Corrective Action Plans

The City will work with all HOPWA subrecipients to ensure that a complete and accurate CAPER is completed in the appropriate format as required by HUD. This will include a focus on inputting the correct (eg, actual expended vs. award amount) funding amount.

The City will use the contract start date (7/1) as the Obligation date, and will submit the FFATA report accordingly.

Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment. Four of the 19 sampled payment requests were received or processed after receipt of the FY22 audit findings, and all of those requests for reimbursement were paid within 30 days of receipt.

CSFO will begin reviewing and signing the Prior Period Comparison Report before payroll is ran each month.

Policies and Procedures for Federal Awards Corrective action planned: Management will consult an advisory firm to assist with providing sample policies and procedures for tracking and usage of federal awards. Management will review and implement policies and procedures no later than 60 days to ensure compliance with tracking and usage of federal awards. Anticipated completion date: June 30, 2024 Contact person responsible for corrective action: Angela St. John, CFO

Finding No. 2023-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material non-compliance and Material Weakness in Internal Control over Compliance This is a repeat finding of 2022-002 from September 30, 2022 (Originally reported as finding 2019-001 from September 30, 2019) Statement of Condition: Out of a total tenant population of approximately 1,142 vouchers, 25 files were selected for testing, and the following errors were discovered. • 1 tenant file had the following error: o The utility allowance was miscalculated by $32 (overstatement). The two-bedroom column utility rates were used when the 1-bedroom column utility rates should have been used. Correcting this error would cause which the HAP rent to decrease from $762 to $731. • 1 tenant file had the following error: o An EIV form was either not run or has been misplaced for the tenant’s annual recertification period. • 1 tenant file had the following error: o The utility allowance was miscalculated by $23 (understatement). The 2022 utility allowance schedule was used when the 2023 utility allowance schedule should have been used. Correcting this error would cause the HAP rent to increase from $494 to $517. • 1 tenant file had the following error: o The tenant did not check the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen. However, based on the birth certificate the tenant is a U.S. citizen. • 1 tenant file had the following error: o An EIV form was either not run or has been misplaced for the tenant’s annual recertification period. • 1 tenant file had the following error: o The tenant’s asset income was miscalculated. Correcting this error would increase the HAP rent by $4. • 1 tenant file had the following error: o The 50058-form reported childcare income support of $6,000, however, the support for the childcare income showed $5,800. Correcting this error had no effect on the HAP rent. • 1 tenant file had the following error: o No support for the tenant’s wage income of $23,296 on the 50058 form. Appears to be reported correctly, since the EIV shows an amount that approximates the tenant’s wage income of $23,296. Nonetheless, there needs to be support in the tenant file for the wage income. o Missing HAP contract. • 1 tenant file had the following error: o The utility allowance was miscalculated by $19 (understatement). Correcting this error would cause the HAP rent to increase from $924 to $943. In addition to the above, we noted the following during our new admissions testing (out of a total of 161 new admissions, 17 files were selected for testing.): • 1 tenant file had the following error: o The tenant did not check the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen. However, based on the birth certificate the tenant is a U.S. citizen. • 1 tenant file had the following error: o HAP contract was not executed timely (within 60 days). • 1 tenant file had the following error: o The voucher extension date was not documented on the voucher. • 1 tenant file had the following error: o The request for tenancy addendum was executed (dated) two days after the voucher extended due date. o The unit size on the voucher did not agree to the family voucher size on the 50058 and the wrong payment standard was applied to the tenant. 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: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income, and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an “Other Adult” packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant's file. The Counselor's caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors' strength and weaknesses and to determine if additional training and/or monitoring is needed. A Counselor has been assigned to only handle specialty vouchers (EHV, VASH, Homeownership, and FUP). The FSS Coordinator is responsible for the full management of HCV FSS participants. The Authority has hired an Intake Housing Counselor/Portability Specialist to focus on determining eligibility of new applicants pulled from the waitlist and to manage the waitlist. This Counselor also determines eligibility and compiles document packet for portability clients. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor's processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. All new admissions move-in files are now being to the Housing Programs Director for review prior to approval. A sample size of 15% is now being reviewed at the end of month by the Compliance Director and Housing Programs Director for compliance. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV Counselors, except the new Intake Counselor, have attended Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training and successfully passed the certification exam. Effective Date: June 21, 2024 Contact Information Gwendolyn B. Dawson, CEO Ocala Housing Authority 1629 NW 4th Street Ocala, Florida 34475 (352) 369-2636

Finding 2023-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Medical Center had a revenue calculation error of $192,326 on the HHS special report with no impact to the actual lost revenues as the quarter with the error did not result in any lost revenue being reported (i.e., lost revenue claimed was accurate on the HHS special report but key line items were misstated). Responsible Individuals: Cathy Huss, CFO Corrective Action Plan: All tracking documents that have calculations will be reviewed by the CEO if the CFO compiles for accuracy and vice versa. The reviewer will sign off by email that they have reviewed and agree with the calculations. The calculation of lost revenues will be updated with our next reporting to HHS. Anticipated Completion Date: 6/30/2023

Condition: The District recorded a duplicate deposit of $133,868 in federal funds to the general ledger. Corrective Action Planned: The Central Office will ensure that the general ledger transactions are reconciled to the final financial reports before submission to DESE. Anticipated Completion Date: June 30, 2025 Contact: William Plunkett, Director of Finance

Corrective Action Plan The University will establish processes and policies to pull attendance reports after census date of each term/semester for any students who receive Title IV aid and are identified as non-attendance. We will use this information to recalculate Federal Pell Grant and Federal Direct Student Loan awards based on enrollment or change in enrollment status. At the end of each term/semester, the University will review F/FA grades for any student who receives Title IV aid and will adjust their aid accordingly to comply with Title 34 of the Code of Federal Regulations, Part 690.80. In addition, we are currently reviewing F/FA grades for the 2023-2024 academic year. Anticipated Completion Date: June 2024 Contact Person(s): Alicia Bookout Associate Vice Chancellor, Financial Aid

Condition: Tiered environmental reviews were not completed for the City’s emergency and minor home rehabilitation activities. The environmental review for major rehabilitation activities was incomplete and was not submitted in the HEROS system. Planned Corrective Action: This finding was partly due to the staff members' need for more training. HUD mandated that staff undergo training on the HERO system as part of the resolution. The extra training enabled staff to revisit and finalize previous environmental reviews, ensuring compliance with environmental review regulations. After a follow-up with HUD, the agency considers the issue resolved. Going forward, environmental reviews will be conducted once every five years, which is in compliance with HUD regulations. Tiered reviews will be added as projects are completed. Our rehab specialist will be responsible for entering HEROs, and the division director will be responsible for public notices and hearings. Contact person responsible for corrective action: Madison Bjertness Anticipated Completion Date: 5/22/2024

Eligibility – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: CLA recommends management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: : Following CLA’s recommendation, SVP of Housing Choice will audit a random sample of 10 files on a monthly basis. Agency working with Human Resources contractor to fill open staff positions Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

Finding 2023-003 Finding Summary: The Organization did not have adequate controls to document the review and approval of qualified invoices prior to payment. Responsible Individuals: CFO (Amanda Moon), CEO (Karen McCandless) Corrective Action Plan: Ensure that all invoices are approved as eligible program costs prior to issuing payment. Anticipated Completion Date: 7/1/2024

To address the discrepancy and ensure accurate capital asset records, the technology director will do a: 1. Physical Re-inventory: Conduct a comprehensive physical re-inventory of all capital assets, focusing on areas where misplaced items are suspected. 2. Records Reconciliation: Compare physical inventory findings with existing records. Identify and rectify any errors in location data, descriptions, or asset status. 3. Asset Tracking Improvement: Implement measures to improve asset tracking, such as: Updating asset tags with clear and accurate identification information; doing a major search to retire all old devices still in inventory; and cleaning out storage areas for all outdated assets. 4. Investigation: If theft or damage is found on any of these missing devices, an official investigation per the district's policies will occur.

Auditor Description of Condition and Effect: Internal control procedures are required to ensure that the costs and activities are allowable under the grant. The County is required to have evidence that the costs and activities are reviewed and allowable. During our testing, all invoices tested did not have evidence they were reviewed to ensure they were for an allowable activity and cost. This condition is a result of the County not having tangible evidence that invoices are reviewed and in line with the allowable activities and costs of the grant. As a result of this condition, the County is exposed to an increased risk of having ineligible expenditures. Auditor Recommendation: The County should adjust their procedures to ensure there is tangible evidence expenditures are being reviewed to ensure they are in line with grant requirements. Corrective Action: We agree with the finding and will implement this procedure going forward.

AHEC will maintain a spreadsheet which will include reporting deadlines and a reporting calendar to include due dates of all reports for each grant award.

Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.

Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.

Planned Corrective Action: The Seattle Indian Health Board has adopted a sliding fee program that provides discounts to eligible patients and Indian tribes. To address the auditors' concerns and further strengthen our internal controls, we are implementing a comprehensive corrective action plan. Firstly, we will ensure that all personnel involved in eligibility checks, including front desk staff and benefits specialists, are fully trained and aware of federal regulations and internal policies. This will be achieved through comprehensive training sessions and the development of a detailed training manual outlining eligibility criteria, documentation requirements, and procedural steps. Periodic refresher training sessions will reinforce adherence to these policies. Secondly, we will establish a robust internal audit system to regularly review and verify compliance with eligibility requirements. This includes integrating a monthly audit of eligibility determinations into the month-end reporting process, conducted by the clinical operations team. The clinical operations team will use a standardized checklist during these audits to ensure consistency and thoroughness. They will document findings and follow up on any issues or discrepancies with the relevant personnel to ensure timely corrections and adherence to procedures. Management believes that we have adequate internal control systems to safeguard the organization's assets and comply with federal and local regulations. However, we remain committed to further strengthening our controls and processes where necessary. Name of Responsible Party: Zecharias Mesgane, CMA, Director of FP&A Anticipated Completion Date: September 30, 2024

Material Audit Adjustments: Corrective Action Planned: The Milford Housing Authority will continue to improve communication of accounting transactions to both accounting personnel and those charged with oversight in order to decrease future proposed material audit adjustments. Anticipated Completion Date: December 31, 2023. Responsible: Management and Board of Commissioners.

Preparation of the Financial Statements: Corrective Action Planned: The Milford Housing Authority's management and Board of Commissioners will rely on its review and oversight authority to mitigate this inherent weakness in its internal control system. Anticipated Completion Date: Continuous. Responsible: Management and Board of Commissioners.

Segregation of Duties: Corrective Action Planned: Milford Housing Authority’s management and Board of Commissioners will rely on its review and oversight authority to mitigate this inherent weakness in its internal control system. Anticipated Completion Date: Continuous. Responsible: Management and Board of Commissioners.

Finding Number 2023-002 Federal Award Agency: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds CFDA #: 21.027 Finding Summary: During the performance of the audit, it was noted the County did not correctly report quarterly expenditures for amounts related to items reported under loss of revenue for each quarter in the fiscal year. Responsible Individuals: Susan Paprocki, Elko County Comptroller Corrective Action Plan: Management will closely review the Project and Expenditure Report User Guide to ensure future reports are in compliance and are properly reviewed prior to submission. Anticipated Completion Date: 6/30/2024

2023-001, 2022-001 - MATERIAL WEAKNESS AND MATERIAL NONCOMPLIANCE - SLIDING FEE Contact Person – Patricia Fournier, CFO Completion Date – 02/01/2024 Finding – We tested 60 sliding fee encounters and noted that 10 out of 60 patients were discounted, charged or adjusted the wrong amount and 4 out of 60 patients sliding fee applications had documentation issues. The Organization failed to verify sliding fee applications were obtained for all patients receiving discounts and incorrectly applied sliding fee discounts to charges. We recommend the Organization continue with the corrective action plan implemented in the prior year in response to audit finding 2022-001 to ensure sliding fee applications are completed before encounters are billed. We recommend that management continue to review and monitor the internal sliding fee application auditing process for further improvements and consider increasing sample sizes. RESOLUTION: 1.Staff Training. Honor continued in-depth monthly trainings for front-end processes. The training includes patient check-in, insurance verification, and sliding fee application completion. We determined through our audit process that health centers without a clinical receptionist continued to have issues. We expanded our training to include all employee classes that complete patient check-in This includes CHWs, BHCs, and call center staff. Participants complete a test to ensure the necessary knowledge and skills were obtained during the training. If the participant’s score is under our benchmark, they will complete the training again. All staff also complete the training as part of new employee on-boarding and participate in the all staff annual update training. 2.Dashboard Reporting. Honor Practice Managers use a daily dashboard to monitor prior day visits to ensure that all patient check-in, insurance verification, and sliding fee applications information is input correctly. 3.Monthly Audit & Follow-up. The Revenue Cycle Manager will publish a monthly report to include all sliding fee applications. The report will be sent on the 15th of the month for the prior month. The report will include all sliding fee applications by location that are not in compliance. The Practice Managers will work with staff to address and correct these applications. The RCM will publish a subsequent report on the 30th of the month to ensure all sliding fee applications have been corrected and are in compliance. Any location with remaining sliding fee application out of compliance on the 30th will report to their immediate supervisor to correct the sliding fee applications. 4.Sliding Fee Application Workflow. Honor worked with a consultant to review the sliding fee workflow process from patient registration through patient payment. With our review we identified processes to implement within the EHR that will automate steps in the workflow to eliminate errors in the entry process. We also updated the payment posting process to auto write-off the remaining balance of the encounter at the time of the patient payment.

Management is currently confident with the abilities of the accounting staff to prepare interim financial statements. The District has also accepted the additional risk associated with the auditor drafting year-end financial statements including the notes to the financial statements. Management will review, approve, and take responsibility for the financial statements.

Finding # 2023-001 Material Weakness over Preparation of Schedule of Federal Expenditures (SEFA) The Organization did not identify all federal expenditures and significant adjustments were required to the SEFA prepared by management. Corrective Action: The Organization agrees with and independently identified this issue and proactively implemented a new payroll process as of January 2024 in order to address this issue. This will ensure all expenses are tracked in one system for all purposes. In addition the Organization created a new grant tracking field in the chart of accounts which tracks the Assistance Listing numbers of all grants, allowing for the automated creation of the SEFA, as well as providing an internal control to ensure that revenue recognition policies and relevant federal guidelines are correctly applied to all funding sources. Anticipated Completion Date: January 2024