Corrective Action Plans

FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025

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 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 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 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, 2025

Name of Contact Person Responsible for Corrective Action: Karen Warmack, Social Services Director Corrective Action Planned: The County will implement additional procedures, including reviews, to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input into MAXIS. County Comment: A Corrective Action Plan has been established with an anticipated completion date of December 31, 2025. Anticipated Completion Date: December 31, 2025.

2024-002 – Allowable Activities – Moving to Work Demonstration Program - 14.881 Significant Deficiency Statement of Condition and Criteria The Authority does not appropriately evaluate and settle inter-program balances on a periodic basis. The Authority is required to implement and utilize HUD program funds in accordance with activities approved in the annual MTW plan. Recommendation We recommend the Authority evaluate and update the system coding of interfund transactions to assist with periodic settlement of balances. In addition, operating transfers should be identified and differentiated from the routine, reciprocal transactions and treated according to their purpose to assist with management of cash balances. Corrective Action The Authority is converting its accounting software to better enable it to manage the various activities of the Authority. Upon conversion, all program balances are to be formally settled. In addition, a process is being developed to capture and identify transactions generated by MTW funded activities to assist with timely and accurate recording.

The Just One Project's CSFP team will maintain a filing system organized by service site, alphabetical client name, and month and year of registration. The team will also utilize the Salesforce system to track registered clients, recertification dates, and services provided each day. Effective immediately, designated CSFP staff will visit all active distribution sites each business day to collect new registration and recertification forms, cross-check them and previously filed forms against the day's Salesforce distribution list, and file new forms in the designated system. This will ensure every client record is complete and current. In addition, the team will conduct an internal audit at least annually to confirm that all participant files contain required documents and certifications, promptly address any deficiencies, and document corrective steps. Staff will also receive periodic refresher training to reinforce record-keeping standards and sustain compliance.

Corrective Action: The finding was a result of prior staff that was replaced in the current fiscal year. Management has designated a resident intake and compliance manager to be responsible for monitoring tenant recertification schedule across all HOME-assisted unites. Any exceptions will be corrected immediately and reported to management.

Management Response #2024-004: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. Corrective Action Plan: All eligibility verification data, including screenshots and signed Rights and Obligations statements, will be stored in a centralized, secure shared drive maintained and managed by the WIC Director to ensure it is protected with limited access and password protection. The drive will be organized using a de-identified naming convention to ensure privacy while maintaining ease of access for authorized staff. To maintain a robust system of checks and balances, tasks related to eligibility verification and documentation will be divided among different team members. This separation will prevent any one individual from having full control over the process, reducing the risk of oversight or potential errors. The WIC Department’s policy and procedure manuals will be revised and updated to include the new eligibility verification process. To ensure adherence to the new protocols, periodic audits and review sessions will be conducted by the WIC Director or designated compliance staff to verify that documentation is being properly maintained and that all procedures are followed. Staff will be required to undergo refresher training sessions as needed to reinforce the updated protocols and best practices. Management expects to be completed by December 31, 2026. Responsible Party: Tracy Harrison, COO

We have hired an outside independent company, Infinity File Compliance, LLC to work with us on updating and maintaining all HUD documentation requirements. We are working on applying all the new policies and procedures and will be implementing trainings to ensure future compliance.

Management has reinforced the effective execution of existing controls around proper documentation of all expenditures and record retention for these expenditures. Monthly and year-end procedures have been updated to ensure compliance with these procedures. Anticipated completion date: June 30, 2025.

Finding 2024-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871, 14.879 & 14.EHV Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: No Significant deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Twenty-five (25) names were selected from the new move-in list and those names were to be traced to the waiting list to verify new move-ins were chosen in an order that was in accordance with the Authority’s policy. It was determined that one (1) out of twenty-five (25) new move-ins selected could not be traced with any certainty back to the Authority's waiting list. Known Questioned Costs: $9,231 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. 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 programs are in non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the significant deficiency in the Housing Voucher Cluster programs and will implement internal control procedures that will ensure compliance with federal regulations. Nicole Alexander, HCV Program Director, is responsible for implementing this corrective action by December 31, 2025.

The County will ensure that procedures are in place to ensure support is provided for review and approval of eligibility determination.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2024-003 - Medicaid and CHIP Eligibility Determination Timeliness Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: December 2025 Recommendation: The DSS through the MHD and the FSD review, strengthen, and enforce internal controls to ensure participant eligibility is determined within the required timeframes. DSS Response: The DSS agrees with this finding. DSS is currently working with Centers for Medicare and Medicaid Services (CMS) to create a plan to mitigate the backlog of applications and ensure eligibility determinations are completed timely according to 42 CFR 435.912(c)(3) and 457.340(d). The backlog plan was sent to CMS February 13, 2025. DSS estimates the backlog to be complete by the end of December, 2025. To address the continued increase in applications, DSS is leveraging new and available technologies. These technologies are intended to assist the department and participants with necessary actions such as submitting applications, verifying income and resources, and providing required information. DSS is completing an analysis of policies and procedures to determine areas in which changes can be made to improve efficiencies. Corrective action planned is as follows: The DSS will continue to work towards completing applications within the established timeframes outlined in 42 CFR 435.912(c)(3) and 42 CFR 457.340(d).

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2024-002 - Medicaid and CHIP Participant Eligibility Terminations Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: September 1, 2025 Recommendation: The DSS through the MHD and the FSD continue to review, strengthen, and enforce internal controls to ensure ineligible participant cases are closed when necessary and resume the DHSS vital records death match in the MEDES. DSS Response: The DSS partially agrees with this finding. DSS has controls in place to close coverage when a customer requests closure; however, the procedures were not followed. During the audit period, the FSD Call Center had processes in place to accept calls for applications, renewals, change in circumstance, enter evidence and inquiries. However, contracted staff are unable to authorize any action that results in a case closing and that authorization must be completed by a DSS employee. There were procedures in place for contracted staff to submit a form that will create a task for DSS staff to finalize the actions. For the case cited in the finding, the task was not created, resulting in DSS staff not receiving the request to voluntarily close the case. Although call center staff noted in the electronic case file the purpose of the call, there are not systematic controls in place to take action or create tasks for DSS employees from the case notes. Currently, a death match with Department of Health and Senior Services (DHSS) vital records is functional in the Family Assistance Management Information System (FAMIS) eligibility system currently used for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and MO HealthNet for Aged, Blind, and Disabled (MHABD) individuals. When the match is received into FAMIS from DHSS, that information is included on the eligibility file submitted to the Medicaid Management Information System (MMIS) to ensure that the death date is captured in MMIS to prohibit any payments after the death of the individual. This control ensures that no improper payments are made on a beneficiary’s behalf after the date of death. DSS has processes in place to close eligibility when death information is received from family members and providers during the certification period. Additionally, in compliance with 42 CFR 435.949, DSS administers an electronic verification match with the federal hub at application and during the annual review process to inquire about death. DSS is continuing to evaluate necessary steps to reinstate the death match with DHSS vital records, but do not have an anticipated completion date. Regarding the questioned costs, eligibility errors are governed by section 1903(u) of the Social Security Act. Therefore, questioned costs identified in the single statewide audit should not be subject to recoupment. Corrective action planned is as follows: DSS is strengthening controls by revising the procedures of the contracted FSD Call Center to ensure case actions are completed timely. DSS will use a system action to close cases with out of state address evidence in the Missouri Eligibility and Enrollment System (MEDES).

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services – Family Support Division Audit Finding Number: 2024-001 – Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: N/A Recommendation: The DSS through the MHD and the FSD continue to review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. DSS Response: The DSS disagrees with this finding. The DSS disagrees there is a significant deficiency in internal controls. As noted in the finding, from the 60 participants selected, the SAO did not identify any participants with previously-established overrides; therefore, no incorrect payments were cited. Section 6008 of the Families First Coronavirus Response Act (FFCRA) required states to provide continuous coverage, through the end of the month in which the PHE period ends, to all Medicaid beneficiaries who were enrolled in Medicaid on or after March 18, 2020, regardless of any changes in eligibility unless the individual voluntarily terminated eligibility, is deceased, or moved out of state. As required by the Centers for Medicaid and Medicare Services (CMS) during the PHE, the DSS had processes in place to terminate eligibility for individuals who were deceased, voluntarily requested closure, or reported they have moved out of state when a current change was reported. The Consolidated Appropriations Act, 2023, signed on December 29, 2022, amended section 6008 of the FFCRA such that the continuous enrollment condition ended on March 31, 2023. During the PHE, the DSS did not conduct reviews of cases that did not report current changes. DSS resumed initiating renewals starting in April 2023 under the unwinding plan submitted to CMS with the goal to complete all unwinding related renewals prior to the deadline of August 31, 2024. However, DSS encountered challenges in completing all unwinding renewals by the established deadline. On August 29, 2024, CMS released guidance recognizing the challenges that many states faced impacting the ability to complete unwinding related renewals and restore routine operations within the original timelines established, extending the allowance for states to continue to use the exception under 42 CFR 435.912(e) through December 31, 2025. A report identifying all individuals with manual overrides was created in August 2023 to ensure that individuals with determinations created outside of the MEDES system are being renewed timely. The DSS continues to work this report monthly. DSS staff are working to complete renewals on participants included on the report that require an annual renewal. DSS will complete redeterminations on all cases with manual overrides that have had continuous coverage for over one year by July 31, 2025. DSS notes that not all cases with manual overrides have had continuous coverage for more than one year and therefore do not currently require a redetermination. DSS will complete redeterminations on these cases when they become due. DSS will continue to use this report to ensure that all individuals that receive coverage outside of the MEDES system will receive their annual renewal as required by CFR 435.916.

To address the eligibility documentation issue identified during the audit, BASIC NWFL, Inc. will improve how eligibility files are reviewed by using a checklist and having two staff members verify each file. Staff will get regular training on federal rules, and internal checks will be done frequently to catch any problems early. Policies will be updated to make sure marital status and household size are clearly documented, and a eligibility specialist will oversee the process and report monthly to management. These steps will help ensure all eligibility decisions are properly supported.

# 1 The workers will be utilizing a checklist to ensure income was verified for all members. DOVE, IEVS, or the portal verification is run for each case. A request for information letter is sent if self-reported income and DOVE/electronic verification is not within 25%. # 2 All renewals will be reviewed by a specialist, supervisor, or administrator. When an individual is self-employed we request the most recent income tax form.

Financial Statement Findings Findings 2024-001 and 2024-002 listed below are also financial statement findings which are required to be reported in accordance with Government Auditing Standards. Federal Award Findings and Questioned Costs Finding 2024-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871, 14.879, 14.EHV Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness 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 2,533 units. Of a sample size of thirty-six (36) tenant files, the following was noted: • Verification of income was unable to be recalculated in 4 files • Verification of assets was unable to be provided in 1 file • HUD 50058 annual recertification was not filed timely in 2 files • Citizen Declaration Section 214 form was unable to be provided in 9 files Our sample size is statistically valid. Known Questioned Costs: $84,235 Cause: There is a material weakness in the Housing Voucher Cluster 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 Programs are in material 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 over the maintenance of tenant files that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Kathleen Wyatt, Director of Housing Operations, will be responsible to implement this corrective action by December 31, 2025.

Recommendation: We recommend the Foundation strengthen its policies and procedures to ensure procurement is adequately documented for the goods and services purchased in accordance with Uniform Guidance and other federal guidelines, including simplified acquisition procedures for purchases above the micro-purchase threshold ($10,000). Grantee Response and Corrective Action Plan 2024-001: In response to the audit finding under 2 CFR Section 200.320 regarding the necessity to have and use documented procurement procedures for acquisition of goods and services under a federal award or a sub‐award, it is acknowledged that the Foundation did not previously have a formal policy specifically addressing procurement. Recognizing the importance of formalizing these practices into policy, we are committed to developing and implementing a comprehensive policy that explicitly addresses procurement. In line with our recent enhancements in internal controls, including the engagement of a Finance Manager in 2024, this policy will reinforce our ongoing efforts to uphold the highest standards of compliance and accountability in all our operations. Responsible Parties: Allie Kelly, Executive Director Anticipated Correction Date: December 31, 2025

2024-003 ALN 14.850 – Public Housing Operating Fund - Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Date: December 31, 2025

Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibility will be developed. This procedure will include detailed steps and required documentation, supported by a standardized eligibility checklist to guide staff in confirming and accurately recording participant eligibility. Additionally, all program staff involved in intake and eligibility determination will be trained on the new procedure. Contact Person - Responsible for Corrective Action: Elizabeth LaRoy, Program Manager Anticipated Completion Date: December 31, 2025.

Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting documentation of eligibility determinations to be retained. As a result, no corrective action will be taken. Contact Person - Responsible for Corrective Action: Jen Agnello, Program Manager Anticipated Completion Date: N/A

Contact Person – Bruce Starkey, County Administrator Corrective Action Plan – The County will review procedures over application filing. Completion Date – 9/30/2025

Housing Voucher Cluster-Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend the Authority implements controls to ensure all files are maintained and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAKC will take the necessary steps to ensure files are placed back in the file room and are available upon request with the required documentation placed in the file. HAKC will complete the initial process and complete ongoing compliance reviews. Name(s) of the contact person(s) responsible for corrective action: Lisa Earnest, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 7/31/2026

Housing Voucher Cluster-Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend that the Authority implements controls to ensure the tenant files include all required documentation at the time of recertification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAKC has moved to mass annual recertification appointments to address the program delinquency and inspect files for required documentation; the recertifications will be completed and processed ensuring all documentation has been received in the file. HAKC will perform a QC sample on a monthly basis to address the files and ensure proper documentation. In addition to QC samples, the HAKC has awarded a QC contract to audit 100% of the files. HAKC will complete the initial process and complete ongoing compliance reviews. Name(s) of the contact person(s) responsible for corrective action: Lisa Earnest, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 12/31/2026

Finding Number 2024-002 ELIGIBILITY – DEFICIENCY - COMPLIANCE Agency Name FEDERAL AGENCY: U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Program ALN 14.850 – PUBLIC AND INDIAN HOUSING Contract # N/A Criteria Eligibility for Individuals - Most PHAs devise their own application forms that are filled out by the PHA staff during an interview with the tenant. The head of household signs (a) a certification that the information provided to the PHA is correct; (b) one or more release forms to allow the PHA to get information from third parties; (c) a federally prescribed general release form for employment information; and (d) a privacy notice. Under some circumstances, other members of the family may be required to sign these forms (24 CFR sections 5.212, 5.230, and 5.601 through 5.615). Condition/Context The Authority received funding from the HUD. The Public and Indian Housing Program is to provide and operate cost effective, decent, safe, and affordable dwellings for lower income families through an authorized local PHA. Of the sixty (60) case files selected for testing in which 540 pieces of audit evidence (eligibility forms as noted in the Criteria section above) were requested to be provided: • Ten eligibility forms were not provided (Three missing application forms, two missing Federally prescribed general release form for employment information; two missing verification of income; two missing calculation of rent forms and one missing reexamine family income). These forms are required documentation to be maintained in the case files to support eligibility for Public and Indian Housing Program. Therefore, we were not able to determine if the eligible participants met all the eligibility criteria. Recommendation We recommend the Authority strengthen its controls over the Public and Indian Housing Program case files to ensure that all eligibility forms are received, reviewed, and maintained in the case files to support the determination of eligibility. Corrective Action Plan In January 2011, NYCHA implemented the Siebel Customer Relationship Management (CRM) system, which included digital file storage and an online application process, which replaced our previous paper application process. Any applications in process from that date onward were subject to document scanning and documentation was stored digitally. Any applications processed prior to this date were kept in a paper format and stored at the development, where the applicant was certified or where the tenant resides. If a tenant family transferred to another development, the physical tenant folder and documents were sent to their new location. In June 2020, NYCHA sought to digitize all tenant folders; however, the cost of the project was determined to be prohibitive so the goal of digitizing the tenant folders was not realized. Any documents damaged or lost prior to 2011 cannot be recovered, including those impacted by Hurricane Sandy. Action Date September 12, 2025 Final Implementation September 12, 2025 Name And Phone Number Of Person Responsible for Implementation Sylvia Aude Senior Vice president Office of the Senior Vice President for Public Housing Operations Tenancy Administration +1-212-306-3921