Corrective Action Plans

Catholic Charities respectfully submits the following corrective action plan for the year ended June 30, 2024. Name & address of public accounting firm: Kernutt Stokes 1600 Executive Parkway, Suite 110 Eugene OR 97401 Audit Period: June 30, 2024 Major Federal Award Findings: Finding Reference #: 2024-001 Significant deficiency Recommendation: We recommend management design and implement internal controls over compliance to ensure tenant recertification is performed within the timeframe specified by HUD. Corrective Action: Renaissance Court has contracted with a new property management company, effective April 1, 2024. Due to the transition, certain tenant recertifications were completed late. Management will work with Guardian Management to improve the procedures and ensure tenant recertifications are completed in a timely manner, as specified by HUD. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.

Subrecipient Monitoring Material Weakness in Internal Control Over Compliance and Material Noncompliance Federal Agency Name: Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Finding Summary: The subrecipient agreement requires the submission of quarterly performance reports by the subrecipient within fifteen days of quarter end. However, no quarterly performance reports were submitted by the subrecipient for the year ended June 30, 2024, as of August 1, 2024. Responsible Individuals: Stella Runde, Budget Director Corrective Action Planned: Dubuque County acknowledges the comment and has implemented a process to receive and review quarterly performance reports from the subrecipient. Anticipated Completion Date: June 30, 2025

2024-001 Federal Program - Federal Program AL # 93.224 and 93.527 Health Center Cluster Recommendation – Along with providing proper training to employees , we recommend that the Center develop a tool the eliminates manual calculations for the front desk staff to use in determining which fees to apply to vision patients. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.

Finding 2024-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster - Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Vouchers Programs Assistance Listing Number: 14.871, 14.879 and 14.EHV Noncompliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority's files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 9,051 units. Of a sample size of eighty-nine (89) tenant files, the following was noted: • HUD-9886 Authorization for Release of lnformation was missing in 4 files Our sample size is statistically valid. Known Questioned Costs: $24,363 Cause: There is significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: Of the Eighty Nine (89) tenant files audited, four (4) tenant files contained a deficiency in the same indicator---the Authorization for the Release of lnformation/ Privacy Act Notice (HUD Form 9886) retained in the tenant file was executed after the audit date range, not within the audit period (4/1/23- 3/31/24) or within the three months prior. The HACCC discovered two contributing factors for this deficiency and identified a plan to ensure compliance with this requirement which is detailed below. First, the HACCC's Housing Choice Voucher program entered into a partnership with Paul Edwards Management and Consulting (PEM) on May 1st 2024. This partnership provides the HACCC's Housing Choice Voucher program with technical assistance and coverage of vacant positions within the Housing Choice Voucher program Continued Eligibility team. The PEM team members assigned to Continued Eligibility are responsible for completing timely Annual Recertifications for all assigned Housing Choice Voucher program participants---including the collection of any signature documents required by HUD annually. To ensure compliance with this requirement, contract performance indicators related to those positions temporarily assigned to PEM (including the timeliness of Annual Recertifications and a consolidated report of findings within the Electronic File Protocol Quality Control Audit Checklists) will be included in a corrective action plan. The enhanced monitoring provided by the corrective action plan will a) ensure the continued collection of the performance indicator data and b) provide timely feedback regarding the partnerships ability to mediate the deficiency. Second, HUD removed the expiration date from the 9886 form. Effective 01/01/2024, HUD requires Housing Authorities to collect a signature on the 9886 form once throughout the course of participation instead of requiring Housing Authorities to collect a signature on the form annually (or every 15 months). HUD issued PIH Notice 2023-27 on 09/29/2023. The notice indicated "In accordance with the final rule, all applicants must sign the consent form at admission, and participants must sign the consent form no later than their next interim or regularly scheduled income reexamination. After an applicant or participant has signed and submitted a consent form either on or after January 1, 2024 (regardless of the PHA/MFH Owner's compliance date), they do not need to sign and submit subsequent consent forms at the next interim or regularly scheduled income examination ... ". The HACCC' s Housing Choice Voucher program began to request tenant signatures on the updated 9886 form effective 1/1/2024 (within our online recertification workflows) and effective 3/29/24 (within our paper recertification packets). Internal procedures for the storage of electronic documents ("HACCC Electronic File Protocol") related to the 9886 form were updated in accordance with the change, to in effect, retain the 9886 document as any other "vital document" or one-time verification would be stored and retained (ex. birth certificate, social security card, etc)--- storing and retaining only the most recent version of the document. The HACCC agrees that the requirement to retain a 9886 executed within the audit date range for these 4 files was not fulfilled despite the above-mentioned updates taking place within the audit date range. To ensure compliance with this requirement, Electronic File Protocol QC Checklist Procedure Training will be included in a corrective action plan. The training requirement will a) ensure the continued collection and review of the Electronic File Protocol Quality Control reports and b) provide timely feedback regarding whether having a single retention requirement applied throughout an entire fiscal year will effectively mediate this deficiency. We agree with the Auditor's observations on the inspection of the tenant files and will implement internal control procedures that will ensure compliance of federal regulations. Ingrid Layne, Director of Assisted Housing, will be responsible to implement this corrective action by March 31, 2025.

Corrective Actions Taken or Planned: In March 2024, the Program Executive Director implemented a formal written signature process on the access database check request sheets as written evidence of the review and approval process for housing payments. Person Responsible for Corrective Action: Rachel Erpelding, Executive Director, the Kim Wilson Housing Team, and Accounts Payable Specialist.

2024-002: Eligibility Cause: During our testing, we identified that the College’s internal control policies were not effectively designed to ensure funds are disbursed to eligible students. Context: During inquiries with management, the College identified four students that were awarded and disbursed Pell, SEOG, and Direct Loans, who were subsequently determined to be ineligible for the programs. View of the responsible official: MACC does not agree with this finding. MACC has many measures in place to ensure funds are disbursed to eligible students, including verifying identity when enrolling degree seeking students in classes each semester and reviewing high school completion status with a high school transcript, as well as reviewing ISIRs, and other documentation to determine eligibility for federal student aid. While preparing disbursements for fall 2024, the Financial Aid Office identified some odd entries on some ISIRs, which prompted us to review various patterns in admissions documents. MACC believes the students in question may be cases of stolen identities. However, this is only suspicion at this time because when the students in question enrolled in the summer 2024 semester they provided identification, submitted high school transcripts from valid high schools, completed FAFSAs which resulted with valid ISIRs (in one case the student submitted Verification (V4) documentation), submitted loan data sheets and completed entrance counseling via Zoom. The students in question were referred to the Office of Inspector General at the U. S. Department of Education on 10/15/2024; no follow-up has been received from OIG as of 01/15/2025. MACC has also discussed this case with Kathy Feith, Region 7 Branch Chief, of the U. S. Department of Education, Federal Student Aid. During an interview with an auditor from CLA, MACC disclosed the situation described above to the auditor when questioned about any potential fraud cases. MACC firmly believes all internal control policies were followed to ensure funds were disbursed to eligible students. At the time of disbursement, there was no indication these students were not eligible. As noted above, the OIG has not determined that these are in fact ineligible students; therefore, MACC does not believe it should return funds based on suspicion of ineligibility. As a result of these findings, MACC has added new steps to provide an additional layer of protection, including verifying images of state drivers licenses or other forms of identity, and development of guidelines for staff to follow if they have any suspicion of fraud. Name(s) of the contact person(s) responsible for corrective action: Amy Hager Planned completion date for corrective action plan: We expect the plan will be an ongoing effort to ensure compliance.

The City's Department of Housing has an established policy in place for determination of initial program eligibility as well as determination of continued program eligibility. The City's Department of Housing will review its procedures for executing Housing Assistance Payment (HAP) contracts and amendments and make any necessary procedural adjustments to ensure that ineligible families do not receive program assistance. The City's Department of Housing will enhance its quality control review in this area and provide additional guidance to staff as necessary.

Management agrees with the auditors’ recommendation and will evaluate process improvements and additional employee training to ensure the youth intake file audit review process is fully implemented and executed going forward. The organization has already begun to train staff with the Contracts and Compliance Manager attending quarterly Program Director Meetings to report out on file compliance status. In addition, in the first quarter of Fiscal Year 2025, the Director of Practice Development incorporated the training curriculum for program file management into onboarding for new staff. Moving forward, the Director of Development and Compliance Manager will provide specific trainings during the agency-wide Intake Specialist meeting and the Program Manager meeting. These trainings will take place before the end of the calendar year.

Child Nutrition implemented a new policy/procedure for handling free and reduced applications effective July 1, 2024.

Finding 2024-001 – Child Nutrition Cluster – Eligibility Context: During testing over controls for eligibility, we noted there was no formal, secondary review for the applications entered in the food service software determining eligibility. Additionally, there was no documented annual review by School Corporation personnel of the income eligibility guidelines used by the food service software. Contact Person Responsible for Corrective Action: Tracy Wilson Contact Phone Number:317-408-1388 ext. 407 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will review and provide proof that multiple parties reviewed and confirmed the correct income eligibility guidelines in our software each year prior to making the applications available to parents. Anticipated Completion Date: Immediate

2024-003 Reporting Federal Assistance Listing Number: 10.553, 10.555, and 10.559 Program: Child Nutrition Cluster Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Pass-Through Number: ADE ED09-0001 Compliance Requirement: L. Reporting Award Period: July 1, 2023 – June 30, 2024 Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Questioned Costs: $4,397.30 of underreported claims Repeat Finding: This is not a repeat finding. Condition/Context: The District did not properly calculate, and report meal claims accurately for three of 4 months selected during the current year. This led to the District under-reporting $4,397.30 in student meal claims. Criteria: The Uniform Guidance compliance supplement. Local educational agencies (LEAs), institutions, and sponsors determine eligibility by comparing the data reported by the child’s household to published income eligibility guidelines. Child Nutrition Program claim forms should be supported by documentation showing the number of meals for which reimbursement was requested and document that the meals were served prior to the date of the reimbursement request. The claim reports should be filed on a timely basis. Corrective Action: The District will implement review procedures as part of the meal claim process to ensure claims reported match with District records. The District will ensure any over/under reporting is investigated and resolved in a timely manner. The District will review reports from FY24 and ensure any unclaimed meals are properly reconciled, as applicable. Planned completion date for corrective action plan: For the period ending June 30, 2025. Name of the contact person responsible for corrective action: Lori Wilson, Business Manager

Finding 2024-001 – Child Nutrition Cluster – Eligibility Context: During testing over controls for eligibility, we noted there was no formal, secondary review for the applications entered in the food service software determining eligibility. Additionally, there was no documented annual review by School Corporation personnel of the income eligibility guidelines used by the food service software. Contact Person Responsible for Corrective Action: Tom McFarland Contact Phone Number: 574-342-2255 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Following eligibility guidelines being entered into the food service software, a secondary reviewer will sign off that the data was entered accurately. Anticipated Completion Date: immediate (12/11/24)

Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2024 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the institution, must be accurately reported within 30 days whenever attendance changes for a student, unless a roster will be submitted within 60 days. The changes include reductions or increases in attendance levels, withdrawals, graduations, and approved leaves-of absence. It is the institution’s responsibility, as a participant in the Title IV aid programs, to monitor and report these changes to the National Student Loan Data System (“NSLDS”). (NSLDS Enrollment Reporting Guide November 2022, and 34 CFR 685.309(b)) Condition Of the fifteen students selected for enrollment reporting testing, two students within the sample were reported to NSLDS outside the maximum 60-day window. This was not a statistically valid sample. Views of Responsible Officials and Planned Corrective Actions The University concurs with the finding. The University will continue to remain vigilant in its oversight over timely communication of enrollment reporting detail to NSLDS. In both instances, the data we had sent to the National Student Clearinghouse (NSC) was not received by NSLDS in a timely fashion. We will review our reporting schedule and make the appropriate changes to our reporting timeline to ensure the data we report to the NSC is subsequently received by NSLDS within regulations. Names of Contact Person Responsible for Correction Action: Frank Mullen, Associate Vice President of Financial Aid Anticipated Completion Date: November 14, 2024

Federal Program, Assistance Listing Number and Name - ALN 14.239, Department of Housing and Urban Development, Home Investment Partnerships Program Condition: Original Finding Description - The City did not have adequate controls in place to exercise its oversight responsibility of eligibility determinations that were reviewed by a contractor for the program. Contact Person Responsible for Corrective Action / Anticipated Completion Date - Julie Schneider; Anticipated completion date: June 2025 Planned Corrective Action - The City will implement a control for completeness and accuracy by hosting regular meetings with the contractor to review recent projects for which the contractor has documented their determinations of income eligibility. When a recently-reviewed project is not due for an annual review, staff will still have timely insight into the income eligibility of properties in its HOME portfolio, thereby maintaining compliance with HOME program regulations.

Federal Program, Assistance Listing Number and Name - ALN 14.239, Department of Housing and Urban Development, Home Investment Partnerships Program Condition: Original Finding Description - The City’s on-site inspections for compliance with the housing quality standards are triggered by City’s process to audit developers for compliance with HOME eligibility requirements. This basis is more restrictive than Federal requirements for Housing Quality Inspections At the end of an inspection cycle a certificate of completion is completed and signed by the responsible inspector. The City did not have effective controls to ensure the certificate of completion, is reviewed for completeness and accuracy. The City did not inspect the 20% of the units, as required by their policy. Contact Person Responsible for Corrective Action / Anticipated Completion Date - Julie Schneider; Anticipated completion date: June 2025 Planned Corrective Action - The City will review its processes and implement additional controls to ensure certificates of completion are reviewed for completeness and accuracy and to verify 20% of the units are inspected to comply with the HOME Program manual and federal regulations related to Housing Quality Standards.

2024-006 - Student Financial Aid Cluster- (a) Federal Supplemental Educational Opportunity Grant (b) Federal Work Study Grant (c) Federal Perkins Loan Program (d) Federal Pell Grant Program (e) Federal Direct Loan Program, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 - Year Ended June 30, 2024 Condition Found The College did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 2 of the 40 students in the sample (5%). We consider this condition to be an instance of noncompliance in internal control over compliance relating to the Eligibility compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2023-005. Corrective Action Plan Student Financial Services will work with PowerFaids to determine how records are returned to COD for a disbursement date update and ensure reporting is compliant. Responsible Person for Corrective Action Plan Kandi Molder, Registrar and Executive Director of Student Services Deb Beck, Managing Director of Student Financial Services Implementation Date of Corrective Action Plan January 31. 2025

2024-005 - Student Financial Aid Cluster- (a) Federal Supplemental Educational Opportunity Grant (b) Federal Work Study Grant (c) Federal Perkins Loan Program (d) Federal Pell Grant Program (e) Federal Direct Loan Program, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 - Year Ended June 30, 2024 Condition Found During our student file testing, we noted five students out of 40 (12.5%) did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be a significant deficiency with the Eligibility Compliance Requirement. Corrective Action Plan Student Financial Services will develop a report and process that looks at students with a withdrawal or conferral date in Jenzabar or who have dropped below half time, who have taken Direct Loans and ensure that exit counseling materials are sent. Responsible Person for Corrective Action Plan Kandi Molder, Registrar and Executive Director of Student Services Deb Beck, Managing Director of Student Financial Services Implementation Date of Corrective Action Plan March 31, 2025

2024-004 - Student Financial Aid Cluster – (a) Federal Supplemental Educational Opportunity Grant (b) Federal Work Study Grant (c) Federal Perkins Loan Program (d) Federal Pell Grant Program (e) Federal Direct Student Loans (f) Teacher Education Assistance for College and Higher Education ALN No. (a) 84.007 (b) 84.033 (c) 84.038 (d)84.063 (e) 84.268 - Year Ended June 20, 2024 Condition Found 5 of the 40 student files (12.5%) we examined, we noted the students were not properly awarded Direct loans. Corrective Action Plan Student Financial Services has created a report comparing need-based aid awarded to the student’s need eligibility and an overall aid awarded compared to the Cost of Attendance (COA) budget. We will also work to develop a report that compares FAFSA year in school compared to total credit hours earned. Responsible Person for Corrective Action Plan Kandi Molder, Registrar and Executive Director of Student Services Deb Beck, Managing Director of Student Financial Services Implementation Date of Corrective Action Plan January 31, 2025

2024-003 - Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher Education Assistance for College and Higher Education ALN No. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (t) 84.379 - Year Ended June 20, 2024 Condition Found One of the 40 student files (2.5%) we examined, we noted the students were not properly awarded Pell grants. Corrective Action Plan The Student Financial Services Office will implement a weekly task of reviewing students in a Disbursement Review (DR) status and students with zero credits in a term with an active Period of Enrollment (POE). Responsible Person for Corrective Action Plan Deb Beck, Managing Director of Student Financial Services Implementation Date of Corrective Action Plan December 1, 2024

Corrective Action Plan: Anticipated Completion Date January 15, 2025 Prior to Mono County Office of Education (MCOE) taking over this program in 2022-23, another agency was responsible for the original eligibility determinations and special tests and provisions. MCOE investigated further, and it was noted that the staff at the time were not following the procedures and forms that were in place. Items were either not completed or filled out correctly in many instances. When the audit finding was identified in the 2022-23 audit, MCOE took action to immediately implement new procedures to address the items noted. Although a few items were noted during the 2023-24 audit, MCOE has made significant efforts in putting procedures in place, and will continue efforts to ensure all required documentation is complete. MCOE has developed a corrective action plan as follows to adhere to strong internal control in meeting the program’s requirements: • MCOE will ensure that existing and new staff are trained to adhere to the policies and procedures for the program. • MCOE will be conducting annual reviews of all service providers and children served to ensure MCOE is maintaining the required documents on file. • MCOE has developed a double-check procedure to ensure that staff is keeping the required documentation on file for both providers and children served moving forward. I, Jennifer Weston, CBO, will be responsible for the implementation and monitoring of the corrective action plan. Sincerely, Jennifer Weston Chief Business Officer Mono County Office of Education

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Moving to Work Demonstration Program to ensure that established internal control policies are being followed on a timely basis. Adam Bovilsky, Executive Director, is responsible for implementing this corrective action by March 31, 2025.

The School District will implement monitoring control procedures to review software system eligibility determinations to ensure compliance with federal income guidelines. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Mara Powell

2024-001 Audit Finding: ALN: 10.565 Grant No.: 204642 Grant Period: Year ended September 30, 2024 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: • Scanning Applications: o CSFP staff scan applications daily. These applications are then stored in SharePoint. We have 2-3 volunteers weekly who rename applications based on Client ID, Name, and Expiration Date, then file them electronically based on their expiration date. This ensures that we are always up to date on having an electronic version of our CSFP applications. o Before shredding any applications that have been scanned, we confirm that the application exists in the system (done by CSFP staff). • If an application is missing: o Confirm that application information is in ClientTrack and document through a generated printed application. o Send application to distribution site for next distribution, to ensure participant signs new application before they receive another CSFP box. Anticipated Completion Date: This process was fully implemented at the end of May 2024. It should be noted that applications have a 3-year certification period, so the full effect of the new process won’t be realized until spring of 2027. Contact: Dan Fuhrman, Controller Second Harvest Heartland 7101 Winnetka Ave N Brooklyn Park, MN 55428 651-209-7901 651-484-1064 (fax)

Condition: Pertaining to the Nutrition Cluster, the District could not find 8 free/reduced applications selected and one application selected was not signed as required. Recommendation: We recommend ensuring that no matter in which format the District collects the applications, that they have access to the data for any possible future audits. Management Response: Management and the Food Service Department will ensure that all records are appropriately saved in digital and paper formats in anticipation of future audits. The Food Service Department will implement a triple check process to ensure that all electronic and paper applications are signed. Anticipated Date of Completion: June 30, 2025

Condition: Pertaining to the Nutrition Cluster, there were 8 cases where the household size was larger than the number of household members listed in Step 1 and Step 3 on the free/reduced application. In 3 cases there was no change in the free/reduced status if the smaller number of household members were used. In 5 cases there were changes in the status. There was an additional case where the listed income put the family in the reduced status but they were listed as free. Recommendation: We recommend reviewing applications to ensure that the household size and the listed household members in Step 1 and Step 3 match. Management Response: The Food Service Department will implement a triple check process to ensure that all household data matches and the appropriate criteria is being used to calculate household eligibility. Anticipated Date of Completion: June 30, 2025