Corrective Action Plans

Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will now scan in the physical intake form that Adult ESL students self-report their eligibility status for MA DESE ACLS as well as have the student sign that form. This form will be stored electronically in addition to the information from the form being entered into the Adult ESL Access database and LACES . Name(s) of the contact person(s) responsible for corrective action: Dr. Kevin O’Connor, Claudia Castro Alves and Kate Fiore Planned completion date for corrective action plan: Effective as of 08/01/2024

Finding Reference Number: 2023-002 Name of Responsible Person: Amy Reigel, Executive Director Reporting Views of Responsible Officials: We concur that multiple grants are being tracked in the same accounts making it difficult to determine if the expenditures billed to the specific federal award to were charged to the grants in the period of performance. Concur or Do Not Concur with this Finding: Concur Agree or Disagree with Auditor Recommendations: Agree Completion Date or Proposed Completion Date: December 31, 2024 Actions Taken or Planned on this Finding: COHHIO's chart of accounts / financial management system will be updated to track each grant in a separately.

Finding 2023-006 Supporting Documents for Eligibility Requirements During September 2024, POF updated its Housing Procedures Manual in compliance with Section 200.303 of Uniform Guidance and Ohio Recovery House Regulations. This document now more fully addresses, among other things, eligibility and required minimum documentation standards. POF has already begun to build individual client files to retain and periodically update these required supporting documents for all Its affected residential clients.

The County is in the process of hiring a Grants Administrator who will be responsible for the allowable cost compliance requirement of State and Local Fiscal Recovery (SLFRF). The Grants Administrator, along with the Chief Financial Officer and Financial Services Division Director will review and update the policies and procedures to ensure all internal controls are being followed in order to be compliant with the Uniform Guidance and SLFRF Program.

Finding Number 2023-005 Contact Person(s): Mansour Camara, CFO, Carmelle Palomino, Controller Corrective Action Planned: Management reviewed the document retention policy with all program managers and directors and IT created online files for each department to retain program documents as per the policy. Management will conduct implementation audits for each department. Anticipated Completion Date: Date completed 10/31/2024

United States Department of Education 2023-007 Student Financial Aid Cluster – Assistance Listing No. 84.063 Condition: Students were disbursed Pell funds inaccurately. Auditors’ Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Summer 2023 Martin University’s main power source was struck by lightning. This caused all Summer processing, that had not yet been backed up on our servers, to be deleted from the system. All transactions that took place at that time had to be manually re-entered. During that manual process, there appears to be a human error in inputting the dates. SIS dates will be corrected to original and actual COD disbursement dates. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: November 30, 2024

Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SOR program. Additionally, the OBHC team is currently working with the HCA in restructuring the rate schedule to incorporate the payroll costs into the direct service rates for the SOR/SABG grants. This effectively removes this issue going forward in FY25 once approved by the HCA. Name(s) of the contact person(s) responsible for corrective action: Patty Brandt Planned completion date for corrective action plan: Feb 2024 & Sep 2024

Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted in an overhaul of the processes in place to properly develop the volunteer checklists and assure all records for staff and volunteers are now compliant. Our Quality and Compliance and Finance team worked closely with the new Program Manager to assure that we will be fully compliant and remain so.

An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail. Anticipated Completion Date: Pending HUD approval of age waiver

1) Revisit our training materials provided to our Patient Access Representatives upon being hired and revise such materials to emphasize sliding fee requirements more thoroughly. Provide testing to new hires after training to establish if training was effective. a. Anticipated completion date: 10/31/2024 for revisions, ongoing with new hire training 2) Establish front desk (Patient Access Coordinator) supervisor “recap” trainings establishing the requirements for sliding fee designations. During this training, allow for on-hands role-playing of scenarios conducted both at group and individual levels. a. Anticipated completion date: 10/31/2024 3) Establish routine spot audits. Our Patient Access Coordinator will do spot audits on a monthly routine, and more a formal process at the CFO level completed quarterly. a. Anticipated completion date: Ongoing

Authority Response and Planned Corrective Action: The Authority agrees with the finding and will increase oversight related to the maintenance of tenant files to better monitor adequacy with compliance requirements. Donald Paredez, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

The Clifton Public Housing Agency has contracted with PHA-Web as the software system managing the Housing Choice Voucher Program. This system allows the PHA to put "on hold" any landlord/tenant payments that are not to be processed due to outstanding requirements such as lease documents, tenant income verification, inspection failures or any other missing information that the PHA may need to process the monthly payment. Therefore, "on Hold" checks are not processed until the tenant/landloard complies with all the requirements. Also, any checks that are released are forwarded to the City's positive pay file for processing.

2023-001 - Determination of Contract Rents, Maintenance of Tenant Files Condition: Eligibility recertification procedures required as a part of the annual recertification have not been performed or not performed sufficiently for tenants housed as of December 31, 2023. Corrective Action Planned: Staff has worked diligently to get all tenants housed at the Housing Authority recertified with sufficient documentation. Management believes all issues with tenant files to be corrected as of the report date. Staff are to receive continued education training on the operations of the RAD program and the compliance requirements. Person responsible for corrective action: Akinola Popoola, Executive Director Telephone: (256) 232-5300 x 8 Trudi Harris, Property Manager Anticipated Completion Date: Management believes files have been corrected as of the 2023 year-end audit report date.

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2023-001: Major Programs: Major Program: Section 202 Supportive Housing for the Elderly, Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all tenants’ 90-day EIV reports are generated within the required time period to verify tenant information promptly and help reduce errors in subsidy payments. ACTION TAKEN The Project will be monitoring use of the EIV system for move ins and recertifications.

Finding – Of a sample size of 21 tenant files, income was miscalculated on one file resulting in questioned costs of $304. This is considered a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Agency has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Recommendation – The Agency design and implement internal control procedures that will reasonably assure compliance with Uniform Guidance and the compliance supplement. Corrective Action - The Agency will increase oversight in the Section 8 Housing Choice voucher Program with respect to calculated income to ensure that established internal control policies are being followed on a timely basis. Implementation Date -August 1, 2024

Additional training will be provided to staff regarding the process for verifying patient sliding fee scale status and eligibility to ensure the sliding fee scale documentation and assignment procedures are followed correctly.

Finding 2023-002 – Federal Award Finding Name of Official Responsible for Corrective Action: Earl Richardson, First AME Housing Association Interim Executive Director Corrective Action Planned: Explanation: We acknowledge the oversight and would like to provide context to understand better the circumstances that led to the delay. We had internal challenges when our previous management company departed, leaving us with incomplete files and late recertifications or recertifications that never started, making it next to impossible to catch up promptly. Next, staff staffing issues contributed to the delays because staff members were not properly trained. Despite these challenges, we recognize the importance of adhering to HUD regulations and are committed to taking corrective measures. Corrective Actions Taken: We initiated immediate corrective actions to rectify the situation upon discovering the late recertifications. We have instituted the following measures to prevent the recurrence of late annual recertifications. 1. Created a recertification schedule and calendar with the annual recertification date, specific dates to notify residents that their annual recertification is due, and dates for submitting the information to CMS and to trac. The schedule and calendar are submitted to the executive director every two weeks to monitor progress, and a meeting is scheduled with staff every two weeks to review recertification issues. 2. We hired a consultant specializing in recertification to train the staff and work with staff daily to answer questions concerning our certification. This is not a one-anddone; our recertification consultant is permanently on call to answer certification issues and continuous staff training. These measures are designed to ensure timely compliance with HUD regulations and to strengthen our internal processes.

Finding: According to the Uniform Guidance, 2 CFR 200.303(a), non-Federal entities receiving Federal awards must establish and maintain effective internal controls over these awards. These controls must provide reasonable assurance that the entity manages the Federal award in compliance with applicable Federal statutes, regulations, and the terms and conditions of the award. The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, May 2023, requires the Alabama Department of Labor to operate a Worker Profiling and Reemployment Services (WPRS) or Reemployment Services and Eligibility Assessments (RESEA) program. The Alabama Department of Labor operates a RESEA program. Under the RESEA program, Alabama Department of Labor staff must be promptly and appropriately notified of any eligibility issues identified during any review of a claimant’s information. Claimants are also required to attend appointments for reemployment to maintain their eligibility status. The Alabama Department of Labor has controls in place to provide notification of claimants who failed to report to scheduled RESEA appointments, however those controls were not operating as designed. While reviewing 25 claimant’s information, we noted that 8 claimants failed to report to their scheduled appointments for reemployment. These failures to appear are reported to staff at the Alabama Department of Labor and should prompt a stop of benefit payments; however, the Alabama Department of Labor did not stop payment on these 8 claimants which resulted in overpayments totaling $8,884.00. There was also one instance where Alabama Department of Labor could not provide documentation to support staff was appropriately notified of the eligibility status for a claimant. The Alabama Department of Labor’s policies and procedures did not operate as designed to prevent payments to ineligible claimants. Because the Alabama Department of Labor’s internal controls were not operating as designed, this caused benefits to be paid to ineligible claimants. Recommendation: The Alabama Department of Labor should ensure internal controls are operating as designed to help ensure payments are not made to ineligible claimants. Response/Views: ADOL does not agree with this finding as explained in the Request for Views CAP letter. Corrective Action Planned: Issues reported were beyond ADOL control due to another system shared by multiple state agencies being brought down due to cyberattack. The shared system is not the system of record for UI benefit payments. UI claim records were manually reviewed by UI staff and noted accordingly upon review. Additional measures and procedures have already been implemented in case of future occurrences. Anticipated Completion Date: Already corrected. System processes implemented in October 2023 Contact Person(s): Thomas Daniel, ADOL Unemployment Compensation Division Director

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

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

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

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

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

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

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