperwork as required. 5. Increased Frequency of Quality Control Reviews: • The Authority will continue to conduct quality control file reviews and will increase the frequency of these reviews to identify errors sooner. This proactive approach will help address the root causes of errors quickly and prevent systemic issues from developing. 6. Ongoing Quality Reviews: • Continuous quality reviews will be conducted for all files to ensure that all required documents are present and that all recertifications are performed on time. This ongoing process is designed to maintain high standards of accuracy and compliance in tenant file management. Name of the contact person responsible for corrective action: Deputy Executive Director LaMonyka French Completion Date: December 2024

CORRECTIVE ACTION PLAN September 27, 2024 Health Resources and Services Administration Lakewood Resource and Referral Center, Inc. D/B/A Center for Health Education, Medicine and Dentistry respectfully submits the following corrective action plan for the year ended December 31, 2023. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FINANCIAL STATEMENT FINDINGS Finding 2023-001 – Account Analyses MATERIAL WEAKNESS Recommendation We recommend that the Center ensure that all accounting records are analyzed and reconciled on a monthly basis. We also recommend that necessary procedures be enhanced whereby an employee of the Center consistently reviews and follows up on receivables and adjusts the reserves for those receivables appropriately. This will help accurately reflect the cash realizable value of receivables. This will provide the Center with a stronger accounting of patient services receivable with which to better manage cash collections. We also recommend that the Center perform the patient services revenue reconciliation by payor source on a monthly basis. This would help the Center determine whether patient services revenue is being properly recorded by payor source. Action Taken Management of the Center agrees with the finding and has started to work with a new general ledger software package at the start of 2024, to better accommodate monthly reconciliations. We will also ensure that these analyses and reconciliations will be reviewed on a consistent and timely basis. There has been steady improvement throughout 2024, and it is expected to be complete by the end of 2024. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance Listing Number 93.224/93.527) Finding 2023-002 – Special Tests and Provisions SIGNIFICANT DEFICIENCY Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are being properly calculated. Supervisors should monitor and review the sliding fee calculations on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Management of the Center is providing additional training to the relevant staff that deal with the Sliding Fee Discount (SFD). These staff members include front desk staff, financial counselors, and the general finance and billing departments, as applicable. The SFD Policy and SFD Scale are being reviewed by management to ensure that the guidelines and procedures are clear. Revisions to the SFD Policy and SFD Scale will be made, and Board approved, if necessary to improve clarity. To ensure that the SFD is being properly calculated in accordance with the SFD Scale, a monitoring process will be included, which may include internal periodic audits by supervisors. All changes will be finalized and implemented by the end of 2024. If the Health Resources and Services Administration has questions regarding this plan, please call Scott Jackson, Chief Financial Officer at (732) 364-2144 x6138. Sincerely yours, Scott Jackson, CFO

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-008 Activities Allowed or Unallowed; Allowable Costs/Cost Principles; Eligibility Program: Foster Care Title IV-E (ALN 93.658) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While we were able to test manual compensating controls over activities allowed or unallowed, allowable costs/cost principles and eligibility, we were not able to review and test the automated application controls and the related ITGCs within the MAXIS and SSIS systems that reside within the State of Minnesota, but are utilized by the County, to determine whether the system controls are adequately designed and implemented and operating effectively. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS and SSIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2024

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-007 Eligibility Program: Medical Assistance Program (ALN 93.778) Type of Finding: Material Weakness in Internal Control over Compliance; Other Matter Compliance Finding Condition: During our testing, we noted the following 8 instances of noncompliance in the sample of 120 case files tested: • Five MAXIS (eligibility determination system) case files had different bases of eligibility in MAXIS and MMIS (payment system). For three of the five cases, MAXIS indicated the beneficiary was “EX” (age 65 or older) while MMIS indicated the beneficiary was “DX” (disabled). For one of the five cases, MAXIS indicated the beneficiary was “1619(b)” (people who no longer receive an SSI cash benefit and maintain their disability status) while MMIS indicated the beneficiary was “DX” (disabled) and the final case indicated the beneficiary was “DC” (disabled child 18-20) in MAXIS while MMIS indicated the beneficiary was “DT” (disabled child under TEFRA option). • Two MAXIS case files did not have a signed application on file. • One MAXIS case file did not have citizenship verified. In addition, the County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the two eligibility determination systems, MAXIS and METS. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered and the information required by the contract is retained in the County’s records. Hennepin County Employee Responsible for the CAP: Vickie Goulette Planned Completion Date for CAP: December 31, 2024

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-005 Eligibility Program: WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (ALN 10.557) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While we were able to test manual compensating controls over eligibility determination, we were not able to review and test the automated application controls and the related information technology general controls (ITGCs) within the HuBERT system, a state system that is administered by the state and required to be used by the County for eligibility determination, to determine whether controls are adequately designed and implemented and operating effectively. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will encourage the State to provide an independent audit of the design and implementation of HuBERT system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2024