Corrective Action Plans

View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. We issued a Request for Proposals for a third-party Contractor to perform all recertifications. We intend to award this Contract in July 2025. 2. All Managers and assistant Managers will use the third-party Contractor to learn proper recertification and documentation procedures.

Finding 2024-013 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS is continuing to update cases following the end of the public health emergency (PHE) and expects that all existing cases will be updated by July 2025, as MDHHS completes a mass update and renewals for existing cases. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children’s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 2025 Responsible Individual(s) Brant Cole, MDHHS Logan Dreasky, MDHHS Crystal Kline, MDHHS

Finding 2024-055 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with the BSC analyst team to discuss common errors, answer questions, provide guidance, and on a quarterly basis discuss the results of the State Emergency Relief (SER) case reads. During April 2024, MDHHS SER program policy management and staff began attending BSC leadership meetings to discuss SER case read data findings, policy changes, and communicate common errors found during audits. In addition to updating verification requirements on October 1, 2023, SER program policy management and staff added copay verification requirements on October 1, 2024. MDHHS completed system updates during April 2024 to allow specialists access to directly upload verification documentation to the electronic case file instead of providing the documentation to other areas to process and upload. MDHHS will provide annual training directly to counties that fail to meet the state average for SER case reads relating to verification of the client's income, client contribution payment, and proof of energy crisis. MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support SER processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS

Finding 2024-052 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division updated its FFATA procedure effective March 2025 and has been working to correct the inaccurate FFATA reporting for the Refugee and Entrant Assistance State/Replacement Designee Administered Programs subawards. All of LEO’s open subawards are reported correctly in SAM and LEO completed corrections to the closed subawards in April 2025. Going forward, LEO will ensure that future subawards are reported both accurately and timely in accordance with FFATA requirements. Anticipated Completion Date Completed Responsible Individual(s) Heidi Parker, LEO

Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all specialists that determine eligibility for refugee cash assistance payments by September 30, 2025. MDHHS also will implement ongoing management and peer-to-peer spot checks of cases to ensure that documentation is maintained to support the client’s eligibility beginning October 2025. In addition, MDHHS will determine if technical changes are needed to help ensure the proper documentation is in the electronic case file by December 31, 2025. If potential system modifications are needed, the Bridges technical team will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the determination of whether system modifications are necessary. Responsible Individual(s) Benjamin Cabanaw, LEO Nicole Adams, LEO Bethany Cabanaw, MDHHS Kent Schutz, MDHHS Mariah Schaefer, MDHHS

Finding 2024-012 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children’s Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the identified exceptions for parts a. and c. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Children’s Health Insurance Program (CHIP) cases with MAGI determinations cited in part b. did not have case file documentation supporting the beneficiary eligibility determination. The Centers for Medicare and Medicaid Services (CMS) has determined that a reasonable compatibility indicator can be used for CMS audit purposes to determine if the attested income information was electronically verified for MAGI cases and MDHHS disagrees that documentation was not maintained to support the eligibility determination. The SOM MiIntegrate system communicates with various State and federal electronic trusted data sources and sends the information from these sources, along with the beneficiaries’ attested income, to the SOM MAGI Rules Engine where the MAGI eligibility determination is made. As part of the MAGI eligibility determination, a reasonable compatibility test is completed to determine if beneficiary/applicant attested income is within a specified percentage of the electronic trusted data sources or if the attested and verified income are below the threshold for the applicable program. The results of the MAGI eligibility determination are sent back to MiIntegrate using an Account Transfer (AT) packet that contains the results. MiIntegrate then communicates the results to the SOM MAGI Viewer and Bridges using an AT packet and Bridges stores the AT packet number only that can be used to view the details of the AT packet within the SOM MAGI Viewer. The version of the AT packet within the MAGI Viewer also contains a reasonable compatibility indicator that documents the outcome of the reasonable compatibility test and supports the SOM MAGI Rules Engine eligibility decision. MDHHS stores the AT packet information, including facts essential to the eligibility determination, within MiIntegrate and the MAGI Viewer instead of Bridges to help protect and secure the federal income tax data and unemployment data used for the determination. The AT packet for each individual determination can be retrieved from the MAGI Viewer using the AT packet number stored in each beneficiary’s case file within Bridges. MDHHS is not aware of any federal regulations that preclude MDHHS from storing this information in a separate system to help secure the data and restrict access as required by federal and state law. Planned Corrective Action To address the exceptions identified that are not related to MAGI-based income verification results, MDHHS has developed mandatory training protocols for eligibility workers and expects to have the first Medicaid audit focused mandatory training implemented by July 2025. MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained within the electronic case file. MDHHS disagrees it did not maintain case file documentation that supports the beneficiary eligibility determination for MAGI cases and does not intend to take further action. Anticipated Completion Date MDHHS will implement the first Medicaid audit focused training by July 2025. Responsible Individual(s) Logan Dreasky, MDHHS Mariah Schaefer, MDHHS

Finding 2024-035 CCDF Cluster, ALN 93.575 and 93.596 - FFATA Reporting Management Views MiLEAP and MDE agree with the finding. Planned Corrective Action MiLEAP will implement a process to ensure it submits subaward information as required by FFATA and federal guidance. Anticipated Completion Date September 2025 Responsible Individual(s) Lora MacKay, MiLEAP

Finding 2024-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., d., f., and g. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees that a process is not fully established to monitor the electronic notifications provided to county/district office caseworkers to ensure they utilized the Income Eligibility and Verification System (IEVS) information to determine the recipients’ eligibility. MDHHS had policies and procedures in effect during fiscal year 2024 to help ensure monitoring of electronic notifications was taking place. Review of IEVS information is fully incorporated into the case read procedure governed by Bridges Administrative Manual 301 and detailed further in desk aids and reading guides. The MDHHS Economic Stability Administration (ESA) provides regular direction and reminders of case read requirements via ESA Memos. For part e., MDHHS disagrees that IEVS information is required to be requested and obtained for modified adjusted gross income (MAGI) based recipients since eligibility is verified upon determination through the MAGI eligibility determination process and then granted for a 12-month continuous eligibility period. Requesting and obtaining IEVS information throughout the eligibility period would be irrelevant since eligibility is continuous. Planned Corrective Action For parts a. and b., MDHHS ESA will continue to provide guidance and trainings to the local office specialists on utilizing the IEVS data timely and appropriately if the data is critical for current eligibility determinations. MDHHS ESA will also continue to review any technical automated solutions of the IEVS data to help ensure its proper utilization and timeliness. For parts c. and e., MDHHS disagrees with the finding and does not intend to take further action. For part d., MDHHS is collaborating with other work areas to identify potential solutions to establish and implement IEVS interfaces for adoption subsidies recipients funded by Temporary Assistance for Needy Families (TANF). For part f., MDHHS worked with the Social Security Administration (SSA) to resolve a discrepancy in how the file was reported to DTMB by SSA and processed the fiscal year 2024 file during February 2025. For part g., MDHHS worked with the National Technical Information Service (NTIS) to regain access to the data during February 2024 and resume receiving the data monthly. Once access was re-established, NTIS sent a complete base file containing the data for the three months identified and the file exceeded the normal processing limit. MDHHS will work with DTMB to identify potential solutions and will process the complete file base by September 30, 2025. Anticipated Completion Date a. and b. Ongoing c. Not applicable d. MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solutions identified. e. Not applicable f. Completed g. September 30, 2025 Responsible Individual(s) a., b., and c. Veronica Maxson, MDHHS d. Kathonya Rice, MDHHS e. Logan Dreasky, MDHHS f. Brant Cole, MDHHS g. Brant Cole, MDHHS Nathan Buckwalter, DTMB

Finding 2024-003 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals, semi-annual review of privileged users, and annual review for all users. Security management and access control processes will continue to be a standing agenda item for ongoing quarterly training sessions with Local Office Security Coordinators (LOSCs). For parts a., c., and d., the Access Management Section began conducting quarterly reconciliations of DSA to the Bridges Integrated Automated Eligibility Determination System (Bridges) during the first quarter of fiscal year 2025. For part b., MDHHS is currently evaluating the feasibility of establishing a quarterly review process to help ensure documentation is maintained for a sample of LOSC monitoring reports. MDHHS anticipates completing the evaluation by September 30, 2025, and will determine an anticipated completion date for implementation, if necessary, at that time. For part e., MDHHS Local Office Directors, District Managers, or designees review a monthly sample of high-risk Bridges transactions to ensure documentation was properly maintained. Beginning September 2024, MDHHS Business Service Centers (BSC) implemented a monitoring process to ensure monthly reviews are completed by the local offices timely and that the documentation is properly maintained. Anticipated Completion Date a., c., d., and e. Completed b. September 30, 2025 Responsible Individual(s) a., b., c., and d. Jim Bowen, MDHHS e. Veronica Maxson, MDHHS

Finding 2024-006 The Authority has hired a new Executive Director in April of 2025. She is undertaking the process of learning the systems in place and adjusting them to meet the requirements of the program. The Authority has hired a consultant that has significant experience in HUD regulations to help guide them to implement the appropriate systems. Planned corrective actions are to be implemented immediately. The Authority has also hired a fee accountant that will work closely with them to get them on the right track with their accounting records.

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • We have brought on a State and Federal Grants Consultant to ensure all required grant related paperwork is completed and saved in a shared location with the Finance Team.

The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy's side. The Finance Director is now responsible for the renewals going forward, and this will not be an issue in the future.

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • We will ensure all reporting is filed on a timely basis.

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested.

Finding 2024-002 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Passed through Hearth Connections and Passed through Dakota County, Continuum of Care. Assistance Listing Number: Federal Financial Assistance Listing #14.267 Program Name: Continuum of Care Program Finding Summary: Guild’s controls did not operate as designed, which resulted in rent reasonableness tests not being performed timely and/or reviewed before the rent being paid. Corrective Action Plan: This clinical program is now under new leadership and is enhancing its controls and oversight. In addition to requiring a monthly rent checklist to be reviewed and signed off by the responsible official, an additional layer of control will be implemented by involving Finance in verifying that proper documentation is in place before rent checks are issued. The program, in collaboration with Finance, will also continue enhancing the approach to standardized documentation. Responsible Individuals: Keith Rachey - Chief Financial Officer, Tiffany Yang – Controller, Diana Harris – Director of Clinical Services Anticipated Completion Date: Completed by September 2025

Elementary and Secondary School Emergency Relief – Assistance Listing No. 84.425U, 84.425W Recommendation: CLA recommends the District review its grant disbursement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving purchases, along with adding controls to ensure that the item purchased was received by the District. CLA also recommends the District review its payroll process and identify payroll tasks that could be reassigned to other district personnel or consider implementing additional review procedures specifically focused on payroll and related fringe benefit costs claimed on federal and state grants. CLA also recommends the District review its grant reporting processes and implement internal controls to help ensure that there is adequate segregation of duties in regards to grant reporting including special reports. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: District staff will accumulate as much of the information required for federal and state awards as we can and reconcile the revenue and expenditures information to the general ledger for these awards. Name(s) of the contact person(s) responsible for corrective action: Adrian Foster, Brooke Rosemeyer Planned completion date for corrective action plan: Ongoing.

Finding 2024-001 Lack of Internal Controls Over Cash Management Name of Contact Person: Galen Gilbert, First Chief Corrective Action Plan: In the prior fiscal year, Arctic Village Council (AVC) experienced delays in drawing down HUD funds due to staff transitions and turnover. While reimbursement was ultimately received, the funds were not deposited until after fiscal year-end, contributing to the reported cash management issue. To strengthen internal controls and avoid future delays, AVC will continue to follow its monthly reconciliation process to ensure that all grant expenditures are accurately aligned with drawdown activity and supported by eligible costs. In addition, AVC will explore establishing a line of credit (LOC) in FY2025 to help bridge timing gaps between expenditures and reimbursement cycles. This LOC would provide short-term liquidity support and help reduce reliance on general fund balances while awaiting federal reimbursements. Proposed Completion Date: September 30, 2025

City of Panama City Beach, Florida Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Finding Numbers: 2024-001 Finding 2024-001 Lack of Documented Review of Annual Project and Expenditure Report The City acknowledges the importance of maintaining strong internal controls. While the report was prepared with diligence and care, we recognize that the absence of documented independent review poses a risk for potential errors and noncompliance with federal requirements. To address this issue, the City has established a formal process to ensure that future reports undergo an independent review before submission. A qualified staff member who is not involved in preparing the report will conduct the review, and both the preparer and the reviewer will sign and date the report to provide evidence of oversight. This documentation will be retained in the grant file for compliance and audit purposes. Staff involved in the reporting process have been informed of these new procedures to ensure consistency moving forward. The revised procedures have been adopted and will be applied to the next reporting cycle. Documentation of the review process will be retained and made available for future audits. The City is committed to maintaining compliance with all applicable federal regulations and improving internal controls to ensure the integrity and accuracy of all grant-related reporting. Anticipated Completion Date: June 2025 Responsible Contact Person: Debra Gibson

Management implemented changes to the preparation and review process for grant reporting. Management will continue to evaluate it's controls regarding current federal awards and requirements to ensure accurate information captured, reported and maintained.

Recommendation: The City should take the necessary steps to ensure that information is provided timely as to ensure that the audited financial statements can be filed with the Federal Audit Clearinghouse within the required timeframe. Action Taken: We concur with the recommendation and it will be implemented through discussions with City personnel and outside CPA firm in preparation for closing out the year ended September 30, 2024.

2024-003 Housing Choice Voucher Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (ALN #14.871) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters This is a repeat finding of 2023-002 from September 30, 2023 (Originally reported as Material non-compliance and Material Weakness in Internal Control over Compliance under finding 2019-001 from September 30, 2019) Statement of Condition: Out of a total tenant population of approximately 1,118 vouchers, 25 files were selected for testing, and the following errors were discovered. • 2 tenant files had the following error: o The HAP contract in the tenants’ file was not signed by a representative of Ocala Housing Authority. • 1 tenant file had the following error: o The tenant's utility allowance was incorrectly calculated using the 2023 utility allowance rates. The 2024 utility allowance rates should have been used. Correcting this error will decrease the Housing Assistance Payment by $4. • 1 tenant file had the following error: o The tenant's utility allowance was incorrectly calculated using the 2023 utility allowance rates. The 2024 utility allowance rates should have been used. Correcting this error will increase the Housing Assistance Payment by $23. • 1 tenant file had the following error: o The tenant's utility allowance was incorrectly calculated using the 2023 utility allowance rates. The 2024 utility allowance rates should have been used. Correcting this error will increase the Housing Assistance Payment by $7. • 1 tenant file had the following error: o The tenant's utility allowance was incorrectly calculated using the 2023 utility allowance rates for a 1-bedroom unit. The 2024 utility allowance rates for a 2-bedroom unit should have been used. Correcting this error will increase the Housing Assistance Payment by $20. 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 sent to the Compliance 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 Counselor handling specialty vouchers, will attend Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training and successfully passed the certification exam during the next 24 months, as budget permits.

2024-003 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payment standard. Cause: Human error in the entry of payment standard which affected the assistance payment. Effect: The cost of the assistance may be disallowed. Context: A sample of grants totaling $29,234 was selected for audit from a population of $12,361,012. The test found questioned costs totaling $212. Our sample was a statistically valid sample. CORRECTIVE ACTION PLAN RESPONSE: Housing counselors have been instructed to double check that the computer system is pulling in the correct payment standard and document if they override it and why. A new transaction check list has been created with a spot where they have to note the payment standard they are using in the transaction. Anticipated completion date: 9/30/25 Responsible party: Michelle Worthington, Section 8 Housing Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.

2024-001 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payment standard. Cause: Human error in the entry of payment standard which affected the assistance payment. Effect: The cost of the assistance may be disallowed. Context: A sample of grants totaling $29,234 was selected for audit from a population of $12,361,012. The test found questioned costs totaling $212. Our sample was a statistically valid sample. CORRECTIVE ACTION PLAN RESPONSE: Housing counselors have been instructed to double check that the computer system is pulling in the correct payment standard and document if they override it and why. A new transaction check list has been created with a spot where they have to note the payment standard they are using in the transaction. Anticipated completion date: 9/30/25 Responsible party: Michelle Worthington, Section 8 Housing Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.

Finding 2024-004 Personnel Responsible for Corrective Action: Director of Sponsored Programs - Eva Kain, Grant Accountant – Charme Benson and Comptroller – Steve Wille Anticipated Completion Date: June 30, 2025 Corrective Action Plan:. The Grant Accountant, in collaboration with the Comptroller and Director of Sponsored Programs, will compile SEFA data on a quarterly basis and reconcile it against CX reports. The Sponsored Programs Director will verify all Assistance Listing Numbers (ALNs), subrecipient amounts, and accruals. Documentation of all federal awards and drawdowns will be maintained in a centralized repository for internal and audit access.

Finding 2024-007 Personnel Responsible for Corrective Action: Grant Principal Investigators and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: All expenses must be supported by documentation and comply with Generally Accepted Accounting Principles (GAAP) standards. A pre-review checklist will be required for all charges against FIPSE grants. Prepaid items must be recorded in the prepaid ledger and amortized appropriately. Documentation will be retained in alignment with the University Record Retention policy. Management will implement a formal review and approval process to ensure that all allowable costs are verified for compliance with applicable regulations and approved by designated personnel prior to reimbursement or payment.