Corrective Action Plans

Condition: The Authority could not provide depositor agreements with financial institutions holding Federal funds for the Authority. Status: A similar finding was noted in fiscal year 2023. See corrective action plan for current year finding 2023-001.

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. Internal control document and procedure that is consistent with the compliance requirement for: i. CFR §200.318, General procurement standards identify all requirements which the offerors must fulfill and all other factors to be used in evaluating bids or proposals i. §200.319, Competition requirements will be met with documented procurement actions using strategic sourcing, shared services, and other similar procurement arrangements ii. §200.320 Methods of procurement to be followed. 2. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance, ShelterCare 3. The anticipated completion date: a. The written policies will be updated by 05/01/2024.

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HUD within 90 days of the fiscal year end. 2. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance, ShelterCare 3. The anticipated completion date: a. New property accountant was hired in August of 2023.

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. Pinehurst Management was overseeing property through 4/30/23. ShelterCare was assigned as new managing agent 5/1/2023. b. ShelterCare is working to ensure that the onsite manager will be trained in HUD compliance. c. We are currently prioritizing recertifications by oldest first so we are able to catch them up and get the property certifications back on track. d. Monthly review of TRACS reports to ensure recertifications are being completed in a timely manner. 2. The name of the contact person(s) responsible for the corrective action a. Dana Petersen-Crabb, Sr. Director of Housing, ShelterCare b. Amanda Smith, Property Development Manager, ShelterCare 3. The anticipated completion date: a. Monthly review of TRACS reports will be implemented by 10/1/2023. Training was provided to new staff in February of 2024. Recertifications are expected to be completed by June 30, 2024.

II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 50000 - ELIGIBILITY Management's Response: We concur. View of Responsible Officials and Corrective Action Plan In the 2023-24 school year, Nutrition Services has implemented an additional step when processing meal applications to improve accuracy. Meal applications are verified a total of three times. The Nutrition Specialist is the Determining Official, the Director is the Confirming Official, and either the Secretary or Clerk is the Verifying official. Each official reviews the application for accuracy. Name of responsible individual: Brenda Zarate Implementation Date: 7/1/2023

Finding 2023-001 – Housing Opportunities for Persons with AIDS Tenant Files – Eligibility – Rent Calculations Noncompliance & Significant Deficiency Housing Opportunities for Persons with AIDS Program – ALN 14.241, Grant Year 2022 & 2023 Corrective Action Plan: The two tenant files with income calculation errors resulting in the tenant overpaying. This has been corrected on both files and tenants have had a HAP payment in excess of their rental amount to provide a credit. The tenant file with no recertification in 2022. We have no idea how this could have happened unless a wrong date prior to this. The recertification was done in July 2023 and scheduled to be done for July 2024, so we are going forward. Additional file reviews will be done in the future. Person Responsible: Joseph Beasley and Connie Howard Anticipated Completion Date: Everything except the additional file reviews has already occurred (2/5/24).

Responsible Contact Person(s): Kevin Platea, Chief Information Officer Stephen Schleck, Associate Director of Enterprise Business Solutions Corrective Action Planned: A Change Request for the case management system was developed 2 years ago and DSS is reviewing the change request to determine a status. It was agreed by Line of Business and ITS EBS & a vendor (the systems provider) that there will be an iterative approach to completing the record retention and purge rules for implementation in the case management system. Estimated Completion Date: 12/31/2024

Responsible Contact Person(s): Mike Jones, Chief Information Officer Steve Hanoka, Chief Information Security Officer Corrective Action Planned: The 2023 Annual Access Review for the claims processing system through secure web application surveys began in the 4th Quarter 2023. Three separate surveys were sent to perform access review for DSS, Contractor and DMAS Internal access review. • DSS annual review sent on November 9, 2023 and ended on November 20, 2023 • Contractor review sent on November 30, 2023 and ended on December 15, 2023 • DMAS review sent on December 15, 2023 and ended on January 13, 2024 All 3 surveys requested managers to review their employees access and confirm if it was required or if the access should be revoked. Survey results are available to perform follow up actions. DMAS Security is currently reviewing the survey results and revoking access where requested. Estimated Completion Date: 6/30/2024

Responsible Contact Person(s): Barry Davis, Chief Information Security Officer and Director of Information Security & Risk Management Steve McCauley, Assistant Division Director Corrective Action Planned: DSS will perform an annual access review of user accounts for the case management system. Estimated Completion Date: 12/31/2024

Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Kavansa Gardner, Information Technology Manager Corrective Action Planned: DSS will perform and document a conflicting access review for the case management system to identify the combinations of roles that could pose separation of duties conflicts and ensure compensating controls are in place to mitigate risks arising from those conflicts. Additionally, DSS will work with a vendor to update the role-based security access documentation to reflect all system changes from prior case management system related releases when there are proposed changes to the roles matrix. Estimated Completion Date: 12/31/2024

2023-002 Special Tests and Provisions – Income Targeting Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance This is a repeat finding of 2022-002 from June 30, 2022 (initially reported June 30, 2021) Statement of Condition The Authority did not have adequate controls over income targeting to assure that the Authority is in compliance with this requirement. During our testing, we noted that tenants with incomes that were extremely low accounted for approximately 70% of new admissions during the fiscal year, which is below the minimum required percentage of 75%. Recommendation We recommend the Authority assure that at least 75% of new admissions be in the extremely low-income bracket. This should be monitored throughout the year. The Authority can also select applicants on the waiting list who are extremely low income by bypassing others on the list that don’t meet the requirement and documenting that the person was selected ahead of others to be able to meet the requirement Action Taken: We concur with this finding. We will closely monitor new admissions and focus on applicants on the waiting list who meet the criteria as extremely low income so that the 75% requirement is met. Our lease rate has been decreasing due to a decrease in availability in our area. We have been issuing vouchers every month and have little to no wait on our waiting list. We are also accepting applications every week. We have been unable to exclude persons due to the extremely low-income bracket requirement because we are trying to increase the overall utilization in our voucher program. We have submitted a request to HUD to allow an exception to the income targeting rule and are currently awaiting a response. Effective Date: February 29, 2024 Contact Information Jenny Hammond, Executive Director Housing Authority of the City of York 221 California Street York, SC 29745 (803) 684-7359

Finding No. 2023-001 Eligibility – Tenant Files Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance This is a repeat finding of 2022-001 from June 30, 2022 (initially reported June 30, 2021) Statement of Condition Out of a total tenant population of approximately 194 vouchers, 20 files were selected for testing. Exceptions were noted as follows: • 1 file where a math error on zero-income calculation resulted in an increase in HAP rent from $709 to $712. • 1 file where a math error on zero-income calculation resulted in a decrease in HAP rent from $961 to $912. • 1 file where social security income was calculated using 2022 amounts despite move-in date in February 2023. As a result, HAP rent decreased from $561 to $546. • 1 file where social security income was calculated using 2022 amounts despite annual re-exam in February 2023. As a result, HAP rent decreased from $709 to $687. In addition to the above, during our new admissions testing (5 tested out of 44 new admissions) we noted the following: • 1 file that did not contain a signed lease agreement. Recommendation The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken We concur with this finding and have implemented various controls. A tenant file and unit quality control procedure has been developed and implemented.

The Downey Adult School concurs with the finding and to prevent future occurrences, the school purchased a new student database management software system (Campus Café) that was implemented on August 1, 2023. The school also partnered with National Student Clearinghouse (NSCH). NSCH articulates with the new student database management software system (Campus Café). The new student database management software system together with National Student Clearinghouse will help to prevent human errors and omissions from occurring when reporting National Student Loan Data System (NSLDS) data. While the district purchased the new system in November of 2022, the school did not begin using the new system(s) until August of 2023 because the switch had to be implemented at the beginning of the fiscal year. Implementation is a several month process and all DAS employees have been receiving extensive training (ongoing) to be proficient and comfortable with the new system(s). We have ongoing weekly training for all DAS staff as we continue to fully implement the new student database management software system.

Finding Number: 2023-001 Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure the completion and accuracy of the inspection protocol. The Housing Authority will continue to implement its 30-day review system for the HCV Inspection Program. Although the system cannot ensure 100% compliance, its effectiveness is demonstrated in the high percentage of compliance. Anticipated Completion Date: 6/30/2024 Responsible Contact Person: Kristen Runion, HCV Supervisor

Finding Number: 2023-002 Planned Corrective Action: The Housing Authority noted the difference but was unable to resubmit the report. Actions have been taken to build automatic flags in the utility tracking spreadsheet to prevent errors in the future. Anticipated Completion Date: 6/30/2024 Responsible Contact Person: Jen Coy, Fiscal and Budget Officer

The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Award Program Audit Finding 2023-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs Federal Catalog Numbers: 14.871 and 14.879 Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Section 8 Housing Choice Vouchers Program - No Mainstream Vouchers Program - Yes Material Weaknesses in Internal Control over Compliance for Eligibility for the Mainstream Vouchers Program Significant Deficiency in Internal Control over Compliance for Eligibility Section 8 Housing Choice Vouchers Program 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 5,295 units. Of a sample size of seventy-one (71) tenant files, the following was noted: • HUD 9886 Form was missing in 1 file • Annual HUD 50058 recertification form and related verification of income and assets was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: • Mainstream Vouchers $19,830 • Section 8 Housing Choice Vouchers Program $1,875 Cause: There is a significant deficiency in compliance for the eligibility type of compliance related to the maintenance of tenant files in the Section 8 Housing Choice Vouchers Program. There is a material weakness in compliance for the eligibility type of compliance related to the maintenance of tenant files in the Mainstream Vouchers Program. The Authority has not properly maintained tenant files in compliance with program requirements following the expiration of HUD waivers. 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. The Mainstream Vouchers Program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement a corrective action plan 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. Following the expiration of the COVID-19 HUD regulatory waivers, the Authority experienced a large backlog of reexaminations along with higher than usual rates of staff turnover and other staff capacity challenges related to the pandemic. Authority management developed and implemented a plan to rapidly work through the backlog, and has made significant progress to bring the program into compliance. The audit resulted in one missing consent form (HUD 9886), and one re-examination (HUD 50058), which is noted as missing. While the consent form had expired and a new consent form was required during the audit period, the income information collected for the household was collected while the consent form was still valid. With regards to the re-examination noted as missing, this re-examination was performed late, having been completed just six days after the end of the audit period. The re-examination was initiated on time, and the delay in completing the re-examination was caused by the program participant’s delay in providing the required documents. Additionally, the Authority has been selected for participation in the Moving to Work program ('MTW'). Alternative re-examination schedules, including biennial re-examinations, are an approved MTW activity allowable through the MTW Operations Notice. The Authority has received HUD approval of a waiver that allows the use of an alternate re-examination schedule effective July 1, 2023. This re-examination schedule is in effect currently and will be in effect for the entire duration of the subsequent audit period. Based on the transition to biennial and triennial re-examinations, the Authority has already come into compliance with timely recertifications. Further, the Authority management is in the process of implementing enhanced Quality Control procedures, with staff to conduct ongoing internal audits over the course of the year. If the U.S. Department of Housing and Urban Development has any questions regarding this plan, please call Aaron Pomeroy, Finance Director at 831-454-5908.

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Utility Allowance Schedule Type of Finding: Instance of Non‐Compliance and Material Weakness in Internal Control over Compliance Views of Responsible Officials: The Housing Authority fully complied with 24CFR 982.517(C)(1) of HUD regulations that states that "A PHA must review its schedule of utility allowances each year and must revise its allowance for a utility category if there has been a change of 10 percent or more in the utility rate since the last time the utility allowance schedule was revised. The PHA must maintain information supporting its annual review of utility allowances and any revisions made in its utility allowance schedule." Each year, the Housing Authority hires a consultant to analyze the Utility allowances for the Fairfield jurisdiction. Once that assessment is completed, Housing Authority staff and Management review it. The Housing Authority staff then meets with the Consultant to discuss any irregularities found or resolve questions emanating from its review. Once staff and Management are satisfied with the information, have clear documentation explaining the Consultant's conclusions, and memorialize any categories that have changed 10% or more, Management will finalize its review of the Utility Allowance Schedule. The Housing Authority will document Management’s approval of the utility allowance adjustments, if any. Responsible Individual(s): Tanya Tran, Housing Division Manager LaTanna Jones, Deputy Executive Director Anticipated Completion Date: June 1, 2024

Finding 2023‐007 Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Housing Quality Standards Inspection Type of Finding: Instance of Non‐Compliance and Significant Deficiency in Internal Control over Compliance Views of Responsible Officials: We concur. The Housing Authority will ensure that HQS inspections are completed at least biennially for all units in the program. Each Housing Specialist maintains a tabulation of inspection deadlines for each unit; hence, 98% of the 60‐unit test group was completed on time. However, Management will more frequently monitor the inspection deadlines with the specialist to avoid even a 2% margin of error, as indicated in this audit assessment. Responsible Individual(s): Tanya Tran, Housing Division Manager Anticipated Completion Date: June 1, 2024

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance Views of Responsible Officials: We concur. The Housing Authority addressed this issue when the City was informed in March 2023 there was not enough documentation prior to online grant reporting for the auditors to verify grant reports were reviewed prior to submission on other grants being audited. The Housing Authority has continuously maintained a check and balance approach for preparing and reviewing VMS reports before HUD submission. All reports are prepared by the Housing Authority and finance staff, then reviewed by either the Housing Authority Manager or the Deputy Executive Director before submission to HUD. The reviewer is now documenting their review prior to submitting the VMS reports. Responsible Individual(s): Tanya Tran, Housing Division Manager Anticipated Completion Date: June 30, 2023

Finding 2023-001: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: September 30, 2024 Recommendation: It was recommended Sessions Village 202 obtain the missing signed documents if the tenant still resides at the project. In addition, it was recommended Sessions Village 202 review all tenant files to ensure all other records are complete. Also, it was recommended staff involved in the tenant move-in process review the requirements and revise their current process and procedures as needed to ensure the appropriate forms are completed correctly and kept in the tenant files going forward. Additional controls could include completing a checklist of required signed forms obtained during the move-in process. Action Taken: The first tenant listed above no longer resides at the project and a signed HUD model lease cannot be obtained. On November 7, 2023, the Property Manager at Sessions Village 202 obtained the missing signed documents for the second tenant listed above. The Property Manager at Sessions Village 202 will review the process and procedures in place, and implement controls to ensure the appropriate forms are completed correctly and kept in the tenant files going forward.

Finding 2023-003: Section 232 Loan – Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities Loan, ALN 14.129 Anticipated Completion Date: December 31, 2023 Recommendation: It was recommended management of Cheney Care Community review their internal controls over the cash and implement a policy to monitor the bank ratings quarterly for the financial institutions the project holds funds at. Action Taken: Cheney Care Community will review and update their policies and procedures to ensure the bank ratings for the financial institutions are monitored on a quarterly basis and the documentation is maintained.

Finding 2023-002: Section 232 Loan – Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities Loan, ALN 14.129 Anticipated Completion Date: September 30, 2024 Recommendation: It was recommended management of Cheney Care Community review their internal controls over the cash disbursement process with the necessary individuals involved in the process to ensure the implementation of general ledger account coding on cash disbursements is consistently performed going forward. Action Taken: The Executive Director and A/P Clerk agreed upon using certain general ledger account codes consistently for similar purchases from the same vendor. In Cheney Care Community’s accounting system, these agreed upon general ledger account codes have been pre-set as a default for certain vendors. When invoices are received that should be appropriately coded to this default general ledger account code, errors of not documenting the general ledger account code on the invoice are periodically made. Cheney Care Community will consistently perform the general ledger account coding internal control procedures on invoices going forward.

Finding 2023-001: Section 232 Loan – Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities Loan, ALN 14.129 Anticipated Completion Date: September 30, 2024 Recommendation: It was recommended management of Cheney Care Community review their internal controls over the financial reporting and close processes to determine whether additional controls over the preparation of the final trial balances and related schedules can be implemented to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP. Action Taken: Cheney Care Community will review their internal controls over the financial reporting and close processes to determine whether additional controls need to be implemented going forward.

Corrective Action Plan Finding: Finding 2023-003-Section III Summary Report Not on File-Reporting Condition: Federal regulations require that the Authority update its inventory of equipment and Office Equipment at least every two years. Corrective Action Planned We will comply with the auditor’s recommendation. Person responsible for corrective action: Skipton Evans, Executive Director Telephone: (918) 423-3345 McAlester Housing Authority Fax: (918) 426-3064 520 W. Kiowa McAlester, OK 74501 Anticipated Completion Date- June 30, 2024

January 24, 2024 United States Department of Health and Human Services Community Health and Wellness Center of Greater Torrington, Inc. and Affiliate respectfully submits the following corrective action plan for the year ended September 30, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: September 30, 2023 The findings from the September 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCIES Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), and Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 2023-001 Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Action Taken Education was provided to the staff who complete the applications, this included a quiz to measure the staff's knowledge of the process and mathematical calculations. Management developed a tool "How to Calculate Household Income for Processing Financial Assistance Applications" which includes step by step instructions for calculating household income. Prevention strategies have been implemented to prevent future occurrences of adverse events. Monthly audits of the calculation of annual income for a minimum of 10% of the total number of patients who have completed a financial assistance application are being performed. The manager of the population health department will report audit results quarterly at the continuous quality improvement (CQI) committee meeting. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Joanne Borduas, CEO at (860) 387-0425. Sincerely yours,