Corrective Action Plans

We have created an eligibility checklist for the WIOA programs that lists all required documentation. Additional training will be provided to the WIOA intake team on required documentation. No later than November 1, 2024, AJCC Associate Directors will implement period spot checks to ensure all necessary documents for eligibility are completed.

1.The inspector has attended an outsourced training from a reputable company that meetsthe HUD requirements and certification criteria. HQS includes requirements for allhousing types, including single and multi-family dwelling units, as well as specificrequirements for special housing types such as manufactured homes. 2.The Housing Authority HCV supervisor will implement greater oversight over theHousing Quality Standards by reinforcing the quality controls and monitoring failedinspection to improve on the standards mandated by HUD regarding biannual inspectionsand failed inspections.

ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024

Tom Keller, Executive Director, Jill Liebelt, CFO, & Chris Brungardt, CEO Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2024

The Authority will update their internal control policies over eligibility to require a review of the tenant file from another qualified personel and have a checklist to ensure compliance.

The County will ensure that procedures are in place to ensure support is maintained on file for eligibility determinations.

Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be taken to prevent ineligible expenses from being submitted in the future: • Exclude all ineligible expenses from any future Provider Relief Fund Portal submissions. • Offset the ineligible costs with lost revenues and unreimbursed expenses attributable to Corona virus. Princeton Community Hospital was a new acquisition into West Virginia University Health System as of January 1, 2023 and had not fully integrated into our processes at the time that this portal submission was completed. Upon further review, Princeton Community Hospital had lost revenues that support a significant portion of the funding received for this reporting period. Those lost revenues, along with eligible expenses, fully support the funding received. Completion Date: 09/27/2024

Finding No. 2023-001 - Tenant Eligibility: The Milton Housing Authority will continue its implementation of increased oversight for the Housing Choice Voucher Program's tenant compliance requirements. To that end, a consultant has been contracted and continues to train Employees on procedures and documentation mandated by HUD. Additionally, the Milton Housing Authority will review each file to ensure all documentation is complete. Planned Implementation Date of Corrective Action: September 27, 2024 Person Responsible for Corrective Action: Earl Fa_y, Executive Director (617) 698-2169

FINDINGS - FINANCIAL STATEMENT AUDIT None FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2023-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all current and new staff are trained on tenants’ 90-day EIV reports and ensuring they 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.

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. Solution: Implement a standardized process for verifying, documenting, and maintaining proof of required documents (e.g. proof of residency, insurance, etc.) in the patient's file during each visit. This will involve revising and implementing the new procedures manual to verify and document patient intake. The procedures manual will support appropriate communication from data collection to when information is uploaded into EPIC to verify if clients have insurance. Our training plan will incorporate these new methods of collecting data from the clients and outline regular internal auditing of patient files to assist the Tribal Assisters to properly verify documents and communicate with providers to assist clients in enrolling with insurance providers such as but not limited to Washington Apple Health (WAH). Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. Responsible: Kathryn Halverson, Health and Human Services CEO, Lummi Indian Business Council Anticipated completion date: 06/30/2025

All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years, allowing clients to be seen by a medical provider quickly. This practice ended in 2023. 30-day eligibility is no longer allowed.

Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent versus actual time spent. ● From a list of 244 clients, 21 client intake forms (used to determine eligibility for services) for Business Growth Services clients were unable to be produced. The auditors recommend the following: 1. Management to implement procedures to ensure all expenditures, including personnel costs, are properly reviewed, approved, and supported with documentation in accordance with federal regulations. SDA Response The SDA accepts the above findings and would like to add the following information for context: ● The requirement to collect T&E forms wasn’t initially established until the completion of the 2022 audit and after the departure of some personnel. Management attempted to collect T&E forms from prior contractors, but was not successful in securing the specific forms identified by the auditors. ● The SDA created a payroll classification document during 2023 which outlined T&E for all W-2 employees at a set rate for the year. This document, however, was not accepted by the auditors as evidence of actual hours expended on each grant, resulting in this finding. ● The SDA onboarded a new Director of Business Growth Services (BGS) in 2023, which led to changes in both the operational structure and the nature of the data collected for BGS activities. During this period, a data migration took place to a newer version of Salesforce that was built specifically for the SDA. Unfortunately, some data was either lost or unmapped during the migration process, leading to discrepancies in the completeness of historical records. SDA Corrective Actions Management is committed to continue training for personnel to ensure timely completion and compliance of hiring as well as time and effort documentation going forward. The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits.

The attorney responsible for this error has been instructed on the LSC rules for eligible income overrides and specific corrections in this case, including that the financial eligibility override reason of "client seeking to maintain government benefits for low-income is only applicable if those benefits are the subject of our legal representation in a case, and families" that a client must be marked "no" for "Income Eligible (LSC guidelines)" even if they are financially eligible for our representation under a non-LSC funding contract. She was also instructed to review the LSC Financial Eligibility Training video. Ongoing compliance trainings and financial eligibility trainings have been modified to emphasize how to use the income override categories, and that a be marked as "no" for "Income Eligible (LSC guidelines)" and "LSC Eligible" even if the case must client's income makes them eligible to be served under non-LSC funding contracts.

LSNYC's Compliance Officer spoke at length with the attorney who mistakenly failed to exclude the value of the client's primary residence from the asset total and an erroneous asset override. She now understands that the "exclude" radio button should entered have been selected for this asset, which would have put the client's assets under the asset ceiling. now understands that an asset override must be approved in writing by her supervisor and She also that the asset override must be uploaded into the case file. Ongoing compliance trainings and financial eligibility trainings have been modified to emphasize the importance of selecting the "exclude" button for assets that do not count toward the total under LSC regulations, and that asset waivers must be approved in writing by a supervisor.

The attorney responsible for failing to obtain a retainer in this case was advised that retainers must always be obtained for full representation cases, and required to review a compliance training video. Ongoing compliance trainings have been modified to emphasize the importance of completing retainers with clients, for LSC compliance purposes, professional liability protection purposes, and to ensure that clients are made aware of the scope of services that LSNYC has agreed to provide and their own responsibilities in their representation.

Finding 2023-001 –– During our current year audit, it was noted that one HCVP was not inspected during the year. In this instance, the Authority did not abate payments for this unit. It was also noted one instance of a unit failing inspection, and not passing within the 30 day window. However, the Authority never put the unit into abatement. Recommendation – We recommend that the Authority review their recertification process and their process for reporting the reinspection, and review the abatement process to ensure units are properly put into abatement when inspections are failed or incomplete. Action Taken – Chester County Housing Authority management agrees with the above recommendation and has instituted policies and procedures designed to address this finding. (Please see the list of approved policies and procedures.)

View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2022 – 6/30/2023 and 7/1/2023 – 6/30/2024 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is aware of the deficiency in internal control over compliance. Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible for Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024

Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.

a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In connection with out lease file review, we noted the following deficiencies: The Enterprise Income Verification (EIV) form in the existing tenant's file for 5 out of 15 tenants tested did not have the EIV completed within 120 days, as required by HUD. The Enterprise Income Verification (EIV) form in the existing tenant's file for 1 out of 15 tenants tested did not have documentation in their lease file that their income was verified. The Enterprise Income Verification (EIV) form in the new tenant's file for 1 out of 2 tenants tested did not have documentation in their lease file that their income was verified. b. Action(s) Taken or Planned on the Finding Management has implemented a monthly compliance file audit that will ensure that EIV’s are pulled and tenant income verified in a timely manner.

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid real estate tax expenses in the amount of $9,400 from project cash while a tax abatement agreement was in effect. b. Action(s) Taken or Planned on the Finding Management contacted City of Middletown Tax Assessor who has agreed to reverse the bill. Management is working with the assessor to get the funds reimbursed.

SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. 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 better capture disallowed costs getting reported. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

TIME STUDY – ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the county streamline the payroll change process between the payroll department and human services department. 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 at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

CASEFILE REVIEW (2022-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the 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 work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

Federal Agency: U.S. Department of Agriculture Federal Program Name: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Federal Award Identification Number and Year: 22MN004W1003, 2023 Pass-Through Agency: Minnesota Department of Health Pass-Through Number: 22MN004W1003 Award Period: Year Ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended Countryside Public Health Service implement procedures to ensure there are always two individuals involved in the determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Countryside Public Health Service will implement procedures to ensure there are always two individuals involved in the determination. Name of the contact person responsible for corrective action plan: Liz Auch, Administrator Planned completion date for corrective action plan: December 31, 2024