Corrective Action Plans

Finding #2024-001 – Program Income Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – December 10, 2024 Corrective Action Plan: Effective immediately, the Organization will comply with the program income compliance requirement of the U.S. Department of Housing and Urban Development (HUD) Continuum of Care Program by netting program income generated from the pass-through grant to the amount to be reimbursed prior to submitting the reimbursement request to HUD, in accordance with the protocol outlined in the manual issued by the Behavioral Health Authority (BHA).

State of Condition:During the year ended June 30, 2024, the Center had unexpended program income for the 5 year term of the cooperative agreement. Corrective Action: Resolved. The Center made restitution for the unexpended amount as well as implemented new procedures to track program income and expenses to ensure the issue does not occur in the future

Town management concurs with the finding, and while audit staff were still onsite for field work, Town staff implemented and added tracking and documentation information for all federally funded capital assets, to include unique descriptors, Catalog of Federal Domestic Assistance grant number, funding source and amount. In addition, inventory counts for federally funded assets will be conducted and recorded at least once every two years.

Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls to ensure all tenant files are maintained in accordance with the HUD Handbook.

Action Taken in Response to Finding: Financial practices addressing program income were in place; however, processes were formalized to ensure full compliance with 2 CFR §200.307. ActivateWork developed and implemented a Program Income Policy as part of its Financial Policies and Procedures, adopted May 2026. As of March 2026, a standardized program income tracking and reconciliation is performed monthly as part of the month-end (EOM) close. This process includes: • Identification and tracking of program income by funding source • Application of program income to actual allowable expenses • Mapping of Federal reimbursement requests to underlying expenses to ensure program income is applied prior to reimbursement • Validation that no duplication of funding occurs between program income and Federal reimbursements These enhancements establish a structured and auditable framework for program income tracking, application, and compliance. Control Enhancement: Program income is tracked and recorded within a standardized Excel-based tool (Program Income vs. Unreimbursed Cost Analysis) and applied in accordance with federal requirements. A standardized program income tracker: • Applies program income to actual expenses • Links expenses to reimbursement requests • Ensures program income is fully utilized prior to requesting Federal reimbursement, unless otherwise specified by award terms • Prevents duplication of income and reimbursement Monitoring & Review: • Program income tracking is reviewed monthly as part of the EOM close process • Review is performed by the Senior Accountant • A secondary review is performed by the Director of Finance & Operations to validate completeness and compliance • Any discrepancies are identified and resolved prior to reimbursement submission Testing & Validation: • Beginning in June 2026, quarterly internal reviews will be conducted to validate program income tracking and application • Testing will confirm that: o Program income is accurately recorded o Program income is applied prior to reimbursement o No duplication of funding exists • Results will be documented and tracked for remediation Documentation & Evidence: • Program income tracker maintained in Teams / SharePoint • Supporting documentation tied to underlying expenses Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Helen Young Hayes, Founder / Chief Executive Officer, in coordination with the Director of Finance & Operations and Finance Staff Anticipated Completion Date: All corrective actions will be implemented by June 30, 2026. Ongoing monthly monitoring, reconciliation, and quarterly validation will continue. Status: • Program Income Policy: Implemented May 2026 • Program income tracking process: Implemented April 2026 • Monthly reconciliation and application (EOM Close): Implemented May 2026 • Quarterly internal reviews will be conducted to validate program income tracking and application: June 2026.

FINDING 2023-002 Finding Subject: CDBG - Entitlement Grants Cluster - Program Income Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: This same finding was part of the 2022 audit in Finding 2022-003. The department was aware that this same finding would be arising in the 2023 audit again due to multiple year errors of previous staff. The corrective action plan proposed and adopted as part of the Corrective Action Plan for finding 2022-003 is still in force and is working to eliminate such findings in the future. The Lake County Redevelopment Commission adopted Resolution 001-2025 on January 16th, 2025 amending the Policy and Procedures Manual of the Department concerning Program Income (PI) internal controls for proper reporting in the IDIS system to address and correct the finding going forward. Anticipated Completion Date: Done

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26

2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are consistently implemented. In addition, documentation should be included in each participant's files to support income calculations and the participant's share of rent payable to the program. Corrective Action: We would like to clarify our approach to income documentation within client files: 1. Income Documentation: While not all clients have income, we will ensure that clients without income provide a zero-income affidavit (also known as a non-income affidavit) to document their status. 2. Stabilized Case Management: Our current case managers have been with Temenos CDC (TCDC) for over a year, providing stability and experience in verifying client income. 3. Policy and Procedure Updates: Recent updates to our policies and procedures have introduced standardized forms that clearly differentiate between households with income and those without. 1. Households with income will include the mandatory TCDC income calculation sheet. 2. Households without income will be required to submit the zero-income affidavit. 4. File Checklists: We have created file checklists to ensure uniformity across all client files, enhancing our documentation process. 5. Annual Audits: All client files will be audited by a supervisor at least once a year to ensure compliance with our policies. 6. HMIS Training: Case managers are required to complete mandatory HMIS training, which supports effective compliance in file management and income verification. These measures are designed to strengthen our documentation practices and ensure compliance with audit requirements. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Mandatory Training Implemented 01/2025 Updated Document Requirements 11/2025

2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income received during 2023, it was noted that the Authority did not report all program income received into IDIS. As a result of not entering all program income into IDIS, our testing indicated that new entitlement funds were drawn down prior to utilizing all available program income on hand. The Authority utilizes a separate general ledger account in the financial reporting software to record all program income received for each federal grant program. The Fiscal Officer enters the program income into IDIS. No internal control existed to ensure the completeness or accuracy of the program income information entered into IDIS. Recommendation We recommend the Authority develop and implement an internal control procedure to ensure that all program income is entered timely within the IDIS system. Prior to drawing down new entitlement funding, the program income general ledger account associated with the grant program should be reviewed and compared to the program income reported within IDIS to ensure all program income is recorded and fully utilized before drawing down additional entitlement funding. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. Current Status of Corrective Action Plan This finding has been resolved by management. The new policy was implemented on April 1, 2025.

Benjie Read CFO and Felecia Read Staff Accountant, will update written policies and procedures to implement the requirements of 2 CFR 200.305 to include a review and documentation of the cash draw requests prior to submission. This will be completed within 90 days of audit completion. In addition, we no longer operate the only Federal program where cash draws were allowed.

Finding Number: 2023-044 Finding Name: Inaccurate Information Included in the Financial Reports Finding Condition(s): The Illinois Department of Transportation (IDOT) did not prepare accurate federal financial status reports for the Airport Improvement Program. Name of Contact Person(s): • Melanie Quinn, Contracts Section Manager – Illinois Department of Transportation, Division of Aeronautics • Joe Segobiano, Bureau Chief of Administrative Services – Illinois Department of Transportation, Division of Aeronautics Corrective Action(s): IDOT is working to fully staff and train the Contracts Section of the Division of Aeronautics to ensure reporting is completed as required. Proposed Completion Date: June 30, 2026

2023-003 Period of Performance - Community Development Block Grants/Entitlement Grants Cluster Assistance Listing Number 14.218 Grant Period - Year Ended December 31, 2023 Condition Found The City did not meet program timeliness spending requirements. The City’s unexpended balance at December 31, 2023 of $2,683,379 is more than 1.5 times the $1,374,790 entitlement grant for the current year. We consider this to be an instance of non-compliance relating to the Period of Performance Compliance Requirement. Corrective Action Plan The City of Decatur Economic & Community Development Department is under new leadership with Lacie Elzy as Acting Economic & Community Development Director. Director Elzy will be reviewing all grant programs and duties in the department and ensuring that grant requirements are being met. Responsible Person for Corrective Action Plan Lacie Elzy, Acting Economic & Community Development Director Implementation Date of Corrective Action Plan April 30, 2025

Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certified enrollment workers across California are consistently adhering to eligibility and documentation requirements. However, due to staffing challenges caused by the redirection of staff during the state of emergency declared for the COVID-19 pandemic, ADAP faced significant workforce shortages from March 2020 through much of 2023. This caused a backlog in SR processing, which delayed tasks, including the review of this client’s application. The client’s eligibility lapsed after 130 days, before SR could be conducted. The Eligibility Operations Section (EOS) of ADAP which conducts SR, is now fully staffed and has successfully addressed the backlog. As of early 2024, SR processing has returned to normal operations and is current. Estimated Implementation Date: Already implemented as of April 2024 Contact: Joseph Lagrama, ADAP Branch Chief California Department of Public Health

Condition: The Organization did not have appropriate segregation of duties surrounding the preparation and review of the monthly NIST schedules which accumulate the information necessary to calculate allowable costs and matching for drawdown requests. Further, while the Organization had written procedures over cash management, they were outdated and did not reflect the current staffing model. Planned Corrective Action: Subsequent to year end, the reorganized finance team put new controls and procedures in place. Moving forward the Accounting Supervisor will calculate the NIST MEP monthly program income which is used to determine the monthly award drawdown of cash from the available grant award funds. This is reviewed by the Controller and this report is used to create SF-425. Contact person responsible for corrective action: Alan Kowalewski, Controller Anticipated Completion Date: 07/01/24

Condition: A process was not in place during the year to ensure program income was reported accurately on the SF-425 reports submitted during the year. Planned Corrective Action: Subsequent to year end, the reorganized finance team performed a recalculation and resubmitted corrected SF-425 reports. Moving forward the Accounting Supervisor will calculate the NIST MEP monthly program income which is used to determine the monthly award drawdown of cash from the available grant award funds. This is reviewed by the Controller and this report is used to create SF-425. Contact person responsible for corrective action: Alan Kowalewski, Controller Anticipated Completion Date: 07/01/2024

Instructions were given to the Program staff to ensure that the program income funds will be used for CDBG activities before the withdrawal of CDBG funds.

Condition: The City did not submit the required annual report related to use of program income. Planned Corrective Action: The City will work with the EPA to determine how to report the use of program income. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025

U.S. Department of Housing and Urban Development AUDIT FINDINGS: Finding Reference Number: 2023-001 Description of Finding: Homes with Hope, Inc. and Affiliate provides supportive housing via HUD Project Number 017-HD015, which requires the establishment and maintenance of a replacement reserve fund in accordance with its HUD Regulatory Agreement. The Project did not make the monthly deposits in a timely manner during the year ended December 31, 2023 as specified in the agreement, and seven months’ worth of deposits were delinquent as of December 31, 2023. This was due, at least in part, to cash flow issues that resulted from delays in the process that the Project’s property manager utilized during the period for invoicing HUD via a third-party vendor for the related rental subsidy funds. Statement of Concurrence or Nonconcurrence: Homes with Hope, Inc. and Affiliate concurs with this audit finding. Corrective Action: A new in-house billing process that does not rely on a third-party vendor has been implemented since year-end, which should eliminate the cash-flow issue, Additionally, all delinquent deposits that were due as of December 31, 2023, were deposited in March 2024. Name of Contact Person: Helen McAlinden President & Chief Executive Director 203-226-3426x14 hmcalinden@hwhct.org Projected Completion Date: Immediately

Finding No.: 2023-022 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza (GEPA) Agency disagrees with the findings. The program income is not tied to assist or supplement the federal awards. The program income is used to supplement the special revenue funds handle by the department.

Federal program title – Community Development Block Grant – CDBG – CFDA 14.228 Recommendation: CLA recommends the County develop procedures, such as reporting checklist to ensure that reporting requirements are tracked and met. Additionally, CLA recommends that the County perform cross training with employees to ensure that knowledge is shared among the team members. Action taken in response to finding: The Grants department had two employees in FY 22/23. The Grant coordinator and assistant both terminated county employment in fiscal year 22/23 and left virtually no records. Information and materials, they did leave behind were stuffed in boxes and tracking in the electronic workbook was not fully completed. Admin staff trained the Grant employees but was unaware they were not following the process and procedures, and only saving information to their personal computer. Current admin staff requested the documents from prior staff members and they were received, though we are unsure if all were sent. Staff is doing their due diligence and working diligently to get back on track in monitoring activities, and train the newly hired staff. There is insufficient budget to hire the staff needed to fully monitor the CDBG efforts. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins Planned completion date for correcting action plan: Undetermined at this time as the staff continues their current minimal CDBG efforts while still maintaining all other duties, and being short staffed. Existing CDBG workload is being closed out as fast as possible.

Financial Reporting and Review Process Description of the Finding: BSEDC did not have a secondary review process over the required financial reporting to Federal EDA. The lack of a secondary review process allowed for errors and omissions to go undetected, thus resulting in omission of $3,614 of loan origination fee income and interest income from federal program income calculations. Planned Corrective Actions: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director have implemented processes for the Senior Director of Finance to perform a secondary review of the required reporting to Federal EDA before it is submitted. Timeline for Completion: BSEDC implemented the secondary review process in October 2024 with the completion and submission of the FY24 annual report to Federal EDA. Responsible Person or Party: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director are both responsible for ensuring that the secondary review is complete before submitting reporting to Federal EDA.

Finding 2023-003 Finding Summary: In connection with the audit performed, it was noted that there was an instance where a patient received more federal assistance and another patient received less federal assistance than allowed based on federal poverty guidelines. Responsible Individuals: Kathryn Boyd, President and CEO Corrective Action Plan: The use of applying slides automatically, without reviewing the account first, has been prohibited by billing staff. In addition, clinic staff are not to apply any payments until the slide has been applied. If there are any issues with the slide, the clinic staff has been instructed to contact the billing staff for review and resolution. The Director of Revenue Cycle will randomly audit staff throughout the year to ensure additional slides are not applied and report out to the Chief Executive Officer. Anticipated Completion Date: 12/02/2024 (disallowing application of slides was previously implemented in 2023)

Finding Reference Number: 2023-003 Name of Responsible Person: Amy Reigel, Executive Director Reporting Views of Responsible Officials: We concur that there is no process in place to track that program income is expended prior to drawing on the federal grants. Concur or Do Not Concur with this Finding: Concur Agree or Disagree with Auditor Recommendations: Agree Completion Date or Proposed Completion Date: December 31, 2024 Actions Taken or Planned on this Finding: COHHIO's chart of accounts / financial management system will be updated to track the expenditure of program income in separate accounts.

2023-001 Program Income The Corporation is increasing its efforts to ensure that its policies and procedures surrounding documentation of patient income, identification, and registration is followed, and specifically that this documentation is archived correctly within every patient file. The Corporation has conducted several staff trainings and has revised its review procedures for checking compliance to improve monitoring of the process by the Corporation. Completion Date: Estimated December 2024. Contact Person: Rajuan Sherman - Chief Financial Officer - 2731 M.L. King, Jr. Blvd, Tuscaloosa, AL 35403 - (205) 614-6070 - rsherman@whatleyhealth.org.

In 2023 there was a change in management within ACED’s financial staff. The current supervisor was unaware that there was program income that had not been recorded. ACED has contracted with an outside auditing firm. All accounts are being reviewed and reconciled and program income is being receipted. ACED will receipt all program income as it comes in and it will be immediately allocated to eligible projects.