Corrective Action Plans

SPECIAL PROVISIONS – STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: It is recommended that income documentation be reviewed for each eligible case file to ensure the information matches MAXIS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work on training new staff on requirements. Name of the contact person responsible for corrective action plan: Kara Terry, Community Services Director Planned completion date for corrective action plan: December 31, 2024

Findings and Questioned Costs Relating to Federal Awards: Energy Incentive Program Disbursement to Ineligible Providers and Beneficiaries The program “Apoyo Energético”, funded by the American Rescue Plan Act (ARPA), that resulted in this finding concluded early 2023, which lack of a complete and robust operational guidance. The guidance used to manage the process were simple, not quite restrictive, and with little internal controls for both suppliers and beneficiaries. DDEC has adopted guidelines for both suppliers and beneficiaries that are more restrictive, and specific with internal regulations that ensure data retention and storage. Currently, the second initiative of this program, being “Apoyo Energético 2.0” commenced April 2024, which is funded by a CDBG-DR funds, for registration of potential suppliers and are following the guidelines issued.

Corrective Action Plan Finding: 2023-003-Tenant file deficiencies and SEMAP errors noted-Eligibility and Special Tests Condition: (a)-SEMAP was not filed before the regulatory deadline. Since the deadline was missed, the SEMAP could not be submitted. We requested the worksheets used to document SEMAP. management brought in the files that they claim were used to review for SEMAP. the other thing available were twenty inspection forms that management claims were HQ’s. We were unable to determine whether the HQ’s covered both failed and passed initial inspections. Again, no worksheets were available to document the results of the tests. in the last two audit periods, we gave examples and explanations to management of an adequate way to document SEMAP. We recommended a couple of webcasts to attend on SEMAP. Management claims they viewed the webcasts. (b)-We reviewed twenty-five HCV files. Nine were current year move ins. sixteen were annual re-exams. Of the nine move ins tested, we could not locate three on the waiting lists (we asked management three weeks before we reviewed the files to tab the waiting list for the tested move ins). In addition, of one of the six that we did locate on the waiting list, we could not find an explanation of why the applicants listed before (above) were not admitted. We reviewed two move-ins for low rent, a non-major program. We located the applicants on the waiting list. however, there was no explanation why the applicants listed before (above) were not admitted. (c)-Of the twenty -five HCV files tested, the September 2023 HAP payment did not agree to the last available 50058 filed before September for two tenants. We asked if there were possibly interim 50058s that did not make it to the file, but we did not receive any. two were immaterial differences-one being $9 per month, the other $3 per month. (d)-Of the nine move-ins tested, we could not locate a reasonable rent survey for two. (e)-Of the sixteen re-exams we reviewed, we could not find an EIV for the re-exam of one tenant. (e)-Income Enterprise Verifications (EIV) should be documented for all tenants when their annual re-examination is done (f)-All 1099’s issued to landlords should be available for third party review. Corrective Action Planned: We will comply with the auditor’s recommendation. I do note that we were short of personnel for the entire audit period. I believe that I have staff presently that can do most of the assigned duties. I admit that not all of the deficiencies noted were due to being understaffed, but lack of training (being new to HUD) and understanding. But we will also correct those errors to the best of our ability. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2024

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified the lack of documentation of review processes surrounding the expenditures of the federal award. Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: We have a process that requires the Grant “owners” to review and sign off on the expenditures related to any Federal Awards and other expenditure in the organization. We will add a quarterly review in the Grants office to verify the expected purpose, compliance with federal statutes, regulations and conditions of the federal award. This will also be reviewed by the CFO to create checks and balances. Anticipated Completion Date: Ongoing

The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table

The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact- Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table

The Child and Family Services Agency (CFSA) concurs with the findings. Corrective action for the licensing issue will be addressed in the development of the permanent CCWIS system, Standing Together Against Abuse and Neglect in the District (STAAND), wherein official foster care provider license certificates will be available for download on demand. STAAND is currently in development with expected completion in late 2025. Corrective action for the household composition issue will also occur in the development of the STAAND system, wherein foster parents will interact with the system directly and provide household composition information during each licensure cycle. In the meantime, starting immediately, CFSA licensing workers will sign and date checklists during each licensure cycle until STAAND has been fully implemented. CFSA will submit adjusting claims for questioned costs following HHS review of this finding. Contact - James J. Murphy, Director, Business Services Administration Estimated Completion Date - September 30, 2025 (with interim corrective action beginning immediately). See Corrective Action Plan for chart/table

The Department of Energy and Environment (DOEE) agrees with the conditions and recommendations of this finding. DOEE personnel perform initial reviews of individual applications before, during, and after certification. Supervisory level reviews of 5 applications are performed per processor per month, which is documented in the Operations Manual. On a semi-annual basis, program personnel will conduct an inventory of applications to ensure a 25% threshold of secondary reviews is being met. Additionally, DOEE will conduct and require staff participation in system demonstration and refresher trainings in order to strengthen existing policies and procedures. Contact - Danielle Wright, Deputy Director Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

The Department of Human Services (DHS) agrees with the finding noting that appropriate actions were taken to approve the case, however, the reviewing supervisor failed to sign the document after conducting the supervisory audit. The corrective action plan developed for the Child Care Services Division (CCSD) is to conduct refresher training with the CCSD supervisory team on the requirement for the Supervisor reviewing the case file to double-check the Internal Audit Form to ensure that it is completed in its entirety and includes the supervisor’s signature and date of review. The internal control will now require the supervisor to forward the Internal Audit Form to the CCSD Section Chief who will conduct a second-level review to ensure the form is completed and can be filed. Contact - Ann Pierre, Deputy Administrator, Division of Customer Workforce Employment & Training (DCWET) Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

The Department of Human Services (DHS) agrees with the finding in this report. These case numbers will have tickets entered and a root cause investigation will be conducted. A solution will be developed based on the results of the investigation and the solution will be implemented. Contact - Stephanie Bloch-Newman, Deputy Administrator for Innovation & Change Management Estimated Completion Date - September 30, 2025 See Corrective Action Plan for chart/table

Department of Human Services (DHS)/Economic Security Administration (ESA) concur with the findings. DHS will re-issue a memorandum related to the Fleeing Felons Policy to all staff. To include verbiage related to the 10-year period that began on the date the individual was convicted in Federal or State court of having made a fraudulent statement or representation with respect to place of residence in order to simultaneously receive assistance from two or more States and any individual who was fleeing to avoid prosecution, or custody or confinement after conviction, for a felony or attempt to commit a felony, or who is violating a condition of probation or parole imposed under Federal or State law. Contact - Francine Miller, Deputy Administrator, DHS/ESA Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

The Department of Housing and Community Development (DHCD) concurs with the conditions and recommendations of this finding. DHCD will create a compliance plan to validate the review of applicant’s eligibility. In January 2024, DHCD updated the Document Checklist to strengthen the program’s eligibility determination and review. Beginning in April 2024, DHCD reviewed the eligibility of applicants before payments were disbursed. Contact - Lesley Edmond, DHCD Housing Compliance Officer Estimated Completion Date - This will be incorporated into the revised monitoring plan on July 28, 2024. See Corrective Action Plan for chart/table

The Department of Human Services (DHS) agrees with the findings. To address any documentation gaps, DHS introduced new Standard Operating Procedures (SOPs) for Family Rehousing and Stabilization Program (FRSP) in fiscal year 2023. The new SOP implements stricter internal control procedures, regular audits, and streamlining the eligibility determination process. The majority of findings were for participants enrolled into FRSP before the new SOPs took effect. DHS will continue execution of the stricter internal controls and audits, to ensure there are no documentation gaps moving forward. Contact - Noah Abraham, Interim FSA Administrator, DC Department of Human Services Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

The District Department of Health (DC Health) concurs with the finding. Management Evaluations to Determine Use of COVID Self Declared by Local Agency Staff: The DC WIC State agency will conduct a statewide management assessment exercise to evaluate at least 8 WIC clinics in DC across all 4 local agencies in June 2024 to evaluate adherence to WIC Program regulations, policies and procedure. The areas to be evaluated will include certification and eligibility determination practices by clinic staff in determining income eligibility. Training for all DC WIC Staff by September 30, 2024: As part of staff development and quality assurance, the DC State Agency will conduct a statewide training for all WIC clinic staff to reinforce the steps in determining and documenting the household income of WIC program applicants. Development to Remove the Option to Use COVID Self Declared in HANDS Management Information System: The DC WIC Program is part of a consortium of seven (7) states using the same software. All system changes that require software development will require the consent of all consortium members. DC Will make a request for the option to remove “COVID Self Declared” from the system. The agency hopes this can be done by the end of December 2024, however, there are other developmental changes ongoing that may push the timeline further. Contact - Akua Odi Boateng, WIC State Director Estimated Completion Date - December 30, 2024 See Corrective Action Plan for chart/table

The Office of the Chief Financial Officer/Office of Finance and Treasury (OCFO/OFT) for Department of Human Services (DHS) concurs with this finding. Strict procedures and practices are in place to ensure contract compliance. OFT manages quarterly audit reviews of UPO practices to ensure proper handling of DHS referral forms and intake documents up-holds to policy and procedures governed in order to mitigate the errors. OFT will continue this practice with UPO EBT Card Distribution sites to secure the EBT cards and document reconciliation. All Intake Procedures and Processes found in the EBT Manual are followed thoroughly by all employees. As practice, UPO will continue to enforce the progressive disciplinary process for errors or omissions identified during daily operations. Contact - Valencia Gregory, Program Analyst, OCFO/OFT Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

The Department of Human Services (DHS) and Department of Health Care Finance (DHCF) DC Access System (DCAS) Program Management Administration team agree with the findings. For the fifteen (15) findings, DHS/ESA has identified the description of the deficiencies, examined the magnitude and geographic extent of the deficiencies, identified the actions completed to eliminate the deficiencies. The District will focus on efforts that will create the maximum impact, which includes creating new options for collaboration, streamlining current communication, and introducing cross-functional prioritization. These strategies will help the District move projects toward completion and are rooted in continuous quality improvement. To guide its strategic efforts and track its impact, DHS has outlined the following four phases of corrective action plans to be taken to ensure the deficiencies will be eliminated: • Review and Prioritization, • Design and Development, • Implementation, and • Monitor and Evaluation. Each phase has several process steps including a completion document that signals the permission to move to the next phase. The detailed process steps are documented under DHS’ Consolidated Semi-Annual SNAP Advance Warning Letter Corrective Action Plan and FFY2024 Quality Control Corrective Action Plan reports dated April 2024. The corrective action plan is facilitated by the Quality Improvement Program and since implementing this process in January 2021, the District has identified root causes for errors and gaps in internal auditing and evaluation processes. Therefore, the flow of the semi-annual corrective action plans reflects the District’s commitment to a collaborative corrective action plan - expanding the data analysis section to include data and analysis of internal methods, a complete summary of each phase completed, and a timeline for upcoming phase/project completion. Contact - Stephanie Bloch-Newman, Deputy Administrator for Innovation & Change Management Estimated Completion Date - September 30, 2025 See Corrective Action Plan for chart/table

Project Legal Name: Booth Residence, Inc., a Georgia Corporation HUD Project No.: 061-11293 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2022-9/30/2023 Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and has taken steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding An experienced third-party management agent approved by HUD was hired to maintain tenant file documentation and to ensure compliance with HUD eligibility requirements.

Project Legal Name: Evangeline Booth Residence, Inc., a Florida Corporation HUD Project No.: 063-EE011-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2022-9/30/2023 Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-002 a. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding Procedures for accruing revenue, as appropriate, will be put in place as the accruing of expenses is already done. 2. Finding 2023-002 c. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. d. Action(s) Taken or Planned on the Finding Access to the Enterprise Income Verification (EIV) system [the system used to access Social Security information and Health and Human Services information] was not available due to the incorrect tax ID being identified to The Salvation Army personnel who had transitioned from another The Salvation Army HUD Project location. It took considerable efforts to get this corrected with HUD. The appropriate access to the system has now been given to the new personnel of this Ocala HUD Project. This lack of access impacted the early part of FY 2023 B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Audit Findings, Questioned Costs and Recommendations 1. Finding 2022-001 In Process. See finding 2023-001 2. Finding 2021-001 In Process. See finding 2023-001

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Treasury The Pentucket Regional School District respectfully submits the Following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF EDUCATION Passed through Massachusetts Department of Elementary and Secondary Education Special Education Cluster Special Education Grants to States Federal Assistance Listing No. 84.027 Special Education Preschool Grants Federal Assistance Listing No. 84.173 2023-001: Controls for Monitoring Payroll Charged to the Grant Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Compliance and Internal Control Over Compliance – Other Matter Criteria or Specific Requirement: Grantees must provide reasonable assurance that Federal Awards are expended only for allowable activities and that the costs of goods and services charged to Federal awards are allowable and in accordance with applicable cost principles. Condition: Payroll expenditures charged to the Special Education Cluster grant are required to be supported with documentation (i.e., semi-annual certifications and personnel activity reports) substantiating that the employees are eligible to be charged to the grant and that the payroll charged relates to time spent accomplishing grant objectives. The District does not utilize semi-annual time and effort certification forms to document the eligibility of the employees paid out of the grant. Context: The District did not maintain sufficient documentation to demonstrate compliance with federal and state time and effort reporting requirements in accordance with the provisions of Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. Effect: The District has not complied with the federal and state time and effort reporting requirements. Cause: Management has established written guidelines and procedures outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. The written guidelines and procedures outlined by management are not being followed as designed. Questioned Costs: Total payroll costs charged to the grant in 2023 totaled $703,789, which was paid on a bi-weekly basis throughout the year. Three of the pay periods were selected for testing, which totaled $117,345 for 61 employees paid out of the grant during those pay periods. From the pay periods selected for testing, the following known questioned costs were identified: Recommendation: The District should follow their written policies and procedures outlining the time and effort reporting and documentation requirements that must be adhered with to ensure compliance with federal and state time and effort reporting requirements. Management should adopt and implement standardized forms that include all data required by federal and state guidelines and provide training to ensure that program personnel understand the time and effort reporting requirements. Views of Responsible Officials and Planned Corrective Actions: The School District immediately began designing the form used for time and effort reporting related to special education grants, and the School District will begin issuing and collecting the forms for the special education grant for 2024, and future periods. If the Oversight Agency has questions regarding this plan, please call Suzanne Wallace, School Business Manager, at 978-346-7424, extension 126. Sincerely yours, Suzanne Wallace School Business Manager Pentucket Regional School District

Finding 2023-001 (Scope Limitation - Eligibility and Special Tests and Provisions) (Assistance Listing 93.767) UPMC follows the processes and procedures set forth by Pennsylvania Department of Human Services. As such, no corrective action will be taken.

Timestudy Testing Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2024

The Authority will implement and execute strengthened controls over tenant file documentation maintenance processes and procedures. Erial Branch, Executive Director, has assumed the responsibility of executing strengthened controls over tenant file documentation maintenance as of September 1, 2024.

Beginning in 2024, the Organization’s General Manager has implemented a process to ensure annual re-certifications and income verifications completed by the Property Manager. Utilizing the property management system, the Property Manager will track those tenants whose annual re-certifications and income verifications are coming due. The Property Manager will complete the re-certification and income verification process and then update the tenant file, as required by the regulatory agreement. Winslow Village, Inc. 1520 Ocean St. Marshfield, MA 02050 The General Manager, Marianne Correia, will oversee this under the guidance of Three-Kay Consulting, LLC. This will be implemented by year end of 2024. Marianne Can be reached at 781-837-5998.

El Proyecto will implement monitoring measures by grant supervising staff to ensure that typos entered into any system are reviewed before final submission. Person Responsible: Haimanot Fekadu Position of Responsible Party: Youth Source Center Sun Valley Completion Date: September 30, 2024

El Proyecto will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. El Proyecto will continue to provide ongoing training to clinic staff who evaluate the sliding fee application at its clinic locations. The training will consist of reviewing sliding fee program policies and procedures along with all applicable patient forms, sliding fee scale, and patient eligibility. Person Responsible: Leticia Vasquez Position of Responsible Party: Billing Manager Completion Date: September 30, 2024