Corrective Action Plans

FINDING 2023-003 COMPLETION AND TIMELY FILING OF SINGLE AUDIT REPORTS Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and incurred significant issues with the implementation resulting in both the financial statement and compliance audits being significantly delayed. This resulted in the Hospital’s financial statements and compliance audits for June 30, 2023 reporting period not being filed within the required timeline. Views of responsible officials and planned corrective actions The financial statement and compliance audit will be filed with the Federal Audit Clearinghouse shortly after issuance. Anticipated completion date Ongoing

Section III –Federal Award Findings and Questioned Costs FINDING 2023-002 DEBT SERVICE COVERAGE RATIO COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. The delays had a negative impact on overall operating results as additional accounts receivable allowances for both contractual adjustments and bad debts were necessary at June 30, 2023. The negative impact on overall operations resulted in the Hospital not meeting the required debt service coverage ratio of 1.5. The Hospital did receive a waiver from the USDA regarding this noncompliance matter. Views of responsible officials and planned corrective actions The implementation of the new electronic health records created a delay in operational workflow processes which required vendor modifications and corrections to the system. This delayed submitting insurance claims for reimbursement which continued throughout fiscal year 2024. Operations have now stabilized and the debt service coverage ratio is expected to be in compliance in fiscal year 2025. Anticipated completion date Ongoing

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-012 CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: CACFP Subrecipient Reimbursements DHSS disagrees. The DHSS through BCFNA maintains a strong system of internal controls over meal reimbursements to CACFP facilities/sponsors to ensure costs are allowable and supported. The system is in compliance with Uniform Guidance and USDA program requirements. The system includes subrecipient monitoring based on risk assessments per the substance and spirit of Uniform Guidance, initial and ongoing training and technical assistance opportunities, and reviews of invoices. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This goes against the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher ranking requirements set forth by specific federal grant funders and awards. The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve its process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. The DHSS’ strong system of internal controls which is documented in the Nutritionist Manual is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. The increased claim testing and recoupment suggested by the SAO would create a significant barrier to participation for sponsors/facilities (many of which are small child care centers, day care homes, emergency shelters and adult day care centers) which is prohibited by USDA. Reviewing supporting documentation with every individual reimbursement claim at the time of submission as suggested in the finding is not feasible given the number of reimbursement claims processed monthly by program staff already functioning at capacity. Neither is it required by Uniform Guidance, the USDA or standard subrecipient monitoring procedures. The BCFNA already requires claims to be paid on a reimbursement basis rather than in advance and performs various reviews of the claims in CNPWeb, so the additional step of requiring supporting documentation with every reimbursement claim at the time of submission is unnecessary and is intended as a specific condition to remedy high risk subrecipients per 2 CFR 200.208. Furthermore, BCFNA offers technical assistance training and reviews in addition to regular monitoring reviews. In addition to the edit checks within the CNPWeb system which validate such things as capacity limits and licensing, BCFNA staff has, and continues to perform, additional verification such as spot-checks for inconsistencies (i.e. a greater number of enrolled participants as compared to licensed or total capacity or suspicious claim irregularities or patterns). Each claim submitted also requires a certification of truthfulness, accuracy, completeness with potential criminal, civil or administrative penalties in accordance with U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812. As noted by the SAO, the risk based monitoring approach implemented by BCFNA has been effective in identifying significant issues and claim errors in recent years. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required and in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies. For example, fifty five percent of the monitoring reviews completed during fiscal year 2023 were graded as a B or C and were give additional technical assistance and/or monitoring follow up as a result.

023-005 –ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third-party management company to ensure compliance with 24 CFP 960.259 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

2023-004 –REPORTING: PERFORMANCE REPORTING Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third-party management company to ensure compliance with 24 CFP 985 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

023-003 –ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third-party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2023 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 FINDING #2023-003: Section 202 Supportive Housing for the Disabled, Assistance Listing 14.157 CORRECTIVE ACTION TO BE COMPLETED: The Organization intends to apply for reinstatement of tax-exempt status. 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. Stewart Grounds, Chief Financial Officer of Arnold-Grounds Apartment Management & Affordable Housing Specialists, LLC.

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2023 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 FINDING #2023-002: Section 202 Supportive Housing for the Disabled, Assistance Listing 14.157 and Section 8 Housing Assistance Payments Program, Assistance Listing 14.195 CORRECTIVE ACTION TO BE COMPLETED: The Corporation completed and submitted the financials for audit for the year ended September 30, 2023. The financial data was submitted into the FASSUB system. 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. Stewart Grounds, Chief Financial Officer of Arnold-Grounds Apartment Management & Affordable Housing Specialists, LLC.

City staff will contact all Community Based Organizations (CBOs) that received Emergency Rental Assistance 2 funding to determine if they were required to complete a Single Audit per the Single Audit Act. This communication will include, if applicable, a request that they submit the organizations most recent audit for review by staff. Should a Single Audit identify any findings or other deficiencies, staff will ask the CBO to provide an update as to the status of the deficiency and if it has been appropriately addressed. Staff will document this communication in the electronic file of the CBO who was required to complete a Single Audit.

HSD acknowledges the identified weakness and implemented an updated Accounts Payable control procedure in 2024, that includes an additional standard monthly report and review process to ensure that reimbursements are processed with the required 30-day period.

Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Iowa Homeland Security & Emergency Management Federal Financial Assistance Listing #97 .039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Cooperative does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards (the schedule) being audited. We requested our auditors to assist with the preparation of the schedule and the accompanying notes to the schedule. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the schedule of federal expenditures of federal awards and the accompanying notes to the schedule. We requested that our auditors, Eide Bailly, LLP, prepare the schedule and accompanying notes. We have designated a member of management to review the drafted schedule and accompanying notes to the schedule. Responsible Individuals: Mark Vander Pol, Office Manager and Jeff TenNapel, General Manager Anticipated Completion Date: Ongoing

Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Iowa Homeland Security & Emergency Management Federal Financial Assistance Listing #97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: In three of three quarterly reports tested, the Cooperative improperly excluded information on the total funds expended to date lines for the federal, state, local and total categories. Corrective Action Plan: Future quarterly reporting will include reporting of total funds expended for applicable line items. General Manager will review quarterly submissions before submitting to Homeland Security. Responsible Individuals: Mark Vander Pol, Office Manager and JeffTenNapel, General Manager Anticipated Completion Date: October 2024

Corrective Action Planned: The Organization will draft, adopt, and implement a procurement policy. Anticipated Completion Date: September 17, 2024 Responsible Parties: Board of Directors

Finding Reference Number: 2023-005 Description of Finding: The organization does not have a control requiring internal review with signature approval of the Schedule of Expenditures of Federal Awards before submitting to external auditors. Statement of Concurrence or Nonconcurrence: The organization concurs with the audit finding. Corrective Action: The organization’s procedures regarding the Schedule of Expenditures of Federal Awards included the CFO create it and the CEO review it; however, it did not include a signature approval by CFO and CEO before submitting to external auditors. The organization has now included the signature approval in its procedures. Name of Contact Person: Cathy Scheirman CFO 520.623.5511 x248 cathys@tucsonymca.org Projected Completion Date: The corrective action plan has been completed.

Finding Reference Number: 2023-004 Description of Finding: The organization did not submit all reports required by the program. Statement of Concurrence or Nonconcurrence: The organization concurs with the audit finding. Corrective Action: The organization has submitted all late reports required by the program. All reports were not submitted as required by the program due to staffing changes within the organization and these reports did not get reassigned. The organization has assigned tasks regarding the submitting and reviewing of reports in a timely manner to multiple staff in order to prevent this from occurring in the future. Name of Contact Person: Cathy Scheirman CFO 520.623.5511 x248 cathys@tucsonymca.org Projected Completion Date: The corrective action plan has been completed.

Title of result and comment:: Frankton FINDING 2023‐006 Contact person Responsible for Corrective Action: First Name: Timothy Last Name: Detrick Contact’s Phone Number:: (765) 754‐7285 Contact’s Email Address:: tdetrickct@gmail.com Views of Responsible Official: We concur with the finding Description of Corrective Action Plan:: We have started a ledger that will keep track of all funds/grants that may not appear on our bank Rec. They will be check every month by the board to make sure they are accurate. Anticipated Completion Date: Year: 2024 Month: 6 Day: 14 If applicable: Document reason issue will NOT be corrected within 6 months::

FINDING 2023-06 Finding Subject: Child Support Enforcement - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance Summary of Finding: No documented oversight Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will meet with every department that has state grants and make sure that all invoices are double check for proper expenditures and have both employees sign off on the claim. Anticipated Completion Date: August 30, 2024

FINDING 2023-04 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: Reports were incorrectly completed, excluded amounts for the report period. Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor start signing off on all reports to verify the dates are correct for the reporting period. Anticipated Completion Date: August 30, 2024

FINDING 2023-003 Finding Subject: Town of Kingman Summary of Finding: The auditor found a lack of internal controls related to the grant agreement. Also, the RD-442-3 was not submitted. Contact Person Responsible for Corrective Action: Kendal Buker Contact Phone Number and Email Address: 765-397-3921; utilities@kingmanin.com Views of Responsible Officials: 􀀃 I concur with the finding of the lack of submission of the RD 442-3. Description of Corrective Action Plan: I will work with official from USDA-RD to complete the RD 442-3. Anticipated Completion Date: I anticipate to have the RD 442-3 completed by 12/31/2024. Sincerely, Kendal Buker Clerk-Treasurer Town of Kingman

Broomfield agrees with the auditors' recommendation to follow the documented internal control process or adjust process for over review of eligibility determinations. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

FINDING 2023-005 Finding Subject: COVID 19 Reporting Summary of Finding: We were required to submit quarterly P & E reports, ours were submitted in error Contact Person Responsible for Corrective Action: Amy Roberts Contact Phone Number and Email Address: ARoberts@dalevilleindiana.org 765-378-6288 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will create controls so reports will be submitted in accurate manner in the future Anticipated Completion Date: March 1, 2025

Since transitioning to the new Finance Director, HealthHIV continues to enhance the internal controls for properly reviewing each subaward. This was an infrequent occurrence and management will make sure to include pass-through federal funds on the SEFA report.

Federal Award Findings and Questioned Costs 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 Assistance Listing Numbers: 14.871 and 14.879 Noncompliance – N. Special Tests and Provisions – HQS Enforcement Non Compliance Material to the Financial Statements: Yes Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions for the Section 8 Housing Choice Vouchers Program Material Weakness in Internal Control over Compliance for Special Tests and Provisions for the Mainstream Vouchers Program. Criteria: HQS Enforcement. For units under HAP contract that fail to meet HQS, the PHA must require the owner to correct all life threatening HQS deficiencies within 24 hours after the inspections and all other deficiencies within 30 days or within a specified PHA-approved extension. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were failed inspections that did not pass reinspection within 30 days without penalty. Context: There were approximately one hundred and thirty-eight (138) Section 8 Housing Choice Vouchers' units and seven (7) Mainstream Vouchers' units with failed inspections. Of a sample size of fourteen (14) Section 8 Housing Choice Vouchers' and one (1) Mainstream Vouchers' failed inspections, two (2) and one (1) failed inspections, respectively, did not pass reinspection within 30 days. Housing assistance payments were not abated nor was the tenant relocated. Known Questioned Costs: Section 8 Housing Choice Vouchers $814 Mainstream Vouchers $1,608 Cause: There is a significant deficiency for the Section 8 Housing Choice Vouchers Program and a material weakness for the Mainstream Vouchers Program in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance and the Mainstream Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to HQS enforcement. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs to ensure that established internal control policies related to HQS inspections are being followed on a timely basis. Ann Malfavon, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

Finding 2023-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions. Criteria: Reasonable Rent. The PHA must do the following: The PHA must determine that the rent to owner is reasonable at the time of initial leasing. Also, the PHA must determine reasonable rent during the term of the contract (a) before any increase in the rent to owner, and (b) at the HAP contract anniversary if there is a 5 percent decrease in the published Fair Market Rent in effect 60 days before the HAP contract anniversary. The PHA must maintain records to document the basis for the determination that rent to owner is a reasonable rent (initially and during the term of the HAP contract) (24 CFR sections 982.4, 982.54(d)(15), 982.158(f)(7), and 982.507). Condition: There were approximately one hundred and sixty-three (163) newly leased units. Of a sample size of sixteen (16) newly leased units, three (3) unit's documentation of reasonable rent did not include the minimum required number of comparable units of three (3), as stated in the Authority's Section 8 Administrative Policy. Known Questioned Costs: $21,531 Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to reasonable rent. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to reasonable rent. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Ann Malfavon, Executive Director, is responsible for implementing this corrective action by December 31, 2024.

Finding 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions. Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Of a sample size of fifteen (15) Section 8 Housing Choice Vouchers' new move-ins, one (1) could not be traced to the Authority's waiting list. Known Questioned Costs: $4,336 Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Ann Malfavon, Executive Director, is responsible for implementing this corrective action by December 31, 2024.