Corrective Action Plans

2022-004 – Reimbursement Claims Reported Meals Delivered to Unidentified Participants Corrective Action – GYAC has purchased an electronic system that assists with the tracking of meal count sheets and attendance rosters. This system compares the names on the roll with the number of meals being claimed, ensuring that participant rosters are accurately maintained and matched with meal delivery records, thereby preventing discrepancies and reducing the error rate in submissions.

2023-003 Compliance of Special Tests and Provisions – National Service Criminal History Checks: Management Response: Management will ensure an individual who does not perform the adjudication will review and document whether information was entered correctly and whether the adjudications are proper and documented prior to a member’s start date. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

Finding: 2023-002 Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2023 Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the HRA implement controls over all areas of the federal program so that controls are in place and working. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The HRA will assess the controls over the federal program and make changes as deemed necessary. Name of the Contact Person Responsible for Corrective Action Plan: Rhonda Moen, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2024.

In June 2021, a procedure was implemented to ensure thorough documentation of participant eligibility within the program. The current audit revealed deficiencies in documentation for clients enrolled in the grant prior to June 2021. The organization will conduct a comprehensive review of all grant participants to address and rectify any documentation gaps, including those enrolled before June 2021.

Finding 2023-001, Significant Deficiency - Eligibility Corrective Action Plan: Goal: To ensure necessary Medicaid corrections are made by caseworkers in a timely manner and verified as completed by Medicaid management and/or Quality Assurance staff. Plan: The County will include a due date to the auditing tool so that correction tasks request can be tracked and monitored for completion and accurateness. Eligibility, Internal Control and Procedural Errors will be given 5 business days to be corrected by workers. Performance Improvement Strategies: 1. Training will be given to supervisors, lead workers, and QA staff on proper usage and monitoring of due date requirements added to the audit tool. 2. Copies of reports will be stored in the shared Teams Channel for Medicaid Services. 3. Supervisor will follow up with caseworkers on 6th business days to ensure corrections have been made. 4. Every month, program managers will select 10 examples from the Medicaid Audit Finding spreadsheet to make sure supervisor have handled the error corrections made by their team. Responsible Parties: Medicaid Program Mangers Amanda Burdge, Jennifer Hurdle and Alison Westbrook Timeframes: A Medicaid Division Meeting will be held with all supervisors to discuss the expectation of monthly audits, corrections, and staying in compliance with State requirements. Also, explain the expectations of the Program Managers audit. Held no later than June 15, 2024.

Disbursements to Ineligible Students Planned Corrective Action: With the new automation process we have exceptions that will prevent the funding from posting if there is no LDA listed. We have also updated the Disbursement Criteria Approval to help prevent inaccurate disbursements from posting. Person Responsible for Corrective Action Plan: Ingrid Ortiz, Director of Financial Aid Anticipated Date of Completion: Implemented as of Fall 2023.

Condition: The Organization did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 7 of the 8 students in the sample (87.5%). We consider this condition to be a material weakness in internal control over compliance relating to the Eligibility compliance requirement. Statistical sampling was not used in making sample selections. Corrective Action Plan: The issue regarding reporting of loan disbursement dates occurred as the result of a miscommunication between the Financial Aid officer at SIEAM and our CPA. Our accountant was unaware that the specific disbursement date reported by Campus Ivy was required to be the disbursement date recorded in our student ledgers. All disbursements occurred very close to the date, but were not recorded on the exact date. This miscommunication and knowledge gap has already been remedied. At this time, both our CPA and our Financial Aid officer understand the statutory requirement for this reporting and have made the needed changes. Responsible Person for Correction Action Plan: Craig Mitchell, President, in conjunction with Sabu Kallingal, Dean of Students and Financial Aid Officer, and Franz Aponte, CPA. Implementation Date for Corrective Action Plan: The CAP was implemented on May 17, 2024.

Low-Income Home Energy Assistance– Assistance Listing No. 93.568 Recommendation: We recommend that the organization implement additional review process over the Fuelware System information when changes are made to family size to ensure the system is updated timely and correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: If a household member is removed from the energy application, the Energy Staff will be required to double check the income guidelines and the household composition to make sure that wrong benefits are not given to clients. With the updates to the energy software system, the awards will be based on the new household composition. In addition, when staff encounter this situation, they will have the ability to manually cancel the award and recertify the application in order to approve the correct award amount. Name(s) of the contact person(s) responsible for corrective action: Michelle James Planned completion date for corrective action plan: May 21, 2024 If the Department of Health & Human Services has questions regarding this plan, please call Michelle James at (203) 744-4700.

Steps to resolve: We will perform a complete review of all Low Income Public Housing and Housing Authority policies over disbursements to ensure compliance with these policies. Management will implement procedures and staffing changes to clear this finding in FY 2024. Timeframe: By FYE September 30, 2024 Individual responsible for correction: Tarena Grant, Interim Executive Director

Steps to resolve: We will perform a complete review of all Low Income Public Housing, Capital Fund Program and Housing Authority policies over disbursements to ensure compliance with these policies. Management will implement procedures and staffing changes to ensure this finding will be cleared by the 2024 FYE. Timeframe: By FYE September 30, 2024 Individual responsible for correction: Tarena Grant, Interim Executive Director

Identifying Number: CF 2023 – 001 Finding: Reporting Corrective Action Taken: The corrective action taken to resolve the reporting finding was an enhancement to the grant monitoring and reporting procedures by adding a scheduled review of the reporting requirements. Contact Name(s): Candida Heater, Administrative Services Division Director; Michelle Quigley, Finance Bureau Chief; Julie Maytok, Budget Bureau Chief Corrective Action Completion Date: 04/17/2024

Identifying Number: IC 2023 – 002 Finding: Reporting Corrective Action Taken: The corrective action taken to resolve the reporting finding was submittal of the quarterly report to the Florida Department of Environmental Protection. Contact Name(s): Candida Heater, Administrative Services Division Director; Michelle Quigley, Finance Bureau Chief; Julie Maytok, Budget Bureau Chief Corrective Action Completion Date: 04/17/2024

Finding 2023-001: Eligibility Finding Type: Significant Deficiency in Internal Controls over Compliance Federal Program Title and AL Number: The Emergency Food Assistance Program (TEFAP) Commodity Credit Corporation Eligible Recipient Funds (10.187) and the Food Distribution Cluster (10.565, 10.568, 10.569). Criteria: Per 7 CFR 251.5(c), a state agency may delegate to one or more eligible recipient agencies with which the state agency enters into an agreement the responsibility for the distribution of commodities and administrative funds. Per the State’s agreement with the Food Bank, the Food Bank shall submit household reports monthly. Condition and context: As part of our eligibility testing, and in order to determine whether the onsite check-in forms were complete, we agreed the onsite check-in forms for our eligibility selections to the household distribution reports. For six out of the 38 statistically valid samples, the number of unduplicated households serviced on the check-in forms did not agree to the household distribution reports. This condition was noted for five out of 11 months selected for completeness. Cause: The Food Bank did not have controls in place to ensure the accuracy of the Household Participation reports. Effect: The number of eligible households that received food distributions was not accurately reported to the State. Questioned Costs: None. Repeat finding: No. Recommendation: We recommend that the Food Bank implement controls to ensure the accuracy of the Household Participation report.Management Response and Planned Corrective Action: The Agency Relations Management team created a procedure to ensure all agency and program TEFAP household distribution reports are accurately entered into the CDSS reporting platform. The TEFAP Specialist will run a CERES report by the 5th of every month showing all agencies and programs that received TEFAP the previous month. This report will be used as the checklist to ensure a TEFAP report is received and that the household information gets entered into the CDSS household reporting platform. Once the TEFAP Specialist enters the reports into the CDSS platform, the Agency Relations Specialist will double-check the entered entries in the CDSS platform against the agency/program report to ensure accuracy before the CDSS portal is locked for the month. In order to ensure the effectiveness of these procedures, the Agency Relations Supervisor will audit 25 reports randomly every month. The Agency Relations Supervisor will review the audit results with the Agency Relations Manager on a monthly basis. For the Food Bank’s TEFAP direct to individuals programs, the Programs Coordinator will tally all TEFAP food recipients from the TEFAP sign-in sheets and complete the HHP TEFAP report form. Before submitting the TEFAP HHP report to the TEFAP Specialist, a different Programs Coordinator will double-check the total number of persons served from the TEFAP sign-in sheets and verify the HHP TEFAP report form is correct. After the second check is completed, the Programs Coordinator will send the monthly LARFB TEFAP reports via email to the TEFAP Specialist with a copy to the Programs Manager and Programs Director. The Agency Relations Manager will oversee the processes completed by the Agency Relations Supervisor, TEFAP Specialist, and Agency Relations Specialist assigned to these procedural tasks. The Programs Manager will oversee the work of the Programs Coordinators for the Food Bank’s direct to individuals programs. We will implement this corrective action on or before June 30, 2024. Individuals responsible for corrective action: Elizabeth Cervantes – Sr. Director of Product Acquisition and Agency Relations 323.974.0073 Hilda Ayala – Sr. Director of Programs & Policy 323.353.0114 Steven Meisberger – Chief Financial Officer 323.318.0319

The tenant recertifications will be monitored by the owner to ensure they are being completed in a timely manner.

Corrective Actions Taken or Planned: Going forward for payments, under the direction of the Executive Director, Rachel Erpelding, the Kim Wilson Housing Staff will sign-off on the access database check request sheets and have the Executive Director provide her physical signature as written evidence of the review and approval process for housing payments. For drawdowns, beginning July 2023, the Director of Fiscal Services, Linnea Cullumber, implemented a monthly reconcile process between the housing check payment requests and grant billing drawdown support provided by the Kim Wilson Housing Staff. The accounting staff now reconcile the payment and drawdown support, then retain the email correspondence supporting the drawdown process providing confirmation of review and approval. Rachel Erpelding, Executive Director of Kim Wilson Housing, and Linnea Cullumber, Director of Fiscal Services are responsible for this corrective action plan. The anticipated completion date is 3/31/24.

Reference Finding Number: 2023-001 Eligibility and Allowable Costs To Whom It May Concern, This letter is in reference to the 2023 audit conducted by Capin Crouse on Harmony Community Development Corporation (Harmony CDC). Please find below the corrective action plan devised by Harmony CDC management to address the findings in the audit: The (SOP) standard operating procedure will be revised to ensure client documentation is being stored in more than one place. There will be a process to backup all files on an external drive. This will serve as a secondary storage place. Currently client documentation is stored in the housing portal and on the shared drive in the organization. In addition, a required documentation checklist will be maintained and verified for each client. A policy will be developed to complete quarterly internal audit reviews and evaluate 10-15% of the client case files. Staff will conduct ongoing peer reviews of the client files. When a staff member is on a Leave of Absence, the employee’s network access will be revoked during the time off. If a staff member is on a disciplinary action plan, the employee’s network access will be monitored. Mandatory compliance & ethical training will be completed by all employees. All employees will review and sign employee handbooks, conflict of interest and code ethics. Person Responsible for Corrective Action Plan: Mark Porter, Executive Director Anticipated Date of Completion: May 1, 2024 and ongoing internal audits quarterly

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2023-001: Major Program: Section 8 Housing Assistance Payments Program, Federal Assistance Listing Number 14.195 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. If the Department of Housing and Urban Development has questions regarding this plan, please call Bryan Joyce at (413)-525-4321.

Views of Responsible Officials of the Auditee Management agrees with this finding and will take corrective actions. Corrective Action Plan The University is in the process of reviewing and modifying its procedures for calculation Federal Pell Grant awards in order to meet compliance according to 34 CFC 690 80. A nticipated Completion Date: May 31, 2024 Contact Person(s): William Washburn, Interim Director of Financial Aid

Management agrees with the finding. Corrections have been made to both tenant files. One tenant has been given a 30 day notice to vacate the unit.

Views of Responsible Officials and Planned and Corrective Actions: As a result of prior audit finding, HHLI has instituted mandated training sessions with a required curriculum for a sliding fee scale. These training were conducted over a period which included competency testing and retraining if necessary. It is documented that we have had a high turnover of clerical staff during the past year. As a result, we had the task of training new clerical staff as we were onboarded. We understand this interrupted the continuity of learned processes for our clerical staff and thus the outlined process. As well, we have continued with our internal audit processes. We have identified an internal report through our data system that weekly provides information on variances of sliding fee scale processes. We have met internally and reviewed the current policy and training curriculum. We look to simplify the process for our clerical staff. We anticipate partnering with our EMR platform and standardizing the language for the sliding fee scale process. We want to leverage technology to support the procedural process for the sliding fee scale. We also will inform staff to document variances of findings. Please note that our patients were not negatively impacted or financially affected. Responsible Party: Stacey Harley, Chief Operating Officer, EMR administrator, and Site Leadership Estimated Time of Completion: September 30, 2024

2023-003 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers – Material Weakness Condition and Criteria: Assistance payments were calculated incorrectly due to errors in data entry. Eligibility for the program requires payment based on substantiated income and expense of the applicants. Cause: Human error in the calculation of income and expense allowances which affected assistance payments. Effect: The cost of the assistance may be disallowed or the Agency could be required to fund amounts that were under awarded. Context: A sample of grants totaling $21,782 was selected for audit from a population of $11,709,832. The test found questioned costs totaling $427. Our sample was a statistically valid sample. CORRECTIVE ACTION PLAN RESPONSE: The files contained errors from staff not having the back-up, or failing to remove income/expenses from the previous transaction. Our Compliance person was pulled from those duties when manpower shortages occurred throughout our department. We are hiring more staff to ensure this will no longer be an issue. Anticipated completion date: 9/30/24 Responsible party: Dianna Clair, Section 8 Housing Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.

2023-001 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers – Material Weakness Condition and Criteria: Assistance payments were calculated incorrectly due to errors in data entry. Eligibility for the program requires payment based on substantiated income and expense of the applicants. Cause: Human error in the calculation of income and expense allowances which affected assistance payments. Effect: The cost of the assistance may be disallowed or the Agency could be required to fund amounts that were under awarded. Context: A sample of grants totaling $21,782 was selected for audit from a population of $11,709,832. The test found questioned costs totaling $427. Our sample was a statistically valid sample. CORRECTIVE ACTION PLAN RESPONSE: The files contained errors from staff not having the back-up, or failing to remove income/expenses from the previous transaction. Our Compliance person was pulled from those duties when manpower shortages occurred throughout our department. We are hiring more staff to ensure this will no longer be an issue. Anticipated completion date: 9/30/24 Responsible party: Dianna Clair, Section 8 Housing Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.

Reporting Finding 2023-004 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The calculation of lost revenues contained errors. Corrective Action Plan: The Authority has enhanced the internal controls to ensure underlying supporting records agree to the final reports submitted to HHS, including a review and approval by someone different than the individual inputting the report data. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: May 2024

Finding 2023-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Catalog Numbers: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of thirty-one (31) tenant files, the following information was unavailable for examination at the time of audit: Annual inspection reports were missing in one file. Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers program is in non-compliance with the special tests and provisions - housing quality standards type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. Allison Landrum, Chief Executive Officer, is responsible for implementing this corrective action by September 30, 2024.

Finding 2023-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Catalog Numbers: 14.871 Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 1,782 units. Of a sample size of thirty-one (31) tenant files, the following was noted: • HUD 50058 Form was missing in 1 file • Verification of income and assets was missing in 1 file. Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The affected files relate to clients that have been on the program for decades and as files get large, archiving takes place. To correct this finding, a directive will be issued to staff that will ensure that when files are archived the original application must be placed in the current working file going forward. Allison Landrum, Chief Executive Officer, is responsible for implementing this corrective action by September 30, 2024.