Corrective Action Plans

Management’s response and corrective action is as follows: The volume, complexity, and rapid pace needed to provide benefits inherently results in higher risk of fraud. The City-Parish's policies and procedures detected the fraud as required by program guidance. Additional restrictions were implemented to further protect the program from fraud including no longer allowing any exceptions to homestead, not allowing any single-room rentals, and requiring a landlord provide documentation of 3 months of rental payments/deposits—no handwritten receipts accepted. The City-Parish also sent an email blast out to applicants to ensure they understood the additional documentation requirements. Consultants for the City-Parish provided a fraud detection tip sheet to case managers, consolidating previously given guidance, to assist them in determining potential incidents of fraud. There have been no instances of suspected fraud since July 2023 due to these measures. Expected Implementation Date: June 2024 Contact person: Dante Bidwell, Chief Administrative Officer, Office of the Mayor-President

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2023-006 Medicaid and CHIP Participant Eligibility Terminations Name of the contact person responsible for corrective action: Heather Atkins Anticipated completion date for corrective action: June 30, 2024 Recommendations: The DSS through the MHD and the FSD review, strengthen, and enforce internal controls to ensure ineligible participant cases are closed when necessary and resume the DHSS vital records death match in the MEDES. DSS Response: The DSS partially agrees with this finding. Although, at this time, a death match with Department of Health and Senior Services (DHSS) vital records is not functional in MEDES, the death match is functional in the Family Assistance Management Information System (FAMIS) eligibility system currently used for SNAP, TANF, and MO HealthNet for Aged, Blind, and Disabled individuals. When the match is received into FAMIS from DHSS, that information is included on the eligibility file submitted to MMIS to ensure that the death date is captured in MMIS to prohibit any payments after the death of the individual. This control ensures that no improper payments are made on a beneficiary’s behalf after the date of death. DSS has processes in place to close eligibility when death information is received from family members and providers during the certification period. Additionally, DSS administers an electronic verification match with the federal hub during the annual review process to inquire about death. DSS also intends to resume use of the DHSS vital statistics match in MEDES in the future, but does not have an expected resumption date at this time. During the audit period, the FSD Call Center had processes in place to accept calls for applications, renewals, change in circumstance, and inquiries. However, contracted staff are unable to authorize any action that results in a case closing and that authorization must be completed by a DSS employee. There were procedures in place to transfer a call that will result in a case closing to a DSS employee. However, the participant cited in the finding failed to remain on the line during the transfer process, resulting in DSS staff not receiving the request to voluntarily close the case. Although call center staff noted in the electronic case file the purpose of the call, there are not systematic controls in place to take action or create tasks for DSS employees from the case notes. The DSS is strengthening internal controls by developing technology to receive changes from participants using technology that will populate the changes reported into MEDES and will create a task for DSS staff to review and authorize the change in the case. Additionally, participants can also report changes, including voluntary case closure on the FSD Portal at https://mydss.mo.gov/. Changes reported through the FSD Portal are uploaded and tasks are generated for DSS staff to review and complete the determination. Corrective action planned is as follows: Technology updates to receive changes from participants will be implemented in June 2024.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2023-016 Child Care Payments Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion date for corrective action: 12/31/2024 Corrective action planned is as follows: DESE agrees with the auditor’s finding. It has been challenging to have adequate internal controls over the child care program with two separate state agencies trying to administer different aspects of the program. The Department of Social Services (DSS) has been implementing eligibility and authorizations for families, while DESE has been administering rates, rules, licensure, and provider agreements. Effective July 1, 2024, eligibility and authorizations for families transfers under DESE’s authority to ensure all facets of program implementation are within one state agency for better internal controls. In addition, DESE transitioned to a new Child Care Data System (CCDS) for provider payments in the beginning of January 2024. Access, interfaces, and updates within the older systems has created multiple barriers and payments issues for the program. This single system, CCDS, allows parents to have a streamlined process for eligibility determinations, report changes in address or income, find or change providers, while also giving providers one place to apply for a contract, view authorizations, update contact information, view payment remittances, and make payment adjustments. By December 31, 2024, the CCDS will have combined all functions of FAMIS, FACES, and CCBIS attendance system into CCDS. DESE users can easily and efficiently make family and rate changes as necessary and view all information in the system, which will also strengthen internal controls. DESE also continues to revise and clarify internal procedures to ensure consistent and accurate eligibility determinations and claims processing. CCDF regulations specifically state pursuant to 45 CFR 98.21(a)(1) that because a child meeting eligibility requirements at the most recent eligibility determination or redetermination is considered eligible between redeterminations, any payment for such a child shall not be considered an error or improper payment due to a change in the family's circumstances. Based on this regulation, DESE will work with the Administration for Children and Families to repay any claims considered questioned costs.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-013 CACFP Subrecipient Monitoring Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: A- Risk Assessments DHSS disagrees with this recommendation because the risk assessment process performed by BCFNA is in compliance with the substance and spirit of federal regulations – both of the federal funding agency, USDA, and 2 CFR 200, Uniform Grant Guidance. BCFNA risk assessments consider relevant information and are used to determine the extent and timing of monitoring as set out in the Nutritionist Manual. The BCFNA risk-based monitoring approach already allows for monitoring subrecipients more frequently than required by USDA. 2 CFR 200.332 states pass-through entities are to evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: (1) The subrecipient's prior experience with the same or similar subawards; (2) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (3) Whether the subrecipient has new personnel or new or substantially changed systems; and (4) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). The BCFNA formal risk assessment process takes into consideration the results of current and previous experience with the same subaward (item 1 in the suggested criteria) as well as whether the subrecipient has new personnel or new or substantially changed systems (item 3 in the suggested criteria). These observations are made when performing onsite monitoring by Nutritionists who are familiar with the program, its requirements and its participants, and are trained in recognizing significant issues. BCFNA also takes into consideration the results of the subrecipient’s prior experience with similar subawards in other programs such as SFSP, NSLP and Child Care Licensing Reviews (item 1 in the suggested criteria), audit results (item 2 in the suggested criteria) as well as the results of Technical Assistance Reviews offered to new subrecipients which could move up the planned monitoring schedule. B- Subrecipient Monitoring Procedures DHSS disagrees with this recommendation. The State Auditor’s Office (SAO) states in this finding, “While our review found the sample monitoring reviews were performed in accordance with the policies and procedures outlined in the Internal Nutritionist Manual we identified areas where these policies and procedures could be strengthened and improved...” The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve it’s process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This is incongruent with the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher-ranking requirements set forth by specific federal grant funders and awards. In addition, the DHSS has a strong system of internal controls documented in the Nutritionist Manual which is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” The DHSS through BCFNA has and will continue to review, strengthen and enforce subrecipient monitoring procedures in accordance with federal program requirements and management evaluation. BCFNA has and continues to exceed what is required by the federal awarding agency by implementing a risk-based monitoring plan that allows for more frequent onsite monitoring than required by the USDA. In addition, even though COVID waivers allowed for monitoring to be suspended during the COVID Public Health Emergency, the BCFNA continued to monitor through the use of desk reviews. BCFNA also returned to onsite monitoring months before it was required by the USDA. Furthermore, BCFNA has recently hired a financial manager to help identify red flags with new and returning sponsors and recently enhanced training and technical assistance opportunities based on issues found during monitoring. Corrective Action Plans Due to the size of the CACFP program it is imperative that a risk-based approach be used in performing monitoring and follow up activities. DHSS through BCFNA follows up and ensures that subrecipients take timely and appropriate action on all deficiencies detected through on-site reviews of the subrecipient using a risk-based approach approved by the USDA. Standard practices are in compliance with federal regulations. Physical verification or review of supporting documentation immediately at the time of submission to verify the CAP is not a federal requirement. Follow-up during the next scheduled review is in accordance with USDA regulations and BCFNA policy and procedure. BCFNA reviews Corrective Action Plans (CAPs) submitted by subrecipients to ensure they are acceptable and correct noted issues. Supporting documentation of CAP implementation may be reviewed by BCFNA’s trained Nutritionist performing the monitoring reviews prior to the next monitoring visit if deemed necessary, or during the next onsite monitoring visit. This follow up is timely and appropriate because the scheduling of the next monitoring visit is determined by the USDA-approved risk-based approach. For example, subrecipients that had significantly deficient issues in their monitoring will be reviewed onsite within 90 days to verify whether corrective actions have been taken and if not, move towards termination. The corrective action plans of other subrecipients that were deemed to not be as significant by the Nutritionist, such as using the wrong percent of milk, are verified at the next monitoring review which could range from 1 to 3 years. The criteria used by the SAO do not specify what is timely or appropriate and allows for BCFNA’s professional judgement and discretion of what is timely and appropriate. Claims testing BCFNA standard practice is test only the selected month(s) claim(s) per USDA requirements, although when warranted, additional reviews are conducted beyond the test month. Actual noncompliance has not been noted in regards to testing. The BCFNA Nutritionist Manual allows for expanded testing if needed and BCFNA does perform expanded testing if deemed necessary. However, the USDA risk-based monitoring approach implemented by BCFNA sets prompt follow-up standards for significant deficiencies to determine if addressed, and if not, move on to termination. Overclaim recoupment BCFNA standard practice is to pursue recoupment of overclaims of only the test month per USDA requirements, although when warranted, additional reviews are conducted beyond the test month. In addition, BCFNA officials pursue recoupment of overclaims for facilities/sponsors with terminated contracts on a case-by-case basis, taking into consideration various factors. BCFNA strives to maintain an appropriate balance between adequate monitoring and not creating barriers to program participation per USDA and the Paperwork Reduction Act. Starting the termination process is more effective than performing additional testing and pursuing historically unsuccessful recoupment of overclaims. CACFP is an important program that provides healthy meals to children and adults. The CACFP plays a vital role in improving the quality of day care and making it more affordable for many low-income families. This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults who are enrolled for care at participating child care centers, day care homes, emergency shelters and adult day care centers. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. USDA prohibits creating barriers to program participation and provision of services. The steps over and above the USDA requirements suggested by the SAO would place significant barriers to participation in the CACFP program and in turn cause harm to needy children and adults. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies.

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

Corrective action planned: Cash flow requirements to fund daily operations will be reviewed more thoroughly so that awarded funds are expended consistent with the terms of their respective agreements. Projects presently on quarterly cost reimbursement schedules will be changed to monthly cost reimbursement requests. Contact person responsible for corrective action: John D. Pepe, Controller. Anticipated or actual completion date: October 1, 2024.

023-006 –PROCUREMENT Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff to ensure compliance with the Authority’s procurement policy. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

Finding 2023-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871 Noncompliance – N. Special Tests and Provisions – Housing Quality Standards (HQS) Enforcement Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: HQS Enforcement. For units under HAP contract that fail to meet HQS, the PHA must require the owner to correct all life threatening HQS deficiencies within 24 hours after the inspections and all other deficiencies within 30 days or within a specified PHA-approved extension. Condition: Based upon inspection of the Authority’s files and on discussion with management, the Authority did not properly abate one (1) out of twenty-five (25) annual failed inspections selected for testing. Context: The Authority did not properly abate one (1) out of twenty-five (25) failed inspections selected for testing. As a result, the Authority was not in compliance with the HQS as required by 24 CFR sections 982.158(d) and 982.405(b). Known Questioned Costs: $1,532 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS enforcement. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS enforcement. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Philisa Smith, HCV Director, is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring by December 31, 2024.

Finding 2023-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program, Federal Catalog Numbers: 14.871 Noncompliance - E - Eligibility Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of forty-three (43) tenant files, the following information was unavailable for examination at the time of audit: (3) Verification of Income (2) Verification of Assets HUD Form 50058 Our sample size is statistically valid. Known Questioned Costs: 7,162 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Section 8 Housing Choice Voucher Program is in non-compliance with the eligibility type of compliance requirements of the program. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Philisa Smith, HCV Director, is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring by December 31, 2024.

The County’s engineer has requested weekly certified payroll and backup for the payroll from the solar array contractor. The County has not paid any labor toward this project until all requirements are met.

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2023 Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING #2023-003: Section 202 Supportive Housing for the Disabled, Assistance Listing 14.157 CORRECTIVE ACTION TO BE COMPLETED: The Organization intends to apply for reinstatement of tax-exempt status. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Stewart Grounds, Chief Financial Officer of Arnold-Grounds Apartment Management & Affordable Housing Specialists, LLC.

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2023 Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING #2023-002: Section 202 Supportive Housing for the Disabled, Assistance Listing 14.157 and Section 8 Housing Assistance Payments Program, Assistance Listing 14.195 CORRECTIVE ACTION TO BE COMPLETED: The Corporation completed and submitted the financials for audit for the year ended September 30, 2023. The financial data was submitted into the FASSUB system. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Stewart Grounds, Chief Financial Officer of Arnold-Grounds Apartment Management & Affordable Housing Specialists, LLC.

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2023 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING 1: Section 202 Supportive Housing for the Disabled, Assistance Listing 14.157 and Section 8 Housing Assistance Payments Program, Assistance Listing 14.195 CORRECTIVE ACTION COMPLETED: On August 7, 2024, the Project deposited $2,450 into the replacement reserve account. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Stewart Grounds, Chief Financial Officer of Arnold-Grounds Apartment Management & Affordable Housing Specialists, LLC.

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, and restricted purpose requirements. Name, address, and telephone of District contact person: Caryn Metsker, Director of Financial Services 800 Eastmont Avenue East Wenatchee, WA 98802-4443 509-888-4686 Corrective action the auditee plans to take in response to the finding: The Eastmont School District respectfully does not concur with the finding regarding our internal controls for ensuring compliance with allowable activities, costs, and restricted purpose requirements in regard to the Emergency Connectivity Funds. The District has completed the necessary corrective actions by revising our board policies and procedures to ensure compliance with allowable activities, costs, and restricted purpose requirements. However, these changes were not implemented by the end of the 2022-2023 school year because the audit for the 2021-2022 school year had not been completed until the 2023-2024 school year. Consequently, the District was unable to implement the new process until the audit status for 2021-2022 was confirmed, ensuring that the corrected steps were compliant The District did not receive any specific guidance from the State Auditor's Office on how to properly document the unmet need identified in the audit. Despite our efforts to seek assistance and clarification, the lack of direction hindered our ability to address the finding promptly. The necessary changes to our policies and procedures required approval from the Board of Directors. This approval, governed by a strict process, was not obtained until December 2023. We began working on the changes immediately following the previous audit but were constrained by the formal approval process. The District is disappointed that despite our efforts to comply, the State Auditor's Office issued another finding for the 2022-2023 audit based on a differing opinion on the "unmet" need. This repetition of findings, despite our documented efforts and changes, suggests a misalignment in expectations and understanding. The audit for the 2022-2023 school year consumed significant resources and taxpayer dollars, which we believe could have been better utilized. The time spent reviewing our information, which was largely unchanged except for the updated policy and procedure, appears redundant. We had asked for documentation and guidance from the State Auditor's Office but did not receive the necessary support or compliance assistance. The District is committed to maintaining high standards of accountability and compliance. We regret that our efforts to address the audit findings were not deemed timely enough and that this has resulted in an additional finding. We will continue to enhance our processes and seek clearer communication and guidance from the State Auditor's Office to ensure that future audits are more aligned with our compliance efforts. We hope this response provides a clear understanding of our position and the steps we have taken. Anticipated date to complete the corrective action: The corrective action has already been implemented within the school district.

The Human Services Department The Human Services Department has acknowledged the issue identified regarding timesheet pre-approvals and will take immediate steps to address the issue. HSD will ensure that proxy timesheet approvers are properly assigned in cases where the primary supervisor is unavailable on the day payroll approval is due. HSD will maintain compliance with payroll policies and ensure the accuracy of timesheet approvals. Office of Housing The Office of Housing has acknowledged the finding regarding timesheet pre-approvals and will take immediate steps to address the issue. Office of Housing will ensure that proxy timesheet approvers are properly assigned in cases where the primary supervisor is unavailable on the day payroll approval is due. This adjustment will be incorporated into the previous improved practices, eliminating the need for pre-approving timesheets. By ensuring that proxy approvers are in place, the department will maintain compliance with payroll policies and ensure the accuracy of timesheet approvals. Parks and Recreation Department The Parks and Recreation Department acknowledges the finding regarding timesheet preapprovals and will ensure that proxy timesheet approvers are assigned moving forward as part of the department's ongoing commitment to improved practices. In addition, the department would like to clarify that the pre-approval noted occurred before the implementation of the current corrective action plan, which addressed the prior year's finding. The department reassures the State Auditor's Office (SAO) that the newly adopted practices, which prevent preapprovals, will continue to be strictly followed, ensuring compliance and accuracy in payroll processing, even during pay periods that coincide with holidays.

For the Rockford Supportive Housing Facility - FINDING 2023-005: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 - HUD SUBSIDY LOAN FROM REPLACEMENT REERVES NOT REPAID - Recommendation: The Project should repay the HUD subsidy loan as soon as funds are available. Action Taken: The Project agrees with the finding. A $15,000 transfer will be made once funds are available. Management will be reminded to carefully review HUD correspondence to make sure HUD subsidy loan terms are being followed.

For the OTR - Arboretum West Apartments Facility - FINDING 2023-007: SECTION 223(f), ASSISTANCE LISTING NUMBER 14.155 - REPLACEMENT RESERVE BALANCE UNDERFUNDED - Recommendation: The Project should deposit the correct amount monthly to the reserve. Action Taken: The Project agrees with the finding. Management will be reminded to deposit the correct amount monthly to the reserve. The Project deposited $488 into the reserve account in January 2024.

For the Hill Housing Facility - FINDING 2023-004: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 - OVERPAYMENT OF MANAGEMENT FEES - Recommendation: The management company should repay the $653 to the Project. Action Taken: The Project agrees with the finding. The management company will repay the management fee overpayment as soon as possible.

For the Hill Housing Facility - FINDING 2023-002: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 - SPONSOR LOAN PAYMENT WITHOUT HUD APPROVAL - Recommendation: The Sponsor should work with HUD to determine if the $130,019 needs to be paid back to the Project. Action Taken: The Sponsor will work with HUD to determine if the $130,019 needs to be paid back to the Project.

For the Hill Housing Facility - FINDING 2023-001: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 - SURPLUS CASH NOT DEPOSITED INTO RESIDUAL RECEIPTS ACCOUNT - Recommendation: The Project should deposit surplus cash as of December 31, 2021 into a residual receipts account as soon as possible. Action Taken: The Project agrees with the finding. Management will deposit $14,079 in a residual receipts account as soon as possible.

Views of Responsible Officials and Planned Corrective Action: We concur. Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Even if lost revenues for the January 1, 2023 through June 30, 2023 time period are appropriately reduced to zero, the Hospital had $7,855,000 of unused lost revenues following submission #4, well in excess of the $1,326,000 of funding received in Period 5 requiring substantiation.

Management recognizes the importance of maintaining proper documentation for grant expenditures and has implemented the following corrective measures to address the deficiency: 1. Development of Comprehensive Documentation Guidelines: We have developed detailed guidelines outlining the specific documentation requirements for all grant-related expenditures. This includes mandatory documentation such as receipts, invoices, contracts, and timekeeping records, as well as detailed descriptions of each expense. 2. Centralized Repository for Grant Documentation: A centralized, secure digital repository has been established to store all grant-related documentation. All departments are now required to upload supporting documents immediately after incurring expenses, ensuring they are readily accessible for review and audit purposes. 3. Staff Training on Documentation Requirements: We have initiated a mandatory training program for all fiscal staff involved in grant management. This training covers the specific documentation and reporting requirements for federal, state, and private grants, emphasizing the importance of complete and accurate records. 4. Strengthened Review and Approval Process: We have enhanced the internal review process for grant expenditures. All grant-related transactions will be subject to a secondary review by the controller and Chief Financial Officer to ensure that the necessary supporting documents are included and expenditures are properly classified and documented. Management will closely monitor adherence to the new documentation policies and conduct quarterly audits to assess the completeness and accuracy of the records. Any discrepancies or missing documentation will be addressed promptly, and corrective actions will be taken to prevent recurrence. Management is fully committed to maintaining detailed and accurate records for all grant expenditures. The actions outlined above are designed to strengthen internal controls, ensure compliance with grant requirements, and support future audits with comprehensive documentation.

To address the identified weaknesses and strengthen internal controls over the preparation of the SEFA, management has initiated the following actions: 1. Establishment of Formal Policies and Procedures: We have developed and implemented a formal, written policy for the preparation and review of the SEFA. This policy outlines clear roles, responsibilities, and timelines for all departments involved in the process. 2. Centralization of Data Collection: We are centralizing the process of collecting expenditure data, which will be overseen by a designated team within the fiscal department. This will ensure consistency and accuracy in reporting across all departments. 3. Staff Training and Development: Key personnel involved in SEFA preparation are undergoing specialized training on federal, state, and city compliance requirements. This includes training on the proper classification of awards and expenditures. 4. Internal Review and Monitoring: A second layer of review has been introduced to verify the accuracy and completeness of the SEFA before it is submitted. A senior financial officer will perform this review, ensuring that any discrepancies are identified and corrected before submission. Management will implement ongoing monitoring to ensure adherence to the new policies and procedures. Quarterly reviews will be conducted to assess the accuracy of the data and the efficiency of the control measures. Management is committed to maintaining robust internal controls over the preparation of the SEFA to ensure the timely and accurate reporting of federal, state, and city awards. The actions outlined above are designed to prevent the recurrence of this deficiency and ensure full compliance with regulatory requirements.

Contact Person - Pattie Solberg, Auditor; Corrective Action Plan - The City should contact the Contractor to determine if the amount that was overpaid will be refunded or adjusted on the next "Pay Estimate." The City will also need to contact the Grantor to determine if the reimbursed dollars should be returned or adjusted on the next draw. To mitigate the risk of overpayment in the future, the City should reconcile construction payments to the "Pay Estimates." Completion Date - December 1, 2024

CORRECTIVE ACTION PLAN SEPTEMBER 4, 2024 The POISE Foundation respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Maher Duessel, CPAs 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: January 1, 2023 to December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule.Finding 2023-001 - Internal Control over Financial Reporting - Allowable Costs U.S. Department of Health and Human Services, Passed through the Pennsylvania Department of Health Immunization Cooperative Agreements, ALN 93.268 Allowable Costs Condition: The Foundation did not have adequate procedures in place to ensure that all costs submitted to the Pennsylvania Department of Health (DOH) were allowable. Close monitoring of invoices was performed by DOH, resulting in repeated requests to adjust invoicing of grant costs to remove unallowable costs. This cycle of submission and rejection went on for many months, elongating the reimbursement process. During our compliance testing, we noted three of twenty-five expenditures charged to the federal grant and selected for detailed testing that were determined to be unallowable costs. These unallowable costs were also identified by the DOH during their invoice review.Total federal expenditures between 2021 and 2023 were $2,549,344. Of this amount, expenditures totaling $1,049,850 have been reviewed in totality and ultimately approved by the DOH as allowable costs, after corrections were made by the Foundation. Remaining federal expenditures incurred in 2023 of $1,499,494 are pending DOH approval. Based on previously identified unallowable costs, we acknowledge there could be additional unallowable costs as the DOH reviews and approves invoices relating to the remaining 2023 federal expenditures. The amount of potential unallowable costs cannot be quantified. As was understood by the Foundation to be the case from grant inception, the DOH intends to review each monthly invoice to ensure 100% of costs are allowable, and will not move forward to the next month until the month under review is corrected by the Foundation and approved by DOH for reimbursement. Criteria: The Foundation administered the federal 93.268 grant passed through from the Pennsylvania Department of Health and therefore committed to following the internal control and compliance regulations set forth in Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance).Cause: The Foundation does not have internal controls in place to ensure adequate review of allowable costs for the DOH grant. Effect: The Foundation was not in compliance with allowable costs. As described above, significant effort was required on the part of the Foundation to invoice and make corrections and re-submit and significant effort was required on the part of DOH to monitor the grant submissions. This resulted in significant delays in the receipt of additional grant reimbursements by the Foundation and negatively impacted the Foundation's cash flows. Questioned costs: Unknown.Context: 100% testing by DOH to date has indicated systemic issues. Our sampling resulted in similar findings. DOH intends to do a 100% test of all transactions.Repeat Finding from Prior Year: No. Recommendation: We recommend that management establish procedures to ensure that all costs charged to the grant are appropriately reviewed and determined allowable per the grant agreement, ideally before even being incurred but certainly before being invoiced to the DOH. POISE Foundation Response: Management acknowledges several costs included in the initial invoice were deemed to be unallowable costs. It was communicated to management that it could not submit the initial invoice until all expenses had occurred for the initial payment. The initial invoice included a span of 19 months and many of the unallowable costs were reoccurring costs that were deemed unallowable. Management has hired a new Managing Director who has oversight of the invoicing process. The Managing Director has reviewed all unsubmitted invoices to ensure past costs that were deemed unallowable will not be charged in subsequent invoices and will review any new costs to ensure they comply with allowable costs. This is currently being done as of the date of this letter. Finding 2023-002: Internal Control over Financial Reporting and Account Adjustments Condition: During the audit process, several adjustments involving contribution revenue and related contributions receivable were proposed by the auditors in order for the financial statements to be prepared in accordance with accounting principles generally accepted in the United States of America (GAAP). Then, using the information provided by management, the auditors prepared the GAAP financial statements, which were subsequently reviewed by management. These adjustments were necessary to properly reflect current year operations and account balances as of year-end. Criteria: Auditing standards continue to place emphasis on determining an entity's ability to fully prepare their own external financial statements, including the posting of all adjustments necessary to present financial statements in accordance with GAAP and evaluating the need for all necessary financial statement disclosures.Cause: Internal controls were not in place to ensure that the Foundation follow appropriate contribution revenue recognition standards for conditional and unconditional grant awards and the Foundation did not post necessary adjustments for contribution revenue to be recorded in accordance with GAAP. Effect: Adjustments were required to be recorded in order for the financial statements to be prepared in accordance with GAAP. Recommendation: We recommend that management evaluate the internal controls over the financial reporting process to ensure that an individual is assigned to review contributions received for proper revenue recognition and to ensure the financial statements are prepared in accordance with GAAP. POISE Foundation Response: POISE Foundation has put in place a process whereby revenue will be classified as conditional or unconditional and booked accordingly based on a review of funding agreements and contracts by the development, program and finance department staff to ensure there is agreement on the nature of the revenue to ensure proper accounting in a timely manner.This is currently being done as of the date of this letter. If the Pennsylvania Department of Health has questions regarding this plan, please contact Mark S. Lewis at 412-281-4967