Corrective Action Plans

CORRECTIVE ACTION PLAN Name and Number of the Project: See below Audit Firm: M Group, LLP Audit Period: December 31, 2023 Project Name of Waters at James Crossing, LP, FHA/Contract No. VA36-L000-130, Questioned Cost of $52,007; Project Name of Brittany Woods/Park Chase, LLC, FHA/Contract No. GA06L00060, Questioned Cost of $73,002; Total of $125,009. Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN OR TO BE TAKEN FINDING #2023-005: Section 8 Housing Assistance Payments Program, Assistance Listing #14.195 CORRECTIVE ACTION TO BE COMPLETED: The Projects will review and monitor tenant eligibility and documentation procedures to ensure compliance. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Michael Nguyen, President of Atlantic Housing Management, Inc.

Finding 2023-001 – Housing Choice Voucher Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: Greensboro Housing Authority (GHA) continues implementation of systems and processes to correct internal control over participant files in the Housing Choice Voucher Program (HCVP) with the following actions: In 2023, GHA made leadership changes through the recruitment of talented and transformational leaders that are knowledgeable of program rules and requirements. In addition to the two-pronged approach that was implemented in the prior year, GHA team members will expand Quality Control and Quality Assurance checks on program participants’ files to verify the accuracy of calculations and compliance requirements. This will be augmented by increased sampling and review from a third-party consultant. GHA will continue to provide internal and external training to team members. We have completed an independent review of over 25% of our files and we are using the results of that review to identify specific areas for ongoing training and development. We have also invested in leveraging technology to help us mitigate the errors identified during the audit. Anticipated Completion Date: The above plans will be implemented immediately and will be continuously monitored. We anticipate a completion date of no later than December 31, 2024. Responsible Person: Meredith Daye, Chief Operating Officer

The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. Anticipated Completion Date: October 2024. Responsible Contact Person: Yohannes Gedlu, Northwest Division Divisional Finance Director & Julie Luft, Northwest Division Social Services Director

2023-004 ALN: 14.871 - ALN 14.850 – Public & Indian Housing – Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Angela Childers, Chief Executive Officer Projected Completion Date: March 31, 2025

Finding number: 2023-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.033, 84.063, 84.268 Award year: 2023 Corrective Action Plan: An in-depth review will be completed for each student who is designated with a SAP Status from the Registrar before Federal Aid is disbursed. SAP designations will be kept as part of the student’s financial aid file from one semester to the next and this status will be reviewed before any Title IV Aid is disbursed. Timeline for Implementation of Corrective Action Plan: May 1, 2024 Contact Person: Shani Wilkerson, Director of Financial Aid

Finding Reference Number: 2023-002 Description of Finding: During our audit for the year ended December 31 , 2023, we noted that sufficient supporting documentation was not available for the annual income amounts. Statement of Concurrence or Nonconcurrence: We are in agreement with this finding. Corrective Action: A new management company has been engaged as of April 1, 2024. The new management company, Kings Daughters and Sons Management Company, Inc., is very diligent in maintaining its records and ensuring they are in compliance. It is expected that they will ensure that the supporting document for annual income amounts will be properly documented and filed going forward. Name of Contact Person: Pat Thatcher, Board Treasurer patthatcher1@gmail.com 203-451-1090 Projected Completion Date: Expectation is that the new management company will ensure proper income verification for all tenants for the year ended December 31, 2024.

Homeowners Assistance Fund– Assistance Listing No. 21.026 – Eligibility Recommendation: The Agency should evaluate the steps they take to ensure that any required documentation not gathered from the program participant is followed-up on and obtained, prior to finalizing an application and providing housing assistance. Any changes in this methodology ought to be documented in the program policies and procedures, and communicated to all employees who engage in the application process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: All staff has been reminded and retrained to fully review each file to ensure that a properly executed 4506C has been uploaded to our operating system. Additionally, a lookback procedure has been instituted to capture any files from the current year that may be missing this document. Also, ERMA/HAF closers have been instructed to ensure that the form is available in our operating system, or they are to instruct the title agent and the applicant(s) that a form must be signed as part of the closing documents NJHMFA provides to the title agency. It is important to note that the document is not a US Treasury requirement and its inclusion in ERMA/HAF files was determined to be necessary to ease income reviews for self-employed applicants as well as those who receive rental income and include it on their IRS 1040 returns. While NJHMFA decided it would request this form for all applicants, the form itself is not utilized in every instance. Name(s) of the contact person(s) responsible for corrective action: William Schmidt (Assistant Director of HAF); James Abrams (HAF Program Manager); Tina White (HAF Program Manager) Planned completion date for corrective action plan: Training for staff and closers has already occurred. Closers have also received instructions to ensure the form is uploaded at time of closing. The lookback procedure shall be completed by no later than September 1st, 2024.

The policy for the return of security deposits received on site is consistent throughout the company. This is taught to incoming sta􀆯 members to make sure that the proper timeline is adhered to during the move out process each month. The policy is specific in saying that the paperwork and letter notifying the tenant(s) status of their security deposit whether it is a refund, or they owe additional funds upon vacating from their apartment is sent by the manager within 7 – 10 business days. The policy is attached for reference. The security deposit refund is also checked by our Regional by the 15th of each month and our inhouse Accounting Department to make sure that all security deposits are completed and sent out prior to 30 days from the day that the resident moves out. Going into 2024, this training is scheduled throughout the year and always available on our HAU Training Programs accessible to all employees. The training is for new hires and existing employees to reiterate the process to make sure all employees are aware of the sensitive timeline associated with the return of the security deposit for our tenants.

Each resident’s information is processed before moving in to ensure they don’t have tenancy elsewhere. Going forward, we will ensure that things are processed timely within the 90-day period. Going forward, management will ensure that the EIV system is utilized correctly and timely. Tenant files have been noted on the late EIV reports. Management is now running EIV reports from corporate to eliminate the pate processing or missing EIV reports.

Onsite team members have received refresher training and have the EIV binder available onsite. They have also set calendar reminders to make sure that EIV reports are pulled in a timely manner. The regional manager will be following up with the onsite staff to make sure they are in compliance.

The onsite team members have received refresher training and policies and procedures regarding the handling of EIV reports have been reviewed with the team so that they will remain in compliance, so the EIV reports do not leave the property. The regional manager will be following up with the onsite staff to make sure they are in compliance. Going forward, management will ensure EIV reports are not transmitted electronically.

Each resident’s information is processed before moving in to ensure they don’t have tenancy elsewhere. Going forward, we will ensure that EIV data is ran within 90 days. We have checklists that the property manager follows when processing a tenant and the regional manager has gone over it and made some modifications. Going forward, management will ensure that the EIV system is utilized correctly and accurate amount of adjusted annual income is reported on the HUD Form 50059.

Each resident’s information is processed before moving in to ensure they don’t have tenancy elsewhere. Going forward, we will ensure that things are processed timely meaning within the 90-day period

Management agrees with the finding, each resident’s information is processed before moving in to ensure they don’t have tenancy elsewhere. Going forward, we will ensure that EIV data is ran within 90 days. We have checklists that the property manager follows when processing a tenant and the regional manager has gone over it and made some modifications. Going forward, management will ensure that the EIV system is utilized correctly, and that accurate amount of adjusted annual income is reported on the HUD Form 50059.

Ineffective Controls Over the Sliding Fee Scale Eligibility Requirements Condition Community Health Concern, Inc. (“CHC”) did not effectively maintain an internal control system over its sliding fee and clinic service eligibility requirements. During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted: • Two (2) patient files/charts did not have the required eligibility information, including sliding fee scale assessments, proof of income, general consent, registration form, etc. • A Medicare patient was assessed a sliding fee scale discount for services that should have been charged to Medicare. Management’s Views: CHC implemented a new electronic health record (EHR), Epic Platform, in October 2023 to replace its 15-year-old legacy system, Intergy. After one year of extensive training, CHC with the assistance of Health Choice Network (HCN), a Health Center Controlled Network, rollout the Epic Platform, During and post implementation of the new platform, CHC encountered significant challenges in its front desk operations (e.g. eligibility information, including registration form, general consent, proof of income and sliding fee scale assessments), hence, two patients’ charts did not cross over from the old system to the new platform and challenges with our outreach teams’ encounters. Also, a Medicare beneficiary was incorrectly assessed a sliding fee scale discount for services that should have been charged to Medicare. As a result of the audit findings, we have identified several areas for improvements to enhance the effectiveness and efficiency of our front desk and outreach teams processes. Corrective Action Plan: The following corrective action plan outlines the necessary steps to address these areas: 1. Monthly Chart Audit by the Lead Patient Services Representative (Lead PSR): • Checklist to include: o Eligibility verification o Consent to treat o Registration packet o Sliding Fee Application o Self-declaration 2. Utilization of HCN Teams Chat Tool • Leverage the HCN Teams chat for addressing insurance-related questions, such as duplicate commercial plans, to ensure accurate and timely responses. 3. Retraining Low Performing Staff • Low-performing staff will undergo retraining with the Lead PSR and HCN Revenue Cycle Management consultants to enhance their performance and understanding of the processes. 4. Competency Test Development • Develop and implement a competency test for PSRs to ensure all team members possess the required knowledge and skills. 5. Monthly Meetings • Hold monthly meetings between the PSR and Billing teams to share knowledge, address concerns, and promote continuous learning and improvement. 6. Staff Registration Limitation • Limit the number of staff able to register patients. PSRs will take the lead role in registration, with MAs serving as backup when necessary. 7. Creation of Insurance Quick-Guides • Create quick-guides to aid in the selection and verification of insurance, ensuring staff have easy access to essential information. 8. Hard Stops on EPIC workflow • Request hard stops on EPIC for the input of key information to prevent incomplete or incorrect data entry, thereby improving data integrity and patient care. Anticipated Date of Completion: Management has implemented approximately 80% of the strategies described in the Plan above. These corrective actions are designed to address the identified issues and enhance the efficiency and accuracy of the registration and billing processes. Management believes that these measures will also lead to significant improvements in the overall operations and patient satisfaction. Management anticipates the successful completion date for the entire Plan to be no later than August 31st, 2024. Contact Person: For inquiries regarding this finding, please contact Benjo Reyes at BenjoR@CamillusHealth.org who is responsible for the corrective actions.

Oversight Agency for Audit, MM III, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2023 through 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 in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2023-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure the verification of tenant income through the EIV system in a timely manner and maintain all required tenant documentation. Action Taken: Staff training has been provided and included in monthly reporting procedures.

FINDING No. 2023-003: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure the Project verifies initial tenant income through the EIV system in a timely manner and maintain all required tenant documentation. Action Taken: Staff training has been provided and included in the monthly reporting procedures. If the Oversight Agency for Audit has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO.

Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2023 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (1) Finding 2023-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action taken - The Authority will implement a comprehensive reporting calendar and tracking system, provide staff training on reporting requirements, establish an internal review and approval process for reports, conduct quarterly internal compliance audits, maintain regular communication with HUD, and continuously improve and document reporting processes with an annual review. These actions aim to ensure timely and accurate report submissions, thereby preventing future findings and maintaining eligibility for HUD funding. (c) Planned implementation date - The Authority plans to implement procedures during the fiscal year ending December 31, 2024 to resolve the reported finding.

Management recognizes the deficiency and has worked with HUD officials, independent auditors, and legal counsel to examine the best course of action for the Housing Choice Vouchers program. Management has decided to relinquish all housing assistance programs, including the Housing Choice Vouchers Program, to another entity.

Views of Responsible Officials: In June 2024, program leadership reviewed grant eligibility and documentation requirements, and revised protocols and training for the implementing staff to ensure understanding and compliance on proper documentation review and retention for eligible participants. Program leadership will perform regular case file reviews to ensure compliance with these requirements.

Finding Number: 2023-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: • Staff will periodically check cases for citizenship. Citizenship verification is supposed to be an automatic process within MAXIS as an interface update with the Social Security Administration. Workers have come to rely on this automatic process, so reminders to staff to check that this process has actually happened, as well as checking cases periodically, will hopefully resolve this error from reoccurring in the future. • Vehicles are now considered a disregarded asset that is unlikely to increase in value. According to the most recent policy change, these vehicle assets no longer need to be reverified or updated within MAXIS as long as the reported asset has already been verified and entered in MAXIS. Review of this policy will be brought up during regular unit meetings 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. This would specifically include any new vehicles that were purchased, or any vehicles sold during the certification period. Income verifications are usually the primary focus when determining new eligibility, however this data is still subject to data entry error. Special attention to this in particular will be highlighted during regular unit meetings. Training on how to review, and calculate income on paystubs will be provided to eligibility staff as well as creating detailed case notes as to how the income was figured and the method used for calculating that income. This will hopefully resolve this error from reoccurring in the future. Anticipated Completion Date: These actions will begin August 5, 2024, during the regularly scheduled in person unit meeting. Unit meetings are held two times per month, once in person, and once virtually. Health Care is a standing agenda topic and adding these audit findings to the next meeting will be the start of our corrective action. This action will be an ongoing effort to eliminate errors in our cases.

Corrective Action Planned: Management has replaced the property manager with a more experienced property manager who has a full and complete understanding of the HUD regulations and processes. Management has developed policies and procedures to establish a timely database of all recertification dates. Name(s) of Contact Person(s) Responsible for Corrective Action: Marcia Drake, Property Manager, Ashley Kratzer, Corporate Controller

Clinic management team acknowledges that from the audit selection made of 60 patients, 22 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. A detail plan of correction has been developed and is listed below. With the exception of the last bullet below, these corrections were implemented in the fourth quarter of 2023 as a result of the 2022 finding. The last bullet was implemented in the first quarter of 2024. • Revamped the job titles and description to encourage better return on recruitment efforts of medical case manager positions. • A position of Certified Case Counselor (CCC) – Supervisor, was created and filled to provide direct oversight over the medical case managers that perform the bi-annual certifications, and other daily tasks. • Added a quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. • Data Analyst(s) generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Supervisor is directly accountable to review the progress of the re-certification and the process is monitored by the Assistant Manager of the clinic. The CCC-Supervisor and Assistant Manager monitor retention of all patient required supporting documentation in the patients’ medical records. • Patients that do not provide the required supporting documentation showing compliance with program eligibility as outlined in the grant agreement or are otherwise not able to be recertified six months after certification will be classified as inactive in the database used to submit invoices to the Ryan White HIV/AIDS Program. Contact Person: Rajesh Mehta, Chief Financial Officer, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2024

Corrective Action Plan - Finding 2023-002 Internal Control over Eligibility Department of Health and Human Services Foster Care Title IV-E - ALN #93.658 and Adoption Assistance Title IV-E - ALN #93.659. The County has reimplemented the previously performed procedure of completion and a sign off of a checklist of the documents reviewed in the Tile IV-E eligibility file. This review will be performed by an independent employee. This will typically be the TANF eligibility employee. A check mark will be placed on the check list beside each document that is reviewed and will include the initials of the employee completing the review. Any questions or concerns will be directed back to the original employee that performed the initial verification. Anticipated Completion Date: August 9, 2024. Person Responsible for Corrective Action: William Kepple Financial Operations Officer Human Services Department County of Butler PO Box 1208 Butler, PA 16003-1208. 724-284-5120. wkepple@co.butler.pa.us

We are currently in the process of retraining staff on the sliding fee scale procedures and required documentation.