Corrective Action Plans

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS concurs with the finding in this audit and would like to note this finding is related to no notice of disenrollment being mailed to a deceased member, and not related to enrollment ineligibility. AHCCCS Division of Member and Provider Services (“DMPS”) will identify the standard process for notification that should have been followed for this case. Once the root cause of the issue has been established, AHCCCS will assess current processes and procedures, as appropriate, to address this issue.

Assistance listing number and program name: 84.010 Title I Grants to Local Educational Agencies Agency: Arizona Department of Education (ADE) Name of contact person and title: Tim McCain, ADE Chief Financial Officer Chris Brown, ADE Business Officer of Education Programs Anticipated completion date: January 2025 Agency’s response: Concur • ADE is working on standardizing fiscal efficiency by adopting uniform guidelines that monitor obligations and expenditures. These guidelines outline available resources and determine allocation amounts within federal awards and earmark expiration dates within programs. • ADE is also working on standardizing how funds may be reallocated to ensure that no funds are at risk of reverting to USED. Specifically, school improvement funds are now also tracked as part of Title I allocation and reallocation process. This will ensure funds are earmarked and obligated in a timely fashion (i.e., in the period of performance). This item is planned to be completed by January 2025.

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, ADE Deputy Associate Superintendent Chris Brown, Business Officer of Education Programs Anticipated completion date: February 2025 Agency’s response: Concur • The Arizona Department of Education (ADE) has already begun to document and execute practices addressing the recommendations issued by the auditor's office. • ADE has already drafted a comprehensive policies and procedures document outlining eligibility, duties, and responsibilities with individuals who oversee and double-check the work. This document was created and refined by reviewing other states’ procedures, federal technical assistance groups, communications with the Title federal program office at the United States Department of Education, and internal procedures in other units. • The Title I unit has been restructured to have an operations team with multiple staff members overseeing data quality and internal controls for allocations. This updated structure ensures that multiple individuals are involved in the allocation process. Staffing for this should be completed by February 2025. • The updated processes include entity management to determine when charter LEAs open and operate each year. Now, other systems validate this information instead of copying the information from the prior year. As such, this item has already been completed. • Finally, the department will follow up with the United States Department of Education (USED) regarding recalculating the fiscal year 2023 and the six ineligible LEAs for Title II funds to determine feasible processes and resolutions to each audit recommendation.

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Department will review and confirm that benefits payments paid to or on the behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Follow existing policies and procedures to obtain required documentation to support requirements related to where the applicant lives and their income to ensure program applicants are eligible to receive benefit payments. The Department will abide by the existing adjudication policies and procedures that require the submission of substantiating documentation supporting the claims made by applicants regarding where they live and their household income to confirm that applicants are eligible to receive benefit payments under the program and to verify the amount of benefits they shall receive. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Department will attempt to obtain or allocate additional resources to staffing to support the program benefits application evaluation process and will provide additional training to staff on eligibility requirements and allowable benefit payment regulations. 4. Update the checklist Division personnel use to perform a post-review of eligibility determinations to include detailed guidance for verifying the determinations aligned with the Division’s written policies and procedures and supported by adequate documentation. The Department will update the checklist being used by staff to perform post-review of eligibility determinations to include detailed guidance on verifying the applicant benefits determinations in alignment with the divisional policies and procedures and evidenced by adequate substantiating documentation.

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

The County will continue to monitor supervisory and cross training processes.

Low-Income Home Energy Assistance – Assistance Listing No. 93.568 Recommendation: CLA recommends the County review controls and procedures surrounding file storage/retention to ensure files are being archived in accordance with Colorado Regulation 3.755.17 - Archiving Case Files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have completed the transfer of all our previous files and now scanning all new and current cases into a new database called Papervision. Each permanent technician will be responsible to scan their own cases into the database. Name of the contact person responsible for corrective action: Samantha Contreras Planned completion date for corrective action plan: New database has been implemented as of September 2024

2023-005 – ALN 14.871 – Housing Choice Voucher Program – Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

2023-002 – ALN 14.850 – Public & Indian Housing – Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

The CFO at TCA Health has addressed the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff were trained in the approved sliding fee scale policy and its requirements. The COO worked with the CFO and third-party billing company, and Athena to roll back the EMR update which contributed to ineffective application of the sliding fee in November 2023. TCA hired a full time Patient Services Manager in 2024 to support ongoing staff training, quality assurance monitoring, and implementation of the updated EMR and registration workflows. Staff have become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. Additionally, TCA began to undergo internal audits of records ensuring that proper documentation is maintained and a patient service manager, utilizing testing template provided by the organization’s auditor.

We have submitted the annual SAC filing as the prior year's audits have been completed. We expect the FY24 audit to be completed by the end of January 2025 and the SAC filing for the fiscal year will be completed shortly thereafter which will be prior to the deadline of nine months after the end of the audit period. Anticipated Completion Date-02/28/2025.Responsible Contact Person-Kathleen Boyce, CFAO

Finding 2023-003 Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendent will ensure MDE's approval is tangible before any obligations. We will implement a tool that allows this process to be measured daily. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Tiffany Lanier, Federal Programs Director Corrective Action Start Date: October 31, 2024

The University concurs with this finding but cannot respond why the student was awarded outside the of procedure and methodology set up for awarding HEERF Funds. The decisions were made by individuals no longer with the University and no documentation was found to determine why the student was awarded outside the policy in place. The Controller’s Office and Financial Aid Office are working together to make sure that in future funds like the HEERF will have documentation attached to secure that we follow procedure and policy and document any exceptions.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Homeland Security Passed through Cumberland County: Grant No. 39 5962 00 Grant No. ARPA R 5962 00 Emergency Food and Shelter National Board Program AL# 97.024 11/2021 12/2023 11/2021 12/2023 Passed through Salem County Board of Social Services Grant No. ARPA R 6028 00 11/2021 12/2023 Passed through Atlantic County Grant No. 39 5948 00 Grant No. ARPA R 5948 00 Passed through Cape May County Grant No. ARPA R 5960 00 Grant No. 39 5960 00 11/2021 12/2023 11/2021 12/2023 11/2021 12/2023 11/2021 4/2023 2023-006 -Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria Emergency Food and Shelter National Board Program (EFSP) funds may be used for food and related expenses (such as transporting food/food preparation and serving equipment); mass shelter; other shelter (such as hotels and motels); and rent/mortgage and/or utility assistance limited to one month. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. ,roj"':::;: Charities USt\, www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I "I'd: 856-342-4100 I Fax: 856-342-4180 Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: a W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. a Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I Tel: 856-342-4100 I Fax: 856-342-4180 Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Health and Human Services Temporary Assistance for Needy Families (TANF) - AL #93.558 Passed through Camden County Health Department: Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through Cumberland County Office on the Aging and Disabled Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through Salem County Board of Social Services Grant No. None Available 1/2022 12/2022 Grant No. None Available Passed through Gloucester County 1/2023 12/2023 Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through New Jersey Department of Human Services Division of Family Development Grant No. SF22009 10/2021 9/2022 Grant No. SF23009 10/2022 9/2023 2023-005 - Activities Allowed and Allowable Costs and Eligibility (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria TANF funds monthly cash assistance payments to low-income families with children. The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102-590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. ,,o,s::::;: C:h.1riries USA. www.catholiccharitiessouthjersey.org 1845 Haddon Avcll1le, Camden, NJ 08103 I Td: 856-342-4100 I Fax: 856-342-4180 Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. • Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I Td: 856-342-4100 I Fu.: 856-3424180 Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org stions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone ii address above.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Veterans Affairs Direct Award: Grant No. 12 NJ 053 55 Grant No. 12 NJ 053 22 VA Homeless Providers Grant and Per Diem Program AL# 64.033 9/2021 9/2023 10/2021 3/2023 Grant No. 12 NJ 053 HL 9/2021 9/2023 Grant No. 12 NJ 053 LT 8/2022 9/2026 Grant No. 12 NJ 053 23 9/2021 9/2023 2023-004 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102 590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive' assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: Theim.proper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to­ day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in Febr·uary 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB. Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above.

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Housing and Urban Development Emergency Solutions Grant Program AL# 14.231 Passed through State of New Jersey Department of Community Affairs: Grant No. 2019 02156 036106 8/2020 3/2023 Grant No. 2022 02156 0337 00 7/2021 7/2023 Grant No. 2022 02156 0339 00 4/2022 7/2023 Grant No. 2022 02156 0338 00 4/2022 9/2023 Grant No. 2022 02156 0052 08 12/2019 9/2023 Grant No. 2020 02156 0042 08 12/2019 9/2023 Grant No. 2020 02156 0042 04 12/2019 9/2023 Grant No. 2019 02156 0361OS 12/2018 9/2023 2023-003 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria ESG funds may be used for five program components: street outreach, emergency shelter, homelessness prevention, rapid re-housing assistance, and HMIS; as well as administrative activities. The five program components and the eligible activities that may be funded under each are set forth in 24 CFR 576.101 through 576.107. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. www.catholiccharitiessouthjersey.org 1845 Haddon A\-enue, Camden, NJ 08103 I Tel: 856•342-4100 I Fu: 856---3424180 Serving si.,;: counties of Southern Nev,1Jersey: Atlantic, Camden, Cape May; Cumbedand, Gloucester & Salem View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETD Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above. Robert T Waite, Controller

2023-001 – ALN 14.871 – Housing Voucher Cluster – Activities Allowed and Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024 2023-002 – Significant Deficiency in Internal Controls over Financial Reporting Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024

Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record

Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record

2023-001 Emergency Food Assistance – Assistance Listing No. 10.569 Recommendation: We recommend the Organization follow its procurement policy that includes procedures for suspension and debarment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Second Harvest North Central Food Bank will update its procurement policy to reflect the review over the required procedures related to suspension and debarment. Name of the contact person responsible for corrective action: Shaye Moris Planned completion date for corrective action plan: December 31, 2024 If the Minnesota Department of Human Services Office of Economic Opportunity has questions regarding this plan, please call Shaye Moris at 218-336-2300.

Management has implemented a filing system to ensure current client information is collected and recertified regularly. CSFP/SNW staff have maintained a system organizing all clients by month and year of registration, site of service, and then alphabetized by client name to aid in certification & recertification. Certification and recertification are occurring at CSFP/SNW distribution sites during service, and CSFP/SNW staff randomly audit files of active clients as they are being served to confirm their certification. CSFP/SNW staff also leverage a tracking system in our TJOP Salesforce Software System to reinforce client certification and recertification status. We will implement an internal audit at lease once annually to ensure participant files have all required documents and certifications.

U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Eligibility Repeat Finding: Yes Auditee’s Corrective Action Plan: Condition #1 Response MOHS acknowledges the finding that 14 out of 40 files did not have management review. Corrective Action: The Program Manager will conduct quality control reviews for 30% of files that have been recertified each month. The quality control review will verify all eligibility components under the program were met. Condition #2 Response MOHS acknowledges the finding that 25 out of 40 selections did not have the supporting thirdparty documentation of income. MOHS followed the HOPWA guidance outlined in the Self- Certification of Income and Credible Information on HIV Status waivers released by HUD for September 2021 and March 2023. The waiver permits HOPWA grantees and project sponsors to rely upon a family member’s self-certification of income and credible information on their HIV status. The HUD-CPD notices are referenced in Exhibits A-B of this response. The program accepted the self-certification of income until the waivers from HUD ended for COVID-19 on March 31, 2023. Corrective Action: MOHS has resumed following the process of requesting third party verification of income, assets, and medical expenses to ensure proper calculation of tenant rent. Client records are being updated with the appropriate verification of income documentation from the third-party source. Condition #3 Response MOHS acknowledges the finding 6 out of 40 selections did not have documentation of the rent reasonableness. Corrective Action: MOHS uses GoSection8, an online rent comparable website to conduct rent reasonableness. Rent reasonableness is conducted at the initial move-in and with each rent increase request. Documentation of the comparison is maintained in the client record. Contact Person: Lakeysha Williams – 410-396-4887 or Lakeysha.williams@baltimorecity.gov Completion Date: July 2024

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile 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 designate an internal reviewer to continually review the casefile eligibility determinations throughout the year. Name of the contact person responsible for corrective action plan: Jill Frisell, Finance Director Planned completion date for corrective action plan: December 31, 2024