Corrective Action Plans

Finding Number: 2022-002 Condition: The Corporation used surplus cash calculated at June 30, 2021, to make a payment on a residual receipts note without prior approval from HUD. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management deposited the surplus cash amount of $28,666 into residual receipts on September 23, 2022.

CORRECTIVE ACTION PLAN November 30, 2022 United States Department of Health and Human Services Generations Family Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2022 The findings from the June 30, 2022 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 DEFICIENCY 2022.001 - Sliding Fee Scale Discount 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: Three new internal controls will be implemented immediately: 1. Upon adding a new charge to the system, the Director of Patient Revenue will post the charge into a test patient account to confirm that the standard fee and slide rates match those entered on the fee schedule. Set up will be verified by the Billing Manager. 2. At the annual review and/or revision of the Agency's fee schedule, the Billing Manager will assist the Director of Patient Revenue in reviewing every charge on the updated/approved year's fee schedule to confirm the rates and slide assignment match the Fee Schedule. 3. A quarterly audit of underinsured and self-pay patients will occur to review that adjustments are correct per agency policy for slide documentation. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please contact me at dsavie@genhealth.org or 860-456-6271. Sincerely, Debra Daviau Savoie, MBA Chief Financial Officer

Item 2022-003: Compliance with Client Placement on the Sliding Fee Scale for the Health Center Cluster Program Corrective Active Plan Administration will set reminders for themselves to look for the new release of the Federal Poverty Guidelines each week beginning January I of the new year. The SFS will be updated immediately with the most current Federal Poverty Guidelines as well as updating our patient software to reflect the most current FPG. Estimated Completion Date: Ongoing Responsible Party Contact Information: Jolene Busby Jbusby@hcmtx.org 936-591-8380 Ext 109

Item 2022-002: Compliance with Client Placement on the Sliding Fee Scale for the Health Center Cluster Program Implementation of Phreesia software will flag any placement discrepancies. Front Desk Staff has completed and signed off of an intensive two-week training. All front desk has been properly trained and will have ongoing and refresher training as needed. Front Desk Staff are required to check their work at the end of the day. We have a dedicated staff member who double checks each SFS registration. The corrected registration packet is returned to the corresponding Office Manager who reviews the corrections with the Front Desk staff member. The Front Desk staff member will make the noted corrections themselves. Front Desk will experience disciplinary action for continued incorrect placements such as write ups, or termination. We conduct an Eligibility Audit on a monthly basis. A report consisting of errors by facility as well as the employee responsible for the errors will be given to office managers and key administrative staff. The information collected is reported during our monthly CPI Committee meetings. Estimated Completion Date: Ongoing Responsible Party Contact Information: Jolene Busby Jbusby@hcmtx.org 936-591-8380 Ext 109

2022-003 Child Nutrition Cluster ? Assistance Listing No. 10.553, 10.555, & 10.559 Recommendation: We recommend the District update policies related to school nutrition reporting to ensure they have appropriate reviews that would prevent or detect errors or fraud. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The School Nutrition Supervisor and Supervisor of Finance approve all expense transactions on an ongoing basis. By the third week of each month, a designated Accounting Assistant runs financial reports used to prepare the monthly school nutrition program claims. The Budget Manager has not approved the claims prior to submission, which has been the practice for all other District programs. Effective July 1, 2022, the accounting assistant schedules a meeting with the School Nutrition Supervisor to review each monthly claim, clarify questions and adjust if needed, prior to submitting a claim to DPI. Name(s) of the contact person(s) responsible for corrective action: Davita Jo Molling, Supervisor of Finance Planned completion date for corrective action plan: July 1, 2022

Recommendation: In conjunction with Rivendell Homes, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, Rivendell Homes, Inc. should pay the invoice amount on a monthly basis. Action Taken: The auditors have worked with the auditee in conjunction with their local HUD field office to determine a course of action. All parties agreed with the recommendation to avoid unauthorized distributions.

Response to 2022-002 We agree there were errors in the calculation of lost revenue. The PRF guidance on reporting changed/updated several times over the course of 2 years and some requirements were missed right before the reporting was due. However, the organization?s eligibility did not change and the funded amount was fully supported by the actual loss of revenue calculation required by DHHS. Management will closely monitor future grant reporting. Contact person responsible for corrective action: Eden Ballatan, CFO Anticipated Completion Date: 3/31/2023

Name of Auditee: Roncalli Apartments, Inc. HUD Auditee Identification Number: 024-EE085 Name of Audit Firm: Otis Atwell Period Covered by the Audit: For the Year Ended June 30, 2022 A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations: 1. Finding 2022-001: a. Comments on the Finding: We concur that the required deposit of surplus cash to the residual receipts account that was to be made in FY 2019 was not made in either FY 2019, FY 2020, FY 2021, or FY 2022, resulting in underfunding of the residual receipts account of $38,308. b. Action Taken or Planned on the Finding: The project had insufficient cash to make the required deposit. Management is in consultation with the HUD representative for an acceptable solution with anticipated resolution by October 31, 2022. B. Status of Corrective Actions on Findings Reported in the Prior Audit Schedule of Findings, Questioned Costs, and Recommendations: 1. Finding 2021-001: The project had insufficient cash to make the required deposit. Contact Person: Mike Pease, Executive Director, DBH Management, Inc.

Name of Auditee: St. Francis Apartments, Inc. HUD Auditee Identification Number: 024-EE142 Name of Audit Firm: Otis Atwell Period Covered by the Audit: For the Year Ended June 30, 2022 A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations: 1. Finding 2022-001: a. Comments on the Finding: We concur that the required deposit of surplus cash to the residual receipts account that should have been made in FY 2019 was not made in either FY 2019, FY 2020, FY 2021 or FY 2022, resulting in underfunding of the residual receipts account of $22,643. b. Action(s) Taken or Planned on the Finding: The project had insufficient cash to make the required deposit. Management is in consultation with the HUD representative for an acceptable solution. B. Status of Corrective Actions on Findings Reported in the Prior Audit Schedule of Findings and Questioned Costs: 1. Finding 2021-001: Unresolved. Management is in consultation with the HUD representative for an acceptable resolution. Contact Person: Mike Pease, Executive Director, DBH Management, Inc.

Finding Type: Immaterial noncompliance with major program requirements Title and CFDA Number of Federal Program: 14.157 Supportive Housing for the Elderly (Section 202) Capital Advance Finding Resolution Status: In Process Information on Universe and Population Size: All replacement reserve deposits were audited which totals twelve monthly deposits Sample Size Information: All replacement reserve deposits were audited which totals twelve monthly deposits Identification of Repeat Finding and Finding Reference Number: n/a Criteria: The Corporation should have made 12 monthly deposits of $11,000 into the reserve for replacements account as required by the regulatory agreement. Statement of Condition The Corporation failed to make two of the required reserve for replacements deposits in the current fiscal year. Cause: The Corporation was aware of a cash shortfall and requested a retroactive suspension of deposits from HUD which was not approved. The Corporation did not make the required deposits per the regulatory agreement due to cash shortfalls. Effect or Potential Effect: The replacement reserve account was underfunded in the current fiscal year by $22,000 Auditor Noncompliance Code: N Reserve for replacements deposits Reporting Views of Responsible Officials: Management agrees with the underfunded amount at September 30, 2022. Context: The replacement reserve deposit was not able to be made due to cash flow shortages. Recommendation: All required deposits should be made in accordance with the regulatory agreement. Management should continue to seek relief from the requirement with HUD in the form of a suspension in deposit or change of the deposit amount Auditor's Summary of the Auditee's Comments on the Findings and Recommendations: Management should make the required reserve for replacements deposits in the current fiscal year. Response Indicator: Agree Completion Date: September 30, 2023 Response: Management acknowledges noncompliance in the current fiscal year and has taken measures to rectify the cash shortfall. Management has made two deposits during the year ended September 30, 2023.

Fiscal Year Ending (?FYE?) 2022 Audit Response Corrective Action Plan Finding 2022-001 ?Housing Choice Voucher Program Tenant Files ?Eligibility-Internal Control over Tenant Files-Noncompliance and Significant Deficiency? RHA Response The Raleigh Housing Authority and Leased Housing Department acknowledge and accept that there were a significant number (27 files of 120 reviewed) of past due annual recertifications during the FYE 2022 review period. The abundance of outstanding annual re-exams started mid-2020. During the height of the Coronavirus pandemic, we changed our process for in-person appointments for completing the Annual Re-exam paperwork to mailing the packets to the families. This caused us problems with obtaining the necessary documentation for processing the recertifications. Also, other agencies that provided the required income/household verifications were closed and families were unable to obtain the required information. The Leased Housing Department modified its procedures and accepted what was minimally allowable based on HUD?s guidance. The staff worked diligently with the families that had outstanding documents to avoid terminating the families which would have likely resulted in homelessness during a national pandemic. There was a moratorium in place that prevented evictions of tenants during that time also. The Leased Housing Department also had a number of vacant positions during this review period. The Client Manager worked a large portion of the previous review period FYE 2021 with two full-time staff person and 2 temporary employees during part of that time. In a department that normally worked with 4 full-time trained employees, this staff reduction and having to train temporary employees slowed the process down. The Leased Housing staff has put the following plan in place to catch up on our annual recertifications and to complete timely moving forward: ? Additional Staffing positions to hire and train o one (1) client specialist ? this team gathers all the required documents and confirms completed properly o two (2) account specialist ? this team calculates the annual recertification income and generates the 50058s transmitted to HUD ? Current staffing positions reassigned to assist including: o 2 Temporary employees o Compliance Officer o Contract Specialist o 2 File Review Specialist ? from Finance Compliance team o Client Manager ? Contract with an outside service provider to help with the volume - We have received quotes from both Nan McKay and Quadel and will look to procure within the next few weeks to help us move through the volume of past due files ? A new tracking system for Annual recertification has been implemented to ensure the number of Annual Re-exams that need to be processed weekly are meet to meet our monthly goals. ? The Client Manager and the Assistant Director of Leased Housing will meet weekly to discuss the progress and work together to meet the monthly lease-up goal. ? Voucher families will be scheduled to come-into the office to pick-up the annual recertification packet and speak to their assigned specialist if needed. ? Voucher families are notified 90-days prior to their annual recertification date and given a time and date to submit the requested documents. If requested documents are not received, the voucher family will receive a pre-term letter with a scheduled appointment to come into the office and meet with the assigned Client Specialist. They will only be given 7-business days to return requested documents after this meeting. If not received the family will be issued a letter of termination. Anticipated Completion: 12/31/22 Person Responsible: Liz Edgerton Respectfully, Liz Edgerton Interim Director

2022-005 Reporting Management Views and Opinion UM management agrees that the PRF Period 1 reporting submission was subsequently revised to remove $14,854,235 of Other Provider Relief Fund Expenses. The Other Provider Relief Fund Expenses removed from the Period 1 submission were allowable. However, given the dynamic reporting guidance and best practices circulated subsequent to the Period 1 reporting submission, it was determined by management to utilize lost revenues to support the PRF funding rather than expenses incurred. Corrective Action Plan UM management believes this to be an isolated incident due to the novel COVID-19 virus. While management will work to avoid the need for revised reporting submissions, management will continue to ensure the reports align with the latest guidance and best practices. Timeline for Action Plan UM management identified the need for a revised report and has already completed the revised submission. Responsible Individuals Charity Fannin, Chief Accounting Officer Craig McAllister, Assistant VP Risk Management

Finding Number: 2022-002 Title and Program Name: HUD Title 24 Part 982 - Section 8 Housing Choice Vouchers Program -CFDA No. 14.871 Category and Award No.: Internal Controls-Eligibility Form HUD-92006, Supplement to Application for Federally Assisted Housing. Section 8 - Award # RQ006 Management Response and/or Corrective Action: The Municipality of San Juan concurs with the finding. As part of the corrective action plan, the Housing Department incorporated the Form HUD-92006 into the system so that it could be included as part of the recertification documents kit. The forms can be filed on the participants case on paper and in a digital form.. Assigned Responsibility: Isamar Pina Rivera (787)480-5500 Director of Housing Department Status: June 30, 2023

Finding Number: 2022-001 Title and Program Name: HUD Title 24 Part 982 - Section 8 Housing Choice Vouchers Program -CFDA No. 14.871 Category and Award No.: Internal Controls ? Special Test - Housing Quality Standards Inspection - Housing Quality Standards Enforcement. Section 8 - Award # RQ006 Management Response and/or Corrective Action: The Municipality of San Juan concurs with the finding. As part of the corrective action plan, the Housing Department appointed an Area Supervisor in January 2023, to oversee the Compliance of Eligibility requirements. The department established as internal control procedures to monthly issue the inspections report to: - verify any backload case of recertifications to be able to reschedule on the recertification term period. -or cases suspended due to deficiencies (HQS) and enforce the repairs or give a new voucher to the affected families. Assigned Responsibility: Isamar Pina Rivera (787)480-5500 Director of Housing Department Status: June 30, 2023

Finding Number: 2022-003 Title and Program Name: Section 8 Project Based Cluster-CFDA No. 14.856 Category and Award No.: Internal Controls-Eligibility - Notice of Re-certification sent within 90 to 120 days Awards No. RQ006MR0001, RQ006MR0003 & RQ006MR0004 Management Response and/or Corrective Action: The Municipality of San Juan concurs with the finding. As part of the corrective action plan, the Housing Department reemphasized its technicians and staff in writing on the importance of filing copies of recertification letters once submitted and documenting in the case file any type of communication with the participant. Also, as part of the internal controls the Department will require quality control inspection on a weekly basis once the technicians perform their scheduled recertifications. Assigned Responsibility: Isamar Pina Rivera (787)480-5500 Director of Housing Department Status: June 30, 2023

Finding 2022-001: For the year ended December 31, 2021, the Corporation did not submit the Data Collection Form to the Federal Audit Clearinghouse in the time period required by Uniform Guidance. Comments on the Finding and Each Recommendation: The Corporation should submit the Data Collection Form to the Federal Audit Clearinghouse within the required time period. Management agrees to the finding and recommendation. Action(s) Taken or Planned on the Finding: The Data Collection Form was submitted to the Federal Audit Clearinghouse on October 11, 2022, no further action is required.

Finance staff will review trial balances and expenditures versus expected program funding quarterly and at year end internally and with department?s grant coordinator. This will begin August 1, 2023, followed by another year end meeting November 1, 2023. Additionally, expected new internal new hire will add an extra layer of review to the process.

CORRECTIVE ACTION PLAN March 27, 2023 U.S. Department of Housing and Urban Development: National Church Residences Chillicothe Land Holdings, Inc. respectively submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: HW&Co. 460 Polaris Pkwy., Suite 300 Westerville, OH 43082-8213 Audit period: January 1, 2022 through December 31, 2022 The finding from the December 31, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT No findings were noted. FINDINGS?FEDERAL AWARD PROGRAMS AUDIT U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Federal Assistance Listing Number 14.129 ? Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities 2022-001 ? Federal Assistance Listing Number 14.129 ? Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities Recommendation: The affiliated lessee (Traditions at Chillicothe) received a level K deficiency during a complaint/infection control survey conducted by the Ohio Department of Health (ODH) completed on February 8, 2022. A level K deficiency is considered a pattern of immediate jeopardy to resident health or safety. The level K deficiency was not reported to HUD and the lender within the required 2 business days of receiving notice of the violation. Management is required to notify HUD and the lender, which was completed on March 23, 2023. Action Taken: Management is required to notify HUD and the lender, which was completed on March 23, 2023. Management of the affiliated lessee (Traditions at Chillicothe) agrees with the finding. The deficiency is an isolated incident and is not reoccurring. The affiliated lessee has implemented a sufficient plan of correction in order to mitigate the deficiency and all situations alike moving forward.

2022-029 Oregon Housing and Community Services Ensure accessible documentation to evidence compliance with program requirements Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 21.023 Emergency Rental Assistance Program (COVID-19) Federal Award Numbers and Years: ERA 1, 2021 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles; Eligibility Type of Finding: Material Weakness Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.302(a); 2 CFR 200.332(a)(5) Department management is responsible for communicating to subrecipients that they are required to permit the department and auditors access to their records as necessary to ensure the department is compliant with program requirements. To ensure compliance with program requirements, subrecipient records must also be sufficiently detailed. The department passed through $140 million phase one program funds to community action agencies (subrecipients) to provide program delivery. The department performed limited fiscal monitoring during the audit period which included procedures to address compliance with activities allowed and allowable cost requirements for administrative costs. The department did not perform any program monitoring during the audit period which primarily addresses compliance with eligibility requirements. To determine whether the department complied with program requirements for the fiscal year, auditors attempted to reconcile detailed subrecipient ledgers with the intent of selecting and testing sample items at each individual subrecipient organization. We noted issues with two individual subrecipients, resulting in an inability to perform testing procedures over a total of $21,438,521 in program expenditures. For the first subrecipient we were able to reconcile their detailed ledgers to the department?s financial records, however their detailed ledger included pass-through payments to a third organization for program delivery. As a result of the combination of direct and pass-through payments, we were unable to obtain sufficiently detailed data that also reconciled to the department?s financial records to select individual transactions for testing. This subrecipient represents $19,877,962 of the unaudited expenditures. For the second subrecipient we were able to reconcile their detailed ledgers to the department?s financial records and select administrative and program transactions for testing. However, the subrecipient was unresponsive to documentation requests to substantiate expenditures. This subrecipient accounted for $1,560,559 of the unaudited expenditures. We recommend department management obtain and reconcile sufficiently detailed subrecipient ledgers and support to substantiate expenditures to allow for fiscal and program monitoring to ensure subrecipients are administering program funds in accordance with program requirements. MANAGEMENT RESPONSE: We agree with this recommendation. To effectively deliver much needed funds to maintain the housing stability of tens of thousands of Oregonians on the brink of experiencing homelessness during the pandemic, agency staff raced to stand up a first-of-its-kind ?single entry point? program for Oregonians to apply for assistance regardless of zip code. In our efforts to focus on speed we acknowledge that there was insufficient planning and capacity to stand up a large-scale emergency program including sufficient assurances our subrecipients could generate evidence of compliance with program requirements including transaction level details to assist with reconciliation. Oregon?s experience is in line with national findings. According to the January 2021 research brief conducted by the National Low Income Housing Coalition around key program challenges with administering emergency rental assistance programs. Survey respondents listed the two most common limitations to be staff capacity and the completeness of applications. Many agencies leaned on whatever local capacity was available to develop programs, review, and process applications, make payments and conduct outreach. Corrective action plan: OHCS had significant compliance monitoring staff turnover in FY22 leading to incomplete subrecipient monitoring reviews. OHCS completing these reviews would?ve ensured subrecipients had adequate time to produce necessary documentation to evaluate compliance, or if not, subrecipients would?ve been required to take corrective actions. For fiscal compliance, OHCS hired a contractor to perform fiscal monitoring of federal funded Grantees. OHCS also hired fiscal staff to pre-FY22 levels, fully trained them, conducted coordinated working sessions, and reached out to the CAA network for discussions on improving processes. OHCS continues to work with the contractor for much needed assistance in monitoring of back log while internal staff move forward to allow for all monitoring to be back on schedule and coordinating both fiscal and program compliance during future fiscal years. Program compliance employees have been hired and compliance efforts are underway. All providers will have internal compliance visits at regular intervals to ensure they have necessary documents and eligibility is being determined in compliance with program requirements. Additionally regular and ongoing check ins and trainings are being offered by program staff. Finally, program compliance teams are working with the Finance compliance team as well as a contracted expert to develop systems and processes in alignment with the Finance compliance team. As a result of program compliance efforts, a risk evaluation is being developed and incorporated into future contracting decisions. Efforts in hiring and systemic investments in infrastructure, processes, and procedures in addition to partner communications have taken place to ensure agency readiness in the event another emergency occurs. As part of our commitment to continual learning, our OHCS research team is collaborating closely with university and national partners to analyze our ERA program data and findings to see what themes emerge for improvement both nationally and in Oregon. Anticipated Completion Date: December 31, 2023 Contact: Jill Smith, Director of Housing Stabilization Division and Dean Criscola, Controller

2022-023 Oregon Housing and Community Services Controls need to be strengthened to ensure the required expenditures are spent timely Federal Awarding Agency: U.S. Department of Housing and Urban Development Assistance Listing Number and Name: 14.231 Emergency Solutions Grants Program (COVID-19) Federal Award Numbers and Years: E-20-DW-41-0001, 2020 (COVID-19) Compliance Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: CPD 21-08(III)(B)(2)(c) Emergency Solutions Grants-Cares Act (ESG-CV) funds were intended to be spent quickly on allowable activities to address the public health and economic crisis stemming from COVID-19. At least 20% of the total award was to be spent by September 30, 2021. Based on our testing, the department was not adequately tracking the percentage or timeliness of expenditures and did not reach the expenditure milestone. Approximately 18% of the total award was expended by September 30, 2021. If the 20% milestone is not achieved, HUD is able to recapture up to 20%, or $11.2 million, of the total award. We recommend agency management develop procedures to ensure grant expenditures are adequately tracked and spent within the required time period. MANAGEMENT RESPONSE: We agree with this recommendation. OHCS did reach out to HUD and requested an extension of the obligation deadline, however, did not receive direct approval. Going forward, OHCS will ensure grant management reports and time-bound expenditure plans are consistently maintained and followed for all OHCS grants and grantees. In addition, OHCS will perform due diligence and ensure follow-up occurs when needed and documentation is retained to support our efforts. Anticipated Completion Date: December 31, 2023 Contact: Beth Brown, Accounting Manager

2022-059 Department of Human Services Ensure issued benefits are accurate Federal Awarding Agency: U.S. Department of Agriculture Assistance Listing Number and Name: 10.542 Pandemic EBT Food Benefits (COVID-19) Federal Award Numbers and Years: Not available (COVID-19) Compliance Requirement: Activities Allowed or Unallowed Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: $3,692,215 (known); $13,554,666 (likely) (COVID-19) Criteria: Public Law 116-127; 2 CFR 200.303 The federal requirements for the Pandemic EBT (P-EBT) program require state agencies follow their approved state plan. Part of Oregon?s simplifying assumptions in their state plan was that the benefit amount was determined at the school level, not the individual level, based on the school?s operating status, for October 2020 ? May 2021. As part of Oregon?s Ready Schools, Safe Learners program, schools were required to weekly report their operating status/instructional model to the Oregon Department of Education (ODE). In fiscal year 2022, the Department of Human Services (department) paid retroactive P-EBT benefits for children related to the 2020-2021 school year. This sample population consisted of institutions (schools and other educational facilities) and months in which children at the institutions received benefits, totaling $391 million. We selected a random sample of 40 institutions and a random month to determine if the benefits provided to the children, based on the status reported by the institution, were accurate. We identified 4 institutions, for April/May, where the benefit paid status of the institution was not the same as reported by the institution to ODE. In all 4 cases, the benefits paid were at a higher level resulting in questioned costs of $38,931 and likely questioned costs of $9.2 million. One of the simplifying assumptions for the P-EBT program, approved in Oregon?s state plan, was ?Oregon will have a limited reconsideration process to revisit benefit allotments at a school level.? However, the department allowed institutions to update their status without additional review, explanation, or documentation. The department could not provide the auditors any support for the changes made by the institutions. Furthermore, the Oregon Governor issued a directive to schools, on March 5, 2021, to begin a phased approach to require all public schools to provide in-person instruction through either a fully on-site or hybrid model on or before the week of April 19, 2021, for all schools. Although benefits issued continued to decrease as the school year end approached, in May 2021, 26% of the institution?s benefits paid were for fully virtual totaling $17 million. We judgmentally selected 36 institutions classified as fully virtual in May with benefits totaling $7.9 million. For 25 institutions, the benefit paid status did not agree to the status reported by the institution to ODE resulting in questioned costs of $3,653,284 and likely questioned costs of $4.4 million. We recommend DHS perform review to identify any additional discrepancies between benefits paid and the institutions reported status, to determine if payments were appropriate, and communicate with the federal awarding agency to determine if repayment is necessary. MANAGEMENT RESPONSE: We respectfully disagree with the findings that schools were not able to directly update their learning mode according to the guidance provided in the P-EBT state plan. The department has included emails and documents that support the actions/decisions taken in the delivery of the Oregon P-EBT school year 2020-2021 state plan was in accordance with federal approval from Food and Nutrition Service (FNS). According to the USDA FNS approval letter received on May 7, 2021, and posted to the FNS website, FNS confirms that Oregon will ?develop(ed) a centralized database to collect student eligibility information and school status? to determine the monthly benefit level for each school (6th bullet on page 2). This information is also confirmed in email correspondence with FNS on April 29, 2021, and May 3, 2021. Within the email the Department details that Oregon will develop a database to collect school status, this is then confirmed by FNS. As part of Oregon?s federally approved simplified assumptions, the state plan allows the school points of contact to update their predominate learning model for each month of the 2020-2021 school year, which may be different than the Ready Schools, Safe Learners (RSSL) Weekly Status Report. An email communication was shared with all identified school points of contact on June 28, 2021. This email requested that school points of contact update their schools predominate learning mode into the Oregon School Meals Benefit (OSMB) system used by the Oregon Department of Human Services to issue P-EBT benefits no later than July 13, 2021. Information reported through the RSSL weekly status report was used to determine the predominate learning mode only in the event that the school point of contract did not update a learning mode manually within OSMB prior to July 13, 2021. On May 9, 2023, the P-EBT policy team confirmed school operating status during the selected months with 5 schools for SOS audit. Email responses from the schools are summarized below: ?See Corrective Action Plan for Table? At the recommendation of the auditors the Department has reached out to FNS Child Nutrition Program about the finding and we are waiting for a response. Anticipated completion date: N/A Contact: Heather Miles, SNAP, CSFP, and TEFAP Program Manager

1. Correcting Plan CHEDA staff are aware of Voucher for Payment of Annual Contributions and Operating Statement report monthly to HUD via the Voucher Management System (VMS) requirements and will implement appropriate review of statements prior to submission. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Ensuring CAP Karie Kirschbaum ? Executive Director 4. Planned Completion Date for CAP Immediately. 5. Plan to Monitor Completion of CAP The Executive Director will monitor completion of the CAP.

1. Correcting Plan CHEDA staff are aware of income eligibility documentation and will implement an internal control process. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding.3. Official Responsible for Ensuring CAP Karie Kirschbaum ? Executive Director 4. Planned Completion Date for CAP Immediately. 5. Plan to Monitor Completion of CAP The Executive Director will monitor completion of the CAP.

1. Correcting Plan CHEDA staff are aware of allowable cost proper documentations, and will implement an internal control process. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Ensuring CAP Karie Kirschbaum ? Executive Director 4. Planned Completion Date for CAP Immediately. 5. Plan to Monitor Completion of CAP The Executive Director will monitor completion of the CAP.

The December 2021 REAC inspection found multiple deficiencies at North General / Foundation House East. Seven Health and Safety violations were identified and resolved within 72 hours. In addition, all smaller repairs were made within two weeks following the inspection. Several major capital repairs were also cited in the REAC inspection, particularly the roof, the facade, windows and trash compactor. These repairs are extensive and required additional funding. In the months following the REAC inspection, Harlem United senior management prioritized identifying new funding specifically for major capital projects in supportive housing buildings. Additional funding was granted by HUD and became available to North General / Foundation House East in spring 2022, and soon after bids were obtained from vendors. Repairs to the roof, facade, windows and compactor are scheduled to begin in July 2023. In addition, facility staff work with program staff to identify and address minor repairs in tenants? units and in common areas on an ongoing basis.