Corrective Action Plans

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy is ongoing.

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

Finding 2023-001 – Documentation of Controls Auditee’s Response and Planned Corrective Action Rensselaer Housing Authority to implement check list to ensure tenant files are organized and reviewed by another employee. Planned Implementation Date of Corrective Action: September 30, 2024 Person Responsible for Corrective Action: Marianne Ogren, Executive Director

2023-002 Condition: Deficiencies Noted in Examination of New Construction Section 8 Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents and implement procedures which will eliminate such errors. Management has implemented procedures in order to clear this finding in FY 2024. Timeframe: By FYE December 31, 2024 Individual responsible for correction: Ms. Zena Zahran, Executive Director

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that Home Forward reviews the controls in place to ensure that recertifications are performed timely and income is supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • We will be conducting a random audit of all LRPH files. • Training on best practice for PH and PBV reviews. This training will emphasize the importance of proper income documentation. • Sending out monthly report for reviews that are coming due. Name(s) of the contact person(s) responsible for corrective action: Suzanne Couttouw, Compliance Manager (audit and training) and Elise Anderson (monthly reporting.) Planned completion date for corrective action plan: March 30, 2025

Finding Number 2023-002 ELIGIBILITY – DEFICIENCY - COMPLIANCE Agency Name FEDERAL AGENCY: U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Program ALN 14.850 – PUBLIC AND INDIAN HOUSING Contract # N/A Criteria Eligibility for Individuals - Most PHAs devise their own application forms that are filled out by the PHA staff during an interview with the tenant. The head of household signs (a) a certification that the information provided to the PHA is correct; (b) one or more release forms to allow the PHA to get information from third parties; (c) a federally prescribed general release form for employment information; and (d) a privacy notice. Under some circumstances, other members of the family may be required to sign these forms (24 CFR sections 5.212, 5.230, and 5.601 through 5.615). Condition/Context The Authority received funding from the HUD. The Public and Indian Housing program is to provide and operate cost effective, decent, safe, and affordable dwellings for lower income families through an authorized local PHA. Of the sixty (60) case files selected for testing in which 540 pieces of audit evidence (eligibility forms as noted in the Criteria section above) were requested to be provided: Eight eligibility forms were not provided (five missing application forms, one missing certifications information provided to the PHA forms and two missing Release form). These forms are required documentation to be maintained in the case files to support eligibility for Public and Indian Housing Program. Therefore, we were not able to determine if the eligible participants met all the eligibility criteria. Recommendation We recommend the Authority strengthen its controls over the Public and Indian Housing Program case files to ensure that all eligibility forms are received, reviewed, and maintained in the case files to support the determination of eligibility. Corrective Action Plan In January 2011, NYCHA implemented the Siebel Customer Relationship Management (CRM) system, which included digital file storage and an online application process, which replaced our previous paper application process. Any applications in process from that date onward were subject to document scanning and documentation was stored digitally. Any applications processed prior to this date were kept in a paper format and stored at the development, where the applicant was certified or where the tenant resides. If a tenant family transferred to another development, the physical tenant folder and documents were sent to their new location. In June 2020, NYCHA sought to digitize all tenant folders; however, the cost of the project was determined to be prohibitive so the goal of digitizing the tenant folders was not realized. Any documents damaged or lost prior to 2011 cannot be recovered, including those impacted by Hurricane Sandy. Action Date September 6,2024 Final Implementation September 6,2024 Name And Phone Number Of Person Responsible for Implementation Sylvia Aude Senior Vice president Office of the Senior Vice President for Public Housing Operations Tenancy Administration +1-212-306-3921

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a secondary person review the reports and in a timely manner. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend 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 adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend procedures and controls be implemented to ensure each quarterly listing is properly reviewed and accurate employees are on the listings. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2023 Recommendation: We recommend that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

Corrective Action Plan Finding: Finding 2023-002-Lack of Adequate Quality Control Regarding Tenant Procedures-Eligibility Condition: The quality of supervision over tenant file functions, such as calculating tenant rent and Housing Assistance Payments should be timely and sufficient to find errors in calculations or mis-application or mis-understanding of procedures. Corrective Action Planned I am Jedidiah Jackson. I was hired as E.D., effective July 1, 2024. We are in the process of addressing the problems noted in the audit, as well as correcting other issues noted by HUD. Person responsible for corrective action: Jedidiah Jackson, E.D. Telephone: (985) 785-2601 St. Charles Parish Housing Authority Fax: (985) 785-6238 200 Boutte Estates Dr. Boutte, LA 70039 Anticipated Completion Date- October 31, 2024

ST. CHARLES PARISH HOUSING AUTHORITY________________________________________PHONE: 985-785-2601 ·FAX:985-785-6238· 200 BOUTTE ESTATES DRIVE ·BOUTTE, LA 70039-0448 ________________________________________ HOUSING AUTHORITY OF ST. CHARLES PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2023 Corrective Action Plan Finding: Finding 2023-001-Internal Controls Inadequate for Disbursements-Allowable Costs Condition: Good internal controls should be in place to make sure that disbursements are for eligible payments, are correctly classified, and are timely paid. Good controls ensure that there is proper, documented review of all these functions. Records should be maintained in an order that is conducive to efficient and timely summarizing by the outside fee accounting firm. Unaudited financial statements should be produced on a timely basis, and reviewed by the Board of Commissioners. Corrective Action Planned I am Jedidiah Jackson. I was hired as E.D., effective July 1, 2024. We are in the process of addressing the problems noted in the audit, as well as correcting other issues noted by HUD. Person responsible for corrective action: Jedidiah Jackson, E.D. Telephone: (985) 785-2601 St. Charles Parish Housing Authority Fax: (985) 785-6238 200 Boutte Estates Dr. Boutte, LA 70039 Anticipated Completion Date- October 31, 2024

Action Taken: MHA will review and enhance as necessary the program’s existing quality control (QC) file review procedures as well as daily data validation reports to include a measure that cross-checks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. To further mitigate the risk posed by frequent turnover among Housing Specialist-I (HS-I) staff, MHA will increase the frequency of training on rent and income determination for all staff including tenured team members and new hires, alike, to occur quarterly. In 2023, MHA implemented a Housing Specialist-II Team Lead to oversee HS-I staff processing annual reexaminations in accordance with 24 CFR 982.516. This team member is responsible for ensuring families are notified in a timely manner and if they do not comply with the annual reexamination requirement, they receive termination notices in compliance with HUD and MHA Administrative Plan requirements. MHA also implemented two compliance analysts in 2023; we will add another compliance analyst staff person in 2024 to increase the percentage of files undergoing quality control review. These three (3) Compliance Analyst will report to the Operations and Compliance Manager who monitors HUD’s PIC system and analyzes discrepancies between PIC data and MHA data housed in the Yardi system of record. This information is maintained in the program file. Name of Responsible Person: Paul and Magdalene Watkins, Program Administration Team Projected Completion Date: 12/31/2024

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

The County agrees that reinforcing existing policies and procedures to require caseworkers to cite source documents supporting a child’s disability when determining initial Title IV-E eligibility and continuation of eligibility is necessary and will continue to do so.

The Department of Children and Family Services management agrees with the findings and will reinforce existing policies and procedures within the Department to ensure that all documents are properly retained and signed.

The County agrees with the findings and will reinforce existing policies and procedures within the Health Department to ensure that all supporting documents are properly obtained.

Finding Number: 2023-002 Finding Title: Eligibility Program: Medical Assistance Program (AL No. 93.778) Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Director and Karen Syverson, Supervisor Corrective Action Planned: To address the findings from the recent audit, Clay County Social Services will take both immediate and long-term corrective actions. First, the case files identified with discrepancies will be revie.wed in detail, and necessary corrections will be made to ensure that the documentation in both the case files and the MAXIS system aligns with program requirements. Requests for case file numbers have already been submitted to the MA team lead to identify the cases needing correction. This will include reverification of asset amounts, we will match MAXIS's citizenship status with the appropriate documentation within the case file. In addition, one-on-one reviews will be conducted with the staff responsible for administering the affected cases. During these reviews, case-specific feedback will be provided, detailing the nature of the errors and explaining corrective actions to prevent recurrence. For long-term preventative measures, Clay County will implement a more comprehensive and mandatory training program for all staff involved in eligibility determination. This training will focus on key areas such as proper documentation for citizenship, asset verification, and data entry protocols to reduce human errors in MAXIS. We will continue conducting periodic case file audits with increased frequency to detect errors early and provide timely feedback to staff. Audit results will be shared with the entire team to promote learning from errors and reinforce best practices in documentation and data entry. Anticipated Completion Date: The cases found in error will be corrected by November 15, 2024. Case file reviews will continue monthly.

Views of Responsible Officials and Planned Corrective Actions: This condition was primarily the result of a heavy reliance on external subject matter experts (SMEs) for technical aspects of programmatic workplan deliverables, as well as the use of single-sourcing selection carveouts in the interests of efficiency, that are provided for in the organization’s procurement policies & procedures. These instances of single sourcing nonetheless required additional levels of documentation and justification when in use, which was always not the case. Starting in August 2024, all program and compliance staff will be re-trained on federal procurement policy documentation and justification requirements. The Organization will also embark on concerted efforts to expand its pool of qualified and eligible SME vendors, to ensure more reliance on competitive bidding and minimize the future use single-source procurement. A comprehensive review of current Organizational policies and procedures will also be undertaken, to ensure that they are aligned and consistent with current federal procurement guidelines and requirements. Responsible Official: Peter Kiburi, Senior Director of Finance.

Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.

In mid-2024 the organization implemented procedures to collect client intake data at the largest program identified in testing and expects to be following intake guidelines for all programs by the end of 2024.

Corrective Action Plan September 25, 2024 Federal Audit Clearinghouse County of Orleans respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: EFPR Group, CPAs, PLLC 100 South Clinton Avenue, Suite 1500 Rochester, NY 14604 Audit period: January 1, 2023 – December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING – FINANCIAL STATEMENT AUDIT FINDING 2023-001 - Material Weakness in Internal Control Over Financial Reporting - Material Adjustments Condition: The County is responsible for maintaining a proper system of controls to allow for all year end adjustments to be made prior to the preparation of the Annual Financial Report (AFR) and the start of the audit. Criteria: A proper system of controls would result in the County making all required year end closing adjustments prior to the preparation of the AFR and the start of the audit. Cause: Auditors were required to make material adjustments as part of the year end audit process. Effect of Condition: The County does not have the controls in place to make all required year end closing entries which resulted in material adjustments as part of the audit process. Recommendation: The County should re-evaluate the year end close process to ensure all required year end closing adjustments are completed timely. A training should be held with all employees involved with year end closing to review the process. Views of Responsible Officials and Planned Corrective Actions: The County Treasurer has created a written Year End Adjustment checklist for the County Treasurer and Deputy County Treasurer to both check and sign before the Annual Financial Report (AFR) is filed with the State Comptroller to ensure all normal year end adjustments are accounted for, justified and confirmed. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT 2023-002 - CCDF Cluster - Child Care Development Block Grant - Assistance Listing No. 93.575; Grant Period - For the year ended December 31, 2023 Condition: Currently the senior social welfare examiner who handles the child care development block grant program processes the application and determines eligibility. There is no requirement for the documentation of review and approval by a secondary individual over this process. Criteria: Implementing internal controls that provide for segregation of duties over the child care development block grant would involve a secondary reviewer resulting in more than one individual being responsible for the entire process. Documenting this secondary approval process would provide for confirmation that the segregation of duties has occurred. Cause: The County does not have procedures in place to require a secondary review on the application process and eligibility determination. Effect of Condition: The County's internal control system for the child care development block grant was not designed to provide segregation of duties and the related documentation. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Recommendation: The County should consider revisiting the segregation of duties over application and eligibility process to provide for a documented review and approval over the process. Views of Responsible Officials and Planned Corrective Actions: Effective immediately, 100% of new, denied and closed Child Care applications and 10% of recertification applications will be reviewed by a supervisor to verify that: o All required documentation is present in the case file. o All information was correctly entered into the electronic Child Care Time and Attendance system which determines eligibility. o A correct eligibility determination was produced. Contact Person Responsible for Corrective Action: Kimberly DeFrank, Orleans County Treasurer – finding 2023-001 and Holli Nenni, DSS Commissioner – finding 2023-002. Anticipated Completion Date: The corrective action plan was completed by September 27, 2024. If the Federal Audit Clearinghouse has questions regarding this plan, please call Kimberly DeFrank at 585-589-5353. Sincerely yours, Kimberly DeFrank

Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MNSADM and 2305MN5MAP, 2023 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Number: 2305MN5ADM and 2305MNSMAP Award Period: Year-Ended December 31, 2023 Type of Finding: Signiflcant Deficiency in lnternal Control over Compliance Recommendation: lt is recommended the County increase review over casefiles and ensure that there are performed on a periodic basis throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action plan: Barb Dietz, Human Services Director Planned completion date for corrective action plan: December 31, 2024

The Project will follow HUD directives regarding recertification procedures for existing tenants.

Contact Person – Bruce Starkey, County Administrator Corrective Action Plan – The County will review procedures over application filing. Completion Date – 9/30/2024