Corrective Action Plans

Unlike other subgrants managed by the Department of Law and Public Safety (DLPS), the subgrants in the Public Assistance program are not issued by the Department but instead are issued by the Federal Emergency Management Agency (FEMA). These FEMA-issued subgrants take the form of Project Worksheets (PWs) and are directly related to a specific disaster. FEMA informs the DLPS of the approved PWs after they are issued. Given the unique nature of the PW issuance, the DLPS is not in a position to report on the FFATA Subaward Reporting System (FSRS) at the time PWs are issued. This contrasts with other grant programs overseen by the DLPS, which do allow for timely subaward reporting in FSRS. The Department will continue to work with our FEMA partners, incorporating any guidance they provide, to develop procedures that ensure subawards are reported in FSRS within the FFATA reporting requirements. COMPLETION DATE/ CONTACT PERSON & PHONE# Fiscal Year 2024 and Ongoing Salvatore Marcello (609) 882-2000 ext.3046 Salvatore.Marcello@njsp.gov

The Department of Human Services’ Division of Family Development (DFD) agrees with the audit finding regarding the required submission of subawards to the FFATA Subaward Reporting System (FSRS). Due to the complexity and time required to compile and report FFATA subaward data, the DFD is in the process of creating a new full-time equivalent position (FTE) for this required federal reporting task. In accordance with the finding recommendation, the DFD will develop internal controls and procedures to ensure the timely reporting of all required subawards to FSRS. An initial review of the FSRS by DFD fiscal staff appeared to indicate that some federal grant award data that should be prepopulated by the awarding federal agency and available on the website was missing (e.g. Child Care M&M available; Discretionary not found). Staff will reach out to the necessary federal agencies to communicate instances of missing federal award information in an effort to ensure that the DFD has the ability to input the required subaward information. DFD anticipates that the assessment and development of policy and procedures related to this task will take approximately three (3) months. Staff assignment, training, and submission of federal grant subaward information to the federal website will occur over the next state fiscal year. COMPLETION DATE/ CONTACT PERSON Policy Completion Date: June 30, 2024 Implementation Date: Fiscal Year 2025 Thomas Mattaliano, CFO-DFD (609) 588-3370 Thomas.Mattaliano@dhs.nj.gov

The Department of Community Affairs (DCA) has recently implemented timely reporting of required FFATA subaward data in the Federal Subaward Reporting System (FSRS). The FFATA reporting process is fully documented, and additional staff have been hired and trained on the process to further support the federal reporting functions. The FFATA reports identified by the auditors with inaccurate subaward amounts reported have also been corrected in FSRS. COMPLETION DATE/ CONTACT PERSON April 30, 2024 Fidel Ekhelar (609) 815-3905 Fidel.Ekhelar@dca.nj.gov

The Department of Human Services’ Division of Family Development (DFD) agrees with the audit finding regarding the required submission of subawards to the FFATA Subaward Reporting System (FSRS). Due to the complexity and time required to compile and report FFATA subaward data, the DFD is in the process of creating a new full-time equivalent position (FTE) for this required federal reporting task. In accordance with the finding recommendation, the DFD will develop internal controls and procedures to ensure the timely reporting of all required subawards to FSRS. An initial review of the FSRS by DFD fiscal staff appeared to indicate that some federal grant award data that should be prepopulated by the awarding federal agency and available on the website was missing (e.g. Child Care M&M available; Discretionary not found). Staff will reach out to the necessary federal agencies to communicate instances of missing federal award information in an effort to ensure that the DFD has the ability to input the required subaward information. DFD anticipates that the assessment and development of policy and procedures related to this task will take approximately three (3) months. Staff assignment, training, and submission of federal grant subaward information to the federal website will occur over the next state fiscal year. COMPLETION DATE/ CONTACT PERSON Policy Completion Date: June 30, 2024 Implementation Date: Fiscal Year 2025 Thomas Mattaliano, CFO-DFD (609) 588-3370 Thomas.Mattaliano@dhs.nj.gov

Based on the Corrective Action Plan (CAP) developed for the prior year FY 2022 audit finding cited for FFATA reporting, the Department of Health (DOH) Grants Unit, with coordination from the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) fiscal staff, added a new function to the System for Administering Grants Electronically (SAGE) that pulls all subaward data for the ELC program using the program’s 93.323 federal Assistance Listing Number (ALN). Thus, the CAP implemented in September 2022 for the prior year FY 2022 audit finding includes SAGE now pulling the subaward data for the entire ELC program by the ALN number and enables the ELC fiscal staff to access all ELC subawards within the DOH. ELC fiscal staff also has a task reminder set to report at the end of each month, enter subaward information into the FFATA Subaward Reporting System (FSRS), and upload each report submitted to the SharePoint ELC Document Library at the end of each month. As per the original CAP created under the FY 2022 audit, FFATA information for ELC subawards were entered into FSRS beginning on September 1, 2022 and DOH actions and efforts have continued to ensure compliance going forward. COMPLETION DATE/ CONTACT PERSON April 10, 2024 Rina Warehall (609) 913-5300 Rina.Warehall@doh.nj.gov

The Department of Health’s (DOH) Vaccine Preventable Disease Program (VPDP) is in compliance with the Federal Funding Accountability and Transparency Act (FFATA) requirements with regard to reporting all active first-tier subawards of federal COVID-19 funds that DOH divisions have issued totaling $30,000 or greater under this Cooperative Agreement and COVID-19 Supplemental. However, it is not in compliance with regard to reporting required subaward data in FSRS by the end of the month following the month in which DOH has made the subawards totaling $30,000 or greater. The VPDP will continue to follow the DOH policy set forth in FMC 22-05 and report to FSRS all active first-tier subawards of federal COVID-19 funds DOH divisions have issued at $30,000 or greater under the COVID-19 Supplementals. The VPDP fiscal/grants leadership team will strive to ensure each of the identified subawards is entered on the FFATA Subaward Reporting System (FSRS) website by the end of the month following the month that DOH has made the subawards. VPDP will continue its efforts to bring the gap in reporting to FSRS down from five months presently to within the specified FFATA submission deadlines denoted above. VPDP also has on boarded a full-time Contract Administrator 2 who will be responsible for reporting FFATA data into FSRS for the Immunization Cooperative Agreement. COMPLETION DATE/ CONTACT PERSON April 4, 2024 Susan Barcarola (609) 943-5302 Susan.Barcarola1@doh.nj.gov

The New Jersey Department of Education (NJDOE) Office of Grants Management (OGM) understands the need to be compliant with FFATA reporting in accordance with the Uniform Guidance. Internal controls and processes are in place to ensure NJDOE’s FFATA reporting process is working efficiently and timely. This noncompliance finding is not due to a lack of controls within NJDOE but lies squarely on system issues at SAM.gov and the FFATA Subaward Reporting System (FSRS) sites and until the issues listed below are corrected on these federal system sites, NJDOE will continue to be noncompliant with timely FFATA reporting. Issues with the SAM.gov and FSRS sites: • SAM.gov has approved NJDOE’s local education agency (LEA) registrations without a ZIP+4, but FSRS reporting system for FFATA uploads requires ZIP+4 for each LEA. The two systems use the same database, which means information registered on SAM.gov feeds directly into the FSRS system. However, because FSRS batch uploads require a ZIP+4, those LEAs that were approved by SAM.gov without a ZIP+4 during the registration process, are rejected from the FFATA report batch upload. There is an option to manually load each LEA and their details into the system, but the process becomes incredibly time consuming, given the 700+ LEAs in the state, the number of federal awards granted, and the steps for identifying & removing rejected LEAs from the batch upload. • Issues NJDOE has with SAM.gov and FSRS have been shared with the federal helpdesk and a USED representative without avail, as the systematic issue remains unresolved and continues to delay our FFATA reporting process. • There are several rural LEAs in the state that do not have a ZIP+4. These LEAs will continue to be rejected from the batch upload, delaying our FFATA reporting process, if SAM.gov and FSRS do not come up with a viable solution. • There were a number of LEAs that were continuously rejected from the upload by FSRS for no obvious reasons. The error message received was the same exact error we receive for incorrect zip codes. After spending much time investigating the cause with the helpdesk support, it was identified that FSRS did not update their system to reflect the Congressional District code changes during New Jersey’s redistricting process. • The FSRS system rejects batch uploads if a single lower-case SAM UEIs is entered in the batch file. However, SAM.gov search box and the FSRS manual uploads are not case sensitive. Batch uploads are the only place where SAM UEIs are case sensitive. Further, this information is not included in any of the FSRS User Guides or manuals. I have shared this with the FSRS helpdesk, but no solution was provided. Again, this discrepancy in their system affects and delays our FFATA reporting processes. NJDOE dedicated personnel, including the director of OGM, continuously work with SAM.gov, FSRS system, and both system sites’ help desks, to bring to light the issues mentioned above in order to express the urgent need for corrective actions at the federal system sites to allow for timely FFATA reporting. In addition internal controls and procedures are in place at NJDOE related to FFATA reporting and corrective actions are constantly performed in real time to perform the below NJDOE Internal Controls and Procedures. Some of these procedures include reviewing internal SAM applications and troubleshooting with NJDOE’s local education agencies (LEAs) to correct data in the application and resubmit to the federal reporting system sites with more detail included below. NJDOE Internal Controls and Procedures: • Due to the large number of LEAs in the state (700+), each FFATA report must be submitted via batch upload, which saves an enormous amount of time it takes to input data manually for every single LEA, for every grant. To address this need and to expedite the process, our vendor has created a reporting tool that generates a FFATA batch report. • We have been contacting the federal helpdesk to address the issues on their sites and asking for support. Some of those tickets were closed without providing any support and most were not helpful. • We have created and implemented an in-house System for Award Management (SAM) application, mandatory for all of our federal grant recipients. This was done specifically for FFATA reporting purposes to ensure data in these applications are directly tied to the FFATA batch reports. • The SAM applications go through a thorough review process, where data entered by the districts is compared with the data registered with SAM.gov (applicants are required to upload a copy of their Entity Overview Record, issued by SAM.gov). • SAM applications are returned for changes whenever an applicant has entered data that is inconsistent with data on SAM.gov (i.e.. Incorrect SAM UEI, incorrect zip code, incorrect zip+4, incorrect City name). • We have asked many of our districts to contact SAM.gov and update their physical address information to include the full 9-digit zip code, which was SAM.gov reviewers’ oversight. Our school districts have commented that this process can take months. • We are communicating with our districts/applicants on a daily basis through the review summary checklist, outlining the changes that must be made, as well as by email and phone. • We have implemented an automatic messaging system, where applicants are reminded to update their SAM registration expiration date, multiple times a month leading up to their expiration date. Due to the system discrepancy in the FSRS system’s batch upload, we had to create a workaround pertaining to the district’s SAM UEIs. As stated above, SAM UEIs, in batch FFATA reports, are case sensitive while not case sensitive anywhere else in the two system sites. We have updated our instructions in NJDOE’s SAM application and have added another layer of application review, to ensure that all UEIs entered are in all capital letters. Because the federal helpdesk has ignored this discrepancy and did not resolve the issue, we are obligated to take additional steps and spend additional time on FFATA batch reports. COMPLETION DATE/ CONTACT PERSON Indeterminate – Completion based on federal implementation of fixes to SAM.gov and FSRS portal as noted in views. Martin Egan, Director NJDOE Office of Grants (609) 376-9089 Martin.Egan@doe.nj.gov

The Department of Labor and Workforce Development (DLWD) transitioned from a manual contract agreement process to a web-based grant administration system in recent years that employs the System for Administering Grants Electronically (SAGE) and IntelliGrants (IGX) applications. The DLWD FFATA Reporting Unit has access to these automated systems and monitors them on a monthly basis to identify when new subaward contracts/agreements are approved in order to report required data in the FFATA system timely. DLWD corrective actions regarding FFATA reporting are expected to be fully implemented as of June 30, 2024. COMPLETION DATE/ CONTACT PERSON June 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) will continue to review and enhance controls to ensure that BAM quality control case investigations are completed timely, that reviews are signed as required by appropriate staff, and that all required case review supporting documentation is maintained in case files. DLWD corrective actions will be completed by September 30, 2024. COMPLETION DATE/ CONTACT PERSON September 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Reemployment Services and Eligibility Assessments (RESEA) policy and controls presently in place at the Department of Labor and Workforce Development (DLWD) require eligibility interviews to be conducted and eligibility review forms to be completed and signed by the participant and UI program representative. DLWD implemented a new process that allows staff to electronically obtain signatures through Simpligov, beginning June 2023. This process requires that staff obtain all necessary signatures before a RESEA claimant record is completed. Supervisors are assigned to monitor this process in order to mitigate the risk associated with missing information on any single RESEA customer registration. DLWD will monitor this process to ensure that all interviews are properly documented, and forms are signed and electronically uploaded to its electronic case management system of record for future reference. During the initial rollout of this process, there were records that didn’t migrate to the case management system of record. This issue has now been addressed through training. DLWD has also developed dashboards that will assist with monitoring data entry. Monthly reviews of RESEA data entry will be conducted to identify possible errors. These RESEA process changes that will be implemented by DLWD will ensure compliance with regulatory standards and assist with maintaining the integrity of its data management process. COMPLETION DATE/ CONTACT PERSON June 30, 2023 Baden Almonor (609) 777-1042 Baden.Almonor@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) has controls in place to only allow an FPUC payment to be made when an underlying Unemployment Insurance (UI) payment has also been processed. FPUC payments should not be issued to any claim without the underlying UI payment being made for the same week. The FPUC payments issued and noted as exceptions during eligibility testing will be reviewed independently by DLWD to determine if the payments issued were to eligible recipients or not. For the PUA exceptions noted during Eligibility testing, overall the DLWD issued PUA payments to over 680,000 claimants during the COVID-19 pandemic. DLWD had controls in place to require a COVID related reason to make the claim PUA eligible and the weekly PUA certification required claimants to choose a COVID related reason for why they were out of work before they could get paid. The PUA payments in question will be reviewed independently by the DLWD to determine if the payments issued under PUA were appropriate or if they should have been paid instead under the regular UI program. DLWD corrective actions related to FPUC and PUA payments were fully implemented as of September 2023. COMPLETION DATE/ CONTACT PERSON September 2023 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

2023-002 U.S. Department of Transportation, National Infrastructure Investments: Better Utilizing Investments to Leverage Development (BUILD) Grant Assistance Listing Number 20.933; Procurement Material Weakness in Internal Control over Compliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award the provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations and conditions of the federal award. Non-federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. The Port Authority’s formally documented policy pre-dates Uniform Guidance and does not include many of the necessary procurement provisions. Corrective Action Plan: An updated Procurement Policy is being drafted to meet the standards set forth in 2 CFR 200.317 to 220.237, then reviewed and approved by our Board at the next appointed board Meeting. Expected Completion Date: March 2024 Responsible Individuals: Kimbra Scott

Corrective Action Planned: The Board will comply with Title 29, U. S. Code of Federal Regulations, Part 5. Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the "Davis-Bacon Act") when using COVID-19 Education Stabilization Funds to fund construction contracts in excess of $2,000. Anticipated C'onipletion Date: March 15, 2024 Contact Person(s):): Cindy W. Parker; Chief School Financial Officer; cparker@blountboe.net

Finding 2023-002 - U.S. Department of Education (USD), Title IV Student Financial Aid Programs (material weakness): We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: (a) The College did not reconcile the following programs between the Office of Financial Aid and the Business Office. Per 34 CFR 685.300(b)(5). i. Federal Pell Grant Program ii. Federal Direct Student Loans iii. Federal SEOG (b) The Office of Financial Aid submitted unreconciled expenditures within the Fiscal Operations Report and Application to Participate (FISAP) for the programs below: i. Federal Pell Grant Program ii. Federal Work Study (FWS) Program (c) One (1) out of 6 students tested for withdrawals and the return of Title IV funds did not have their Title IV program funds returned within the 45-day requirement. HEA, Section 484B & 34 CFR 668.22. (d) One (1) out of 60 students had a credit balance on their account created by Title IV program funds longer than 14 days. 34 CFR 668.164(h)(1). (e) One (1) out of 60 students tested did not make satisfactory academic progress (SAP) for the academic year. The College did not provide supporting documentation for successful appeals and allowed the students to receive Title IV funding. 34 CFR 668.34. Questioned cost for this finding is: $6,198. (f) Five (5) out of 60 students tested did not have high school/GED to prove eligibility for the program they were enrolled within the College. HEA Section 484(d) and 34 CFR 668.32. Questioned cost for this finding is $41,443. (g) Four (4) out of 60 students tested were accepted as transfer students but did not have official (transfer) transcripts to prove eligibility for the program they were enrolled within the College. HEA Section 484(d) and 34 CFR 668.32. Questioned cost for this finding is $40,383. The College should implement corrective actions to ensure that the above findings are resolved and do not recur in future periods. Moreover, internal controls over compliance with federal program regulations should be revisited to ensure adequate supervisory controls, quality assurance reviews of processes, and policies and procedures are being updated and adhered to for compliance purposes. Corrective Actions – Philander Smith College concurs with this finding, and the following action has been taken. Philander Smith College improved the efficiency of reconciling between the Financial Aid Office and COD by standardizing procedures. Staff-wide calendar events have been set to standardize routine processing of reconciliation data. Direct Loan SAS files are imported into the COD "DL SAS Disb On Demand Reader" tool and converted to Microsoft Excel files. Pell SAS/ Reconciliation files are imported into the COD "Pell Recon Reader" tool and converted to Microsoft Excel files. The SAS files and financial aid management system (FAMS) files are imported into Microsoft Access tables and Microsoft Access queries are run to determine discrepancies between SAS file data and FAMS data. This standardization provides an efficient procedure for staff members to follow. Staff have been cross trained to reduce processing delays. This system, incorporating efficient technology, calendar reminders, and cross training has improved the efficiency of reconciliation activities. Financial Aid staff coordinate with Business Office staff for notification after the Financial Aid to COD reconciliation is complete. Financial Aid staff are updating the policies for SAP supporting documentation submission that require students to submit documents via the student financial aid portal where documents will be securely stored and backed up within the College servers. Financial Aid staff are updating processes among Financial Aid, the Registrar's Office, and Academic Affairs to strengthen timely identification of both official and unofficial withdrawals for timely Return to Title IV Funds processing. Finally, during the pandemic, the College experienced some difficulties obtaining official high school transcripts due to school closings. The College is continuing to work to review files to ensure this is fully addressed.

Corrective Action Plan: Due to staff turnover of key personnel in the Housing Division, the Finance Department has partnered with the Community Development Department to ensure that CDBG reporting is timely and accurate. In March 2024, a new consultant was contracted to assist the Housing Division staff with training and oversight for entering data to HUD's Integrated Disbursement and Information System (IDIS) which includes the Cash on Hand reports. Responsible Individual: Kimberly Cole-Muck, Director of Community Development Anticipated Completion Date: September 2024

Currently, the College marks students withdrawn on the date the withdrawal is officially processed in the system, indicating their last data of attendance. The withdrawal policy will be updated to indicate that the withdraw date to be reported for all students withdrawing at either the program or campus level should be processed as the "last date of attendance". In the case of the 5-year program (4+1 internally), we currently do not officially "enroll" a student into the master's program until their bachelor's degree is conferred. The official admit date will be updated to reflect the term a student enters the master's program officially, which will begin after the conferral of their bachelor's degree. Our policy and processes for the 4+1 program will be updated to reflect this change.

In April of 2023, the North Providence Housing Authority hired an outside company to perform yearly rent reasonableness studies. Nelrod has given us the tools to perform these studies fast and efficiently with the use of their software program. Additionally, due to being a small housing authority, with only one HCV staff member, we have hired an HCV Assistant to help the HCV Coordinator in obtaining all information needed to comply with HUD’s regulations. Planned Implementation Date of Corrective Action: April 2023 Planned Implementation Date of Corrective Action: Eileen Reyes/Michael McMahon/Cheryl Lonardo

Finding Number: 2023-001, 2022-001, 2021-001: Material Weakness and Material Noncompliance - Sliding Fee Recommendation: We recommend that sliding fee applications be completed for each sliding fee patient. Procedures should be implemented to verify applications are completed before the encounter is billed. Sliding fee discounts per policy should be agreed in the billing system to ensure the proper discounts are entered and updated. In addition, the Center could consider increasing its internal sampling throughout the year to verify sliding fee applications are obtained, completed, and agree to the discount applied. Action Taken: CHASS management concurs with the audit finding and will put the following corrective action plan in place to mitigate this finding in the future: During Sliding Fee Testing it was found that the actual charge to patient (after slidingfee applied) did not match the actual discount that patient should have had. We have reviewed all process on how EPIC loads up charges (table with applied slidingfee tiers) and found that no one had a master list of the charges, when Billing requests a CPT to be added they just go to accounting and gets added as well as when they request changes on charges for CPT code. There is not one set of approved CPT charges/discount creating discrepancies in patients accounts. In response to these audit findings, CHASS has developed and implemented a comprehensive series of improvements. First, implementation of key improvements involves the implementation of a one person only authorized to request changes on table of charges to EPIC. Second, implementation of a verification process for every patient receiving a sliding fee discount. To achieve this, the Center's Customer Service team now generates personalized labels for each eligible patient and cross-checks their entries by the end of each day. This process ensures each item is diligently reviewed to ensure if any errors are made within this process they are rectified immediately via a Supervisor/Team Leader. Through this process the Supervisor/Team Leader now conducts a second review of the labels to ensure accuracy of the Center's labeling system for each patient utilizing the sliding scale discount program. This review also includes the actual charges on EPIC and Discount being verified with CPI Tables. Third implementation, the Center's Billing Department is now responsible for performing regular weekly audits. During these audits, the Billing Department will now randomly select five claims with sliding fee discounts and examine the applied fees and the corresponding discounts applied to the patient's account (using the approved CPT Table). Through these improvements CHASS aims to ensure that the Sliding Fee Discount Policy is used accurately and appropriately. These methods have been incorporated into the Center's Sliding Fee Discount Policy to guarantee their utilization and accuracy, and to further strengthen the Center's initiatives in providing access to needed health care services. Responsible Parties: Angela Salgado, Chief Operating Officer

Finding 2023-003: Material Weakness in Internal Control over Compliance – Eligibility. Name of Contact Person: Phyllis Wimberley, Deputy Director. Corrective Action: The Heritage program will create and implement a checklist of required documentation to ensure all participants are eligible to participate in the program. Proposed Completion Date: June 2024

Management Response: Local background checks were completed, however when a consultant was hired to complete the federal background checks, the files were stalled at the adjudicator’s office in Albuquerque, NM due to some billing issues with the Tribe. We have 3 trained staff who are certified adjudicators however it was recommended to use an outside adjudicator and we were able to locate someone locally who agreed to perform the federal background checks. Anticipated Completion Date: Currently in progress March 31, 2024 Responsible Party: Troy Lunderman, HR Director Leah Running Bear, HR Assistant Independent adjudicator Jodee Wike

Delta Partners Manor II, Inc. (the "Project") respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit Firm: Harper, Rains, Knight & Company, P.A. 1052 Highland Colony Parkway, Suite 100 Ridgeland, MS 39157 Audit Period: Year Ended December 31, 2023 Audit Finding Reference: 2023-001 Planned Corrective Action: Management will ensure that these reconciliations are performed monthly against the month end bank statements. Name of Contact Person: If the U. S. Department of Housing and Urban Development for audit has questions regarding this plan, please call Scott Russell at 601-856-2362.

Finding: 2023-001 – Compliance and Controls over Compliance – Eligibility Supportive Housing for Persons with Disabilities (Section 811), CFDA No. 14.181 Material Weakness & Noncompliance In 2023, Home Share did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual making the initial determination or annual recertification. Actions Taken or Planned: Management agrees with this finding. Beginning in September 2023, management has changed the contractor they work with for the eligibility determination process. Management is working with the contractor to include a second individual in this process so that there will be a review performed by someone other than the individual making the initial determination or annual recertification. Contact Persons: Robert Pickering, Chief Financial Officer

2023-001 Special Tests and Provisions - Sliding Fee Discounts Corrective Action Plan Management will create a Procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all audit and record retention requirements are met. Anticipated completion date March 31, 2024 Contact person responsible for corrective action Kendra Newbold, Interim CEO

2023-007 - Special Tests – Internal Control and Compliance over Housing Quality Standards Inspections (Material Weakness) Condition: We found five (5) instances out of 9 in which the City did not conduct the HQS failed inspection follow up in a timely manner. We also noted three (3) instances out of 40 samples for eligibility testing has HQS inspections that are over a year apart, which shows that the City did not conduct the HQS biennial inspection in a timely manner. Management concurs. Corrective Actions: Management has directed staff to abide by the PHA policy and HUD regulations for the HQS inspection process. Management will continue to enforce HUD regulations and the use of the PHA’s administrative plan to ensure staff will conduct the HQS biennial inspection in a timely manner. Name of Responsible Person: Ron Garcia, Director of Community Development Imelda Delgado, Housing Manager Projected Implementation Date: Immediately implemented.

Official Responsible for Ensuring CAP Lorie Werle, business manager, will be responsible to ensure that the appropriate measures are taken. Correcting Plan The District will provide Lorie Werle, business manager, necessary training. The Planned Completion Date of CAP Immediately