Corrective Action Plans

Corrective Action Plan September 26th , 2025 Health Resources and Services Administration Delaware Valley Community Health, Inc. and Delaware Valley Community Support Network Trust respectfully submit the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID‐19 Health Centers Program Cluster (Assistance Listing Number 93.224/93.527) Finding 2024‐001 – Special Tests and Provisions SIGNIFICANT DEFICIENCY Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are being properly calculated. Supervisors should monitor and review the sliding fee calculations on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Employees received training in January 2025 to ensure the sliding fee discounts are correctly applied. Additionally, DVCH is planning an annual refresher training for staff for the first quarter of 2026. The Patient Account Counselor Team Leader conducts a monthly internal audit, which began in the first quarter of 2025, of sliding fee discount. In September of 2025, the audit was adjusted to collect additional actionable information. The findings from the internal audit are reviewed with staff, the Director of Revenue Cycle Management, and the Director of Operations. The audit samples each site and department to ensure accuracy across the organization. DVCH is exploring the possibility of engineering a change in our electronic practice management system to facilitate and remind the registration and revenue cycle staff to complete the sliding fee calculations when needed. This discovery process began in September 2025. If the Health Resources and Services Administration has questions regarding this plan, please call Ryan Taylor, Chief Financial Officer at 267-240-2578.

View of Responsible Official: We have undertaken additional training and review of regulations in this area to ensure compliance. Finding resolved timeline: December 1, 2025. Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President and program Authorized Representative

Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any reviews will be documented with an approval via a formal email confirmation. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail

Management’s Response: There is no disagreement with the finding and recommendation noted above. MCBSS experienced short staffing of its Medicaid Department that resulted in a backlog of applications and eligibility determinations. MCBSS continues to monitor the staffing of the Medicaid Department and work towards filling vacant positions. Planned Implementation Date of Corrective Action: December 2025 Person Responsible for Corrective Action: Administrative Supervisor of Medicaid Department

1. Will create a federal procurement compliance checklist before applying for another contract by a federal award. 2. Will hire legal counsel familiar with federal awards to review the contract. 3. Will request that the engineers amend/revise the Grunloh contract and any other contract issues as part of the EPA loan to come into compliance with the statute and grant-specific requirements for procurement language.

2024-002 Special Tests and Provisions - Program Administration The Housing Authority of Okanogan County recognizes we had several oversights in our tenant file documentation and program administrative procedures during 2024. During April 2024, the Housing Authority of Okanogan County underwent a Comprehensive Compliance Monitoring Review review by the Seattle Field Office of the U.S. Department of Housing and Urban Development. Their review report dated May 23, 2024 identified a number of findings and recommendations which were implemented in June and July 2024 by the Housing Authority of Okanogan County. The Housing Authority of Okanogan County provided the Seattle Field Office of the U.S. Department of Housing and Urban Development supporting information documenting resolution and correction of each item identifi ed in thei r report. On October 30. 2024 Seattle Field Office of the U.S. Department of Housing and Urban Development issued a letter documenting that the Authority has fully remedied each finding.

The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and some at the decision of staff. Initial eligibility is currently being restructured with an emphasis on new admissions. All procedures and processes are being evaluated for accuracy, with emphasis on the noted area of noncompliance and includes a complete review and update to the Administrative Plan. There will be increased staff training and file review. In July 2024, TGHA transitioned project-based files from a property management team to the Housing Choice Voucher Department. The files had not been electronically stored. Evidence pointed to deficiencies in file maintenance. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the programs, including staff capability, training and monitoring. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. TGHA files were fully in order by July 2025.

The County will continue to monitor supervisory and cross training process

The County will continue to monitor supervisory and cross training process

Management will conduct a review of current procedures. Based upon this review, management will create standard procedures to ensure all income items are compared against respective supporting documentation. For example, management will prepare a checklist to include all items needed for supporting documentation and verify the accuracy and completeness of this supporting documentation. In addition, management will implement quarterly reconciliation procedures. Finally, relevant personnel will receive a training refresher. Immediately and tis will be monitored on an ongoing basis.

2024-005 Reporting Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2024 Recommendation: It is recommended that the Couty 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 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, 2025.

2024-004 Review of Casefiles Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2024 Recommendation: It is recommended 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, 2025

We have met with the responsible party and explained the need to be more careful. We also have a new person responsible for that input.

CASEFILE REVIEW (PRIOR YEAR 2023-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2405MN5ADM, 2405MN5MAP Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025

ELIGIBILITY (PRIOR YEAR 2023-008) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2401MNTANF Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1, 2025

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: September 18, 2025

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant eligibility, nor did it ensure that non-long-term care program participants were properly classified. Sixty participants were selected for testing and the following exceptions were noted: • For five of sixty participants selected for testing, the County was unable to provide documentation that a program supervisor had approved the application. • For one of sixty participants selected for testing, the County was unable to provide a signed participant application. • For one of sixty participants selected for testing, upon reapplication and further documentation, a long-term care case was determined to be non-long-term care, but the County did not make this change and the participant was misclassified. Questioned Costs Undetermined. Recommendation The County should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility. It should also enhance procedures and internal controls to ensure participants are correctly classified as long-term care versus non-long-term care. Corrective Action Plan The Medicaid Division will continue to emphasize the need for signatures at both levels of eligibility Examiner level and Quality Control Examiner II or higher level. This will be stressed at all appropriate training for not only new staff but current staff as well. As far as the “misclassified” the Consumer left nursing home during a period when documentation requirements were waived, due to the Public Health Emergency (COVID-19); The coverage was correct, but coding indicated the need for Long Term Care. This code does not allow or authorize any services on its own, and as such, no inappropriate services were authorized. Even though this has little impact the Division will continue to stress to staff and supervisors the need to properly code cases. NYS DOH is in the process of transitioning away from LDSS 3209 forms and automating the process; we will continue to work with our state partners to assist in this transition when it becomes available to us. This transition should mitigate these type of situations. Action Date September 5, 2025 Final Implementation Date December 31, 2025 Name And Phone No. Of Person Responsible For Implementation James Sluder – 631-854-5830

2024-001 ELIGIBILITY Intake forms were not completed for the WIOA program. One client tested during the audit was determined to be over the age of eligibility at the end of the year. Recommendation: The Organization should develop, document, and implement a review process that ensures all participant intake forms are completed and reviewed for correct eligibility determinations, and that eligibility is monitored on a regular basis to ensure that clients who age out of the grant are properly removed. Action Taken: The employee that took these actions was terminated once a thorough investigation was completed. This employee marked individuals as eligible even though they were not. The Organization self-reported to the funder and work with the funder to the funder’s satisfaction. This was finalized by the end of September 2024. Additionally, to ensure that all clients are eligible, the Organization, after the problem discussed above instituted a multiple step process to ensure eligibility. If someone is potentially eligible, the Organization reaches out to a third party to confirm eligibility, the case manager will sign off on the eligibility, and then the case manager’s boss will also review and sign off on the eligibility. Finally, the client is then submitted to the grantor for a final review. Contact Person: Shire Kuch Effective Date: 30 September 2024

Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: •Citizenship verification continues to be an error prone area. As an automated system process, the majority of our cases successfully complete the interface with SSA to determine citizenship. Determining the root cause of these errors is not always simple, but some contributing factors are failed interface links between MAXIS and SSA. Citizenship details on the MEMI panel which isn’t part of the normal review workflow for recertifications as it holds “additional” member information that typically doesn’t change from year to year. Also, human error plays a role as this type of verification is typically requested at the time a case opens and normally doesn’t change throughout the life of the case. Despite reminders and manual reviews, cases are still being missed. System modernization would go a long way to mitigate these types of error. In addition to continuing the reminders for staff, and periodically checking cases for failed interface verifications, the financial assistance supervisor will request ad-hoc reports from DHS specifically for healthcare cases that have a missing citizenship verification field or coded as “N” for no verification on the MEMI panel in MAXIS. This report will be shared with staff to target cases with missing citizenship verifications. In addition, it has been determined that the use of SMI to verify citizenship has been approved, however this verification has not been added to the case file in some instances which results in an error finding. •Asset verification rules have changed over the past year and a half and although the previous CAP stated we would hold reviews of this policy during regular unit meetings, the financial assistance supervisor has only held one review. This area will be revisited using state training in Trainlink and staff will be reminded that any information reported on an application or renewal needs to be compared to the information recorded in MAXIS and conflicting information needs to be verified. In addition, the process of receiving verifications will be reviewed. Currently, verification documents must be accepted from the client by any means, including mail, fax, paper, or email. Email containing verifications may be sent to the primary Financial Assistance email (recommended) but also may be sent to the agency’s primary email or the primary worker’s personal work email (not recommend). This puts the responsibility of moving those verifications to the case file on several different people. This process may lead to verifications being received but not added to the case files. Best practices will be shared with staff. Anticipated Completion Date: Trainlink training was shared and reviewed at the next in person unit meeting, September 4th. Ad-Hoc reports will be requested for the next quarter, October 6th Reviewing receipt of verification procedures will occur over the next several months and modifications (if necessary) or best practices will be shared January 2026.

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A at least 2 times per month to identify outstanding verifications for MA cases in METS. This will identify specific cases missing SSN verifications. Anticipated Completion Date: The MNCM 220A reported is generated quarterly. The anticipated completion date is October 6th for the next quarterly report.

Management's View and Corrective Action Plan Audit Finding for the Year Ended December 31, 2024 2024-001 – Community Services Block Grant Eligibility Response Management agrees that there was a misunderstanding of the eligibility requirements of award 450100 of the Community Services Block Grant allowing certain ineligible students to be entered into the program. Management will work in partnership with program leadership to implement the following improvements: •Update registration and intake materials to more clearly screen for all eligibility criteria. •Retrain staff on intake procedures and required eligibility screenings •Institute regular internal reviews of eligibility screening process and participantfiles Anticipated completion date : October 1, 2025 Responsible person contact name: Meghan Sinback, Executive Director

The findings from the December 31, 2024, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding 2024-001 U.S. Department of Housing and Urban Development Moving to Work Demonstration Program - ALN 14.881 Eligibility and Reporting Repeat Finding from 2021(2021-001), 2022(2022-001), and 2023 (2023-001) Maher Duessel Finding Condition: During our review of 40 tenant files prepared by the Housing Authority of the City of Pittsburgh (Authority) as part of the biennial reexamination process, we noted a lack of functioning internal controls which led to the below exceptions in our testing. We noted four instances where a tenant recertification using the HUD-50058, Family Report (Form) (which provides eligibility and reporting information) was not completed, on a timely basis. We also noted one instance where other documentation to support the reporting and eligibility assessment as part of completion of the HUD-50058 was not provided. This includes items such as support for income calculation and medical deductions. These exceptions indicate a lack of functioning internal controls and oversight to ensure compliance with HUD requirements related to timely and accurate tenant recertifications. HACP Management Response/Action Taken: Action Taken: The HACP will continue to monitor and train staff regarding processes and procedures, to include and not limited to the Housing and Urban Development's (HUD) hierarchy of income verification. As noted in previous responses, the HACP continues to experience challenges in hiring and retaining staff as a result of the complexity of the Housing Choice Voucher (HCV) Program. In fiscal year (FY) 2024, the HCV Department had a significant turnover in both line and managerial staff. The HACP promoted an aggressive hiring plan to attract new talent to fill vacant positions due to the great resignation that the HACP, along with other national Agencies, continue to experience. In addition, the HACP has adopted the policy of hiring more staff than needed in the event of turnover. The HACP will continue to utilize the Internal Compliance (IC) Department to review recertifications and compile audit report cards based on the accuracy of recertifications reviewed. The audit report cards are used as an additional management tool to determine whether additional training is needed for staff and the department in general. The HACP continues to: • Send notices regarding re-certifications 120 days in advance of the due date, o Send 10-day notices for missing AR documents o Send 30-day notices when there is no or insufficient response to the 10 day notice sent • Require Managers to review reports to assure timely submission of re-certifications, • Utilize the IC Department to review and sample files from the Occupancy and the HCV portfolio, • Offer periodic staff training on re-certification, • Offer participants the use of technology to complete paperwork In addition to the above noted internal controls, the HACP will institute Bob.ai in FY 2026 as an additional tool to notify both the participant and the HACP staff when the recertifications are due and provide notification of missing documents. The One Stop Shop (OSS) is staffed with three (3) full-time staff members to receive information from participants and landlords to provide timely customer service. In July of 2024, the OSS was equipped with computers for the public to access HACP staff virtually. The use of the computers allows staff to interact with participants regarding minor issues without having the staff physically come to the OSS, thus saving time and money for both the external customer and the Authority. The opening of the One Stop Shop has been successful in receiving the public and responding to concerns.

Corrective Action Management has issued a formal response to HUD’s Finding dated September 30, 2024, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of September 11, 2025. The Authority’s Chief Finance Officer, Tracy Gann, has assumed responsibility for the continued execution of the corrective actions.

C. Current Findings on the Schedule of Findings, Section 8 program administration and Recommendations 3. Finding 2024-3 e. Comments on the Finding and Each Recommendation We concur that EIV reports were not timely filed. Action(s) Taken or Planned on the Finding f. Action(s) Taken or Planned on the Finding Staff has been stabilized and will ensure that reports are run timely. Training and monitoring will be provided.