Corrective Action Plans

OAK STREET SENIOR APARTMENTS, INC. HUD PROJECT NO. 048-EE018 CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Oak Street Senior Apartments, Inc. respectfully submits the following corrective action plan for the year end December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave. Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2024 Corporation Contact Person: Elliott Broderick, Management Agent Representative The finding from the December 31, 2024 schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding – Federal Award Findings and Questioned Costs Finding 2024-001: Considered a significant deficiency in internal control over financial reporting Recommendation: The Corporation should ensure that there are proper internal controls in place over financial reporting to ensure accurate and timely submission of financial transactions, including monthly replacement reserve deposits. Action to be Taken: The Management agent concurs with the facts of this finding and as properly funded the replacement reserve account in 2025.

Views of Responsible Officials: Management agrees and will implement improved documentation and review procedures. Estimate time of completion: February 10, 2025.

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. As a result, three of the sixty transactions tested did not include sufficient documentation to support eligibility determinations, representing instances of noncompliance with the eligibility requirements under the federal program. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.

Finding 2024-03 Insufficient Documentation of Other Direct Expenses Condition: During testing of direct costs charged to the federal program, the Organization did not maintain sufficient documentation to fully support all expenditures claimed. In one instance, a receipt supporting a claimed expense was missing. In three additional cases, although the expenditures were generally supported, the documentation did not clearly reflect how the amounts allocated to the major federal program were determined. While these issues were isolated and the known and likely questioned costs were immaterial, the lack of complete documentation represents noncompliance with federal requirements for allowable costs. Corrective Actions Taken or Planned: The Organization will develop written guidelines specifying the required supporting documentation for each type of direct expense. Set up vendors in QuickBooks. We will hire and train Finance Manager to manage and track revenue and expenses, QuickBooks, grant reporting etc. All receipts and expenses will be scanned in and kept electronically. The Organization will provide training on documentation requirements, proper record submission, and compliance expectations.

Finding 2024-02 Insufficient Documentation of Personnel Expenses Condition: The Organization charges a material amount of payroll-related costs to its major federal program. However, it does not maintain sufficient documentation to support the level of effort charged to the award, as required by federal regulations. While staff members are required to complete timesheets, the current format does not capture the level of detail needed to substantiate payroll allocations to federal programs. Additionally, there is no formal process for supervisory review and approval of these timesheets. Although no overcharges or double-dipping were identified, the lack of adequate documentation results in known and likely questioned costs due to noncompliance with documentation requirements. Corrective Actions Taken or Planned: The Organization will develop and implement a standardized timesheet template (Gusto) that captures employee name, pay period, hours worked by funding source, and supervisory approval. Provide mandatory training for all staff whose salaries are charged in whole or in part to grants on documentation and time allocation requirements. Require monthly reconciliation of time sheets to payroll records before submission to grants. The Organization will conduct quarterly internal reviews to ensure compliance and adjust as needed.

The Chickahominy Indian Tribe respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, Virginia 22801 Audit period: December 31, 2024 The findings from the December 31, 2024 Schedule of Findings and Questioned Costs (the “Schedule”) are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS – FINANCIAL STATEMENT AUDIT 2024-001: Material Audit Adjustments (Material Weakness) Condition: Multiple material audit adjustments were proposed. Criteria: Financial information should be materially correct. Cause: The Tribe switched from using an excel spreadsheet to an accounting software for tracking financial information in 2023. During the year, there were reconciliation issues between the software and the spreadsheet which did not get resolved. Material audit adjustments needed to be made to ensure the accuracy of the financial statement, but the cumulative effect of these entries was significantly less than in the prior year. Effect: Audit adjustments were required to ensure the financial statements are materially correct. Recommendation: We do not consider it necessary to reconcile between the Tribal Ledger and Abila; however, we strongly encourage adding a procedure to the monthly bank reconciliations. Bank deposits should be matched to Abila revenue, and bank disbursements to Abila expenses. This will ensure revenues and expenses are properly recorded in addition to ending cash balances being reconciled. Corrective Action: The accounting software is the only source of accounting information now. The Tribal Ledger is no longer being maintained. We continue to learn the intricacies of the new software and the proper way to use it. We are instituting a more formal schedule for review of accounting entries, to ensure they are done in a more timely manner. We have been developing a handbook which will list proper procedures, including proper entry of non- typical transactions. It will also include the procedure for bank reconciliation. We anticipate that material audit adjustments will not be required in the future. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT 2024-002: Child Care Development Fund Cluster ALN 93.575 and 93.596 Condition There was one expenditure tested under the CCDF American Rescue Plan Act Child Care Supplementary Discretionary grant that did not get obligated by the required date. Criteria Funds should be obligated by the end of the succeeding federal fiscal year after award and expended by the end of the third federal fiscal year. Cause The CCDF ARP Supplementary Discretionary grant was the only grant that did not receive a federal extension or Tribal waiver. The Tribe was under the impression that all CCDF grants would have waivers. Effect One item was not obligated by the required date, total $13,604. Perspective Information One tested of one in the ARP discretionary, but one of 25 in all CCDF. Recommendation We recommend establishing a formal policy regarding definitions of obligation and liquidation. This should be formally approved by Council with a resolution. Corrective Action: During a meeting prior to the end of the obligation period, we decided how we would use the referenced funds. We documented that decision in the meeting minutes and believed we had met the obligation requirements. The Funding Agency was satisfied with our explanation of the funds being considered obligated, as Tribes can define obligation in their own terms. However, the actual contract wasn’t executed until after the obligation period was over. In addition, we also thought the obligation and liquidation periods for this particular grant had been extended along with those of similar grants that we have from this agency, but realized later that they had not been. We immediately started a review at the beginning of each month of all grants to determine those whose obligation period ends that month. We also review at that time for grants whose liquidation period ends that month. When either of these occurs, I issue a notification to FinanceStaff to make them aware. I also notify the manager of those grants to ensure they are aware of the obligation and liquidation deadlines. We will also review our Financial Policy and clarify our definition of Obligation as needed. If the Federal Audit Clearinghouse has questions regarding this plan, please call Wayne Adkins, First Assistant Chief and Finance Officer at 804-829-2027. Sincerely yours, Wayne Adkins First Assistant Chief and Finance Officer

Recommendation The Company must deposit $116,553 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2025 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

Finding Reference Number: 2024-1 Recommendation The Company must deposit $223,644 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2025 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. Name of Contact Person: Amy M Smitherman, amy.smitherman@gmail.com, 646-240-3185 Projected Completion Date: 9/15/2025

Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least biennially to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussion with management, there was a failed inspection that did not pass reinspection within 30 days without penalty. Context: There were approximately six hundred ninety four (694) failed inspections during the audit period. Of a sample size of twenty-five (25) failed inspections, one (1) unit did not pass reinspection within 30 days. HAP was not abated nor was the tenant transferred. Known Questioned Costs: $5,322 Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor and will make the necessary changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement). Sanford Riggs, Director of Operations, is responsible for implementing this corrective action by December 31, 2025

FTCC concurs with the finding and will make every attempt to create time studies and maintain labor distributions reports to support salary allocations in the future. FTCC anticipates to complete the corrective action plan by the year end December 31, 2025.

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to 2023-2024, we only had one primary HUD contract that we were solely responsible for spending and contract timelines. With the addition of three more COC grants, with different, yet close together end dates, we needed to develop a more formalized process to ensure all expenses are billed to the correct contract for the correct dates. Avivo will implement oversight check-in meetings at least one month prior to each contract end and at least one more before final grant submissions. This meeting will include program leadership, RAA, Director of Housing Compliance, and our Contracts Accountant who oversees eLOCCS pulls. We will discuss all final expenditures and any upcoming expenses that may near the end of the grant term, including staff expenditures like mileage reimbursement. We will create an oversight document that highlights all areas to consider and breaks down roles and responsibilities to drive these meetings ongoingly. Accounting and program leadership will closely monitor spending via Papersave, credit card submission and through Paycom falls within the correct payment periods. Additionally, the RAA and Program Managers in the last quarter of the grant cycle, will meet monthly to work to resolve any outstanding rent balances and oversee any staff reimbursement or other charges that may need to be accounted for. Name(s) of the contact person(s) responsible for corrective action: Courtney Knoll & Lyssa Westling. Planned completion date for corrective action plan: December 2025

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2024, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Department of Public Health (ADPH) passed through a portion of the Immunization Cooperative Agreement federal award to subrecipients. A total of fourteen subrecipients requested and received reimbursement of program expenses during the fiscal year. Based upon procedures performed, we noted that of the fourteen subrecipients who received federal award reimbursement, three did not provide adequate detailed documentation to support their request for reimbursements. In addition, sixteen of the fifty-four invoices submitted for reimbursement by the subrecipients did not have adequate documentation, resulting in question costs of $5,072,637.00. The documentation which was submitted by the subrecipients and approved by ADPH for payment consisted only of summary information and did not contain detailed information to ensure that reimbursement request costs were necessary and reasonable for the performance of the federal award. The ADPH did not have adequate policies and procedures in place to ensure that all requests for reimbursement were supported by adequate detailed documentation to ensure all costs are allowed under the federal award. Recommendation: The Alabama Department of Public Health should take action to ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and to ensure costs are allowable under the federal award. Response/Views: We agree with the Examiners' finding; adequate documentation did not exist at the time of the audit to substantiate payments that resulted in questioned costs and improper payments. To confirm the total amount of questioned costs, ADPH's Office of Program Integrity initiated its own ongoing investigation. ADPH also requested the Examiners of Public Accounts to conduct a special program audit which is ongoing. As this process continues, ADPH is requesting additional documentation from the subrecipients, which may affect the questioned costs of this program. Corrective Action Planned:ADPH will continue to strengthen its internal control system for grant management by conducting ongoing grant training internally and externally which is available for all employees who handle grants. ADPH is strengthening the internal control system for grants management. ADPH has and will continue to develop internal grant training for all employees who handle any phase of grant activities or have managerial responsibility for a grant. ADPH is working to make this training mandatory. The Bureau of Financial Services is continuing to work on staffing up a Grants Management Office and grant tools are being distributed or added to document library for use by ADPH programs such as Risk Assessment Forms and monitoring forms. Corrective Action within the Immunization Division Completed and Ongoing through August 2025: There has been a reorganization in leadership within the Immunization Division, however the Department remains committed to hiring additional staff to support grant review and monitoring. Immunization implemented the following procedures: • Reviews grant guidance semi-annually, or when updated, with program grant monitoring staff to ensure compliance. • Invoices and supporting documentation are being reviewed for source documents against grant guidance as received by program staff and approved by Operations Manager or Division Director to ensure costs to the grant are reasonable, allowable, allocable, and consistently applied before forwarding to Finance. Finance is conducting further reviews before uploading into STAARS for payment. • Grant monitoring staff ensures that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and costs are allowable under the federal award. • Invoices or vague requests requiring additional documentation will be held until the necessary information is provided. • All program grant staff have access to attend all available Finance and Grant training courses. • Engages assigned Grant Accountant on a quarterly basis or more frequently as requested. • There were no new subrecipients to conduct a Risk Assessment within 30 days of a signed grant agreement which will be forwarded to OPI for review. • Immunization staff conducted Risk Assessments on all the current subrecipients within 60 days which was forwarded to OPI for review. • Immunization staff, along with Finance and OPI, developed a subrecipient monitoring plan based on the Risk Assessment of each subrecipient. The monitoring plan was completed within 30 days of the receipt of the completed Risk Assessment. • Copies of all completed monitoring activities, as outlined in the monitoring plan, were forwarded to OPI. Anticipated Completion Date: September 30, 2025 with ongoing strengthening of internal controls and trainings. Contact Person(s): Shaundra B. Morris Chief Accountant & Director of Financial Services Alabama Department of Public Health Financial Services Bureau The RSA Tower, Suite 1068, 201 Monroe Street Montgomery, AL 36104 (334) 206-5464 Shaundra.Morris@adph.state.al.us Burnestine P. Taylor, MD Medical Officer, Disease Control and Prevention Alabama Department of Public Health The RSA Tower, Suite 1418, 201 Monroe Street Montgomery, AL 36104 (334) 206-9380 phone Burnestine.Taylor@ adph.state.al.us

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2024, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Medicaid Agency (“AMA”) operates a Non-Emergency Transportation (“NET”) program for individuals who are eligible for Medicaid benefits. This program helps eligible recipients pay for rides to dental and doctor offices, hospitals and other medical facilities when the service is also covered by Medicaid and the costs are paid with federal Medicaid program monies. Eligible recipients can request and receive reimbursements for the costs of utilizing the NET program. Subsequent to the payments of certain NET claims, AMA received information alleging that falsified information related to certain NET expenditures was being submitted and approved on behalf of a specific recipient. Upon receipt of these allegations, AMA initiated a review of the supporting documentation which had been submitted and approved. The review consisted of a detailed examination of all NET claims associated with the recipient. The results of the examination revealed that an AMA employee was entering and approving falsified information on behalf of a recipient. We reviewed, recalculated and verified information provided to us by AMA and did not note any differences. For the fiscal year ended September 30, 2024, there were 347 NET reimbursement requests totaling $30,501.75 submitted in the name of the specific recipient and of those, all 347 reimbursement requests were based on falsified non-existent documentation. The Alabama Medicaid Agency reimbursed the recipient based on falsified reimbursement requests and, therefore, improperly expended Medicaid Cluster federal award program funds. Recommendation: The Alabama Medicaid Agency should take actions to ensure that all reimbursements of expenses are adequately documented, based on true and accurate supporting documentation, and to ensure costs are allowable under the federal award. Response/Views: The Alabama Medicaid Agency agrees with the above recommendation. Medicaid immediately took action when it discovered an employee was defrauding the program by approving falsified claims. The immediate actions included terminating the employee, referring the employee for criminal prosecution, and making corrective actions. Corrective Action Planned: Corrective actions began immediately when the falsified claims were discovered by the Alabama Medicaid Agency. Employee access to the Non-Emergency Transportation (NET) reimbursement system has been reviewed and updated. Payment override access has been limited to two persons. Also, each NET program employee has been required to update their list of family or acquaintances to ensure each employee does not have a conflict of interest when reviewing reimbursement requests. The conflict-of-interest updates have been entered into the system. Finally, all NET employees have been required to attend training on program operation and policies. Anticipated Completion Date: The above-mentioned Corrective Action was completed in February 2025. Contact Person(s): Stephanie Lindsay, Chief Assistant to the Commissioner, at stephanie.lindsay@medicaid.alabama.gov or (334) 353-3781.

County department personnel changes have been implemented, which address this deficiency. Additional training from the Auditor’s Office and state grantors has occurred for newer staff in certain departments with large amounts of federal and state awards.

County department personnel changes have been implemented, which address this deficiency. Additional training from the Auditor’s Office and state grantors has occurred for newer staff in certain departments with large amounts of federal and state awards.

The Organization concurs with the finding and has begun implementing corrective action to address the identified issues, including enhancing internal controls and strengthening review procedures to ensure more accurate and timely financial reporting going forward.

Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Contact Person: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Corrective Action Plan: To mitigate the risk of error in payroll allocation and ensure compliance with allowable cost provisions, CFSC will enhance its payroll review process with the following corrective actions: 1. Enhanced Payroll Verification Process: a. CFSC will implement an additional cross‐checking step in the payroll entry process by requiring finance staff to a run a “Program Summary by Projects Lists” report in the timekeeping system (i.e., Clicktime) before submitting for payroll. b. This report will allow finance staff to verify that total hours worked per project per employee align with the grant allocation and employee timesheets before payroll is processed. 2. Regular Internal Audits & Compliance Checks: a. Finance will conduct quarterly internal payroll audits to identify any discrepancies in time tracking and grant allocations. Anticipated Completion Date: These corrective actions have been fully implemented as of FY25.

Management concurs with the finding and recommendation. The District recognizes the importance of adhering to the procurement standards outlined in OMB's Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). To address the identified deficiency and strengthen internal controls over federal procurements, the following corrective actions have been implemented: Corrective Actions: 1. Policy Clarification o Revise and update the District's written procurement policies and procedures to explicitly incorporate Uniform Guidance requirements, including thresholds and documentation standards' 2. Training & Communication Provide mandatory training to all staff involved in procurement, inlcuding Special Education program staff, on the federal procurement requirements and the City's updated procedures. o Distribuie clear written guidance to staff on the steps required prior to entering into vendor agreements with federal funds. 3. Strengthened Internal Controls o Implement a pre-approval checklist for all procurements to ensure compliance with Uniform Guidance requirements before purchase orders or contracts are finalized. o Require dual review und approval of all procurement transactions funded by federal awards (e.g., Program Director and Business office review). 4. Monitoring and Oversight o Establish a monthly review process conducted by the Grants, Manager/Business Office to confirm that procurements funded with federal awards are compliant and properly documented. o Maintain procurement files with required documentation (e.g., quotes, bids, justification for vendor selection) to support all transactions.

Víews of Responsíble Official and Planned Correctíve Actíon Management agrees with the recommendation. The District recognizes the importance of maintaining accurate and timely documentation to ensure that salaries and wages charged to federal awards are allowable and supported in accordance with federal cost principles. To address the deficiency, the following corrective actions will be taken: . Action: Reinforce the requiremént that all employees whose salaries are charged in whole or in part to federal grants must complete and sign time and effort certifications on at least a semi-annual basis, in accordance with 2 CFR 200.430. . Action: Develop a centralized tracking system to monitor the distribution, collection, and retention of time and effort certifications to ensure completeness and timeliness. . Action: provide training to program directors, supervisors, and staff on the requirements for time and effort reporting and the importance of compliance. . Action: Establish an intemal review process whereby the Grants Manager will conduct periodic spot-checks to confirm thaf certifications are being properly maintained and retained.

Responsible Official’s Response and Corrective Action Planned: We have reached out to FEMA and was provided this summarized response: “The project was obligated as a small project. FEMA does not adjust the funding amount unless specific conditions are met. If the applicant was stating that the actual cost for the small project was more than FEMA obligated, we would have to request what is called a New Small Project Overrun Appeal Request. But in this case, the actual cost resulted in an underrun based on the small project obligated amount. FEMA only asks for the applicants to apply the underrun amount back into the community." Management has also implemented a process to include financial oversight and review of all documents prior to submission to FEMA for reimbursement going forward. We will meet with all leadership staff to discuss documentation requirements necessary for FEMA reimbursements. Lastly, Management will only sign off on reimbursed costs after all changes to FEMA requests have been adequately documented.

2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an instance of noncompliance with regard to the Special Tests and Provisions compliance requirement. Corrective Action Plan All tenant security deposits will be collected/supplied and deposited into the appropriate bank account. Furthermore, all monthly replacement reserve deposits will be made into an interest-bearing account. Responsible Person for Corrective Action Plan The AVP of Asset Management and the CFO of this organization. Implementation Date of Corrective Action Plan December 2025

Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.

Implementation of plan of action - Management will review its internal controls and policies and procedures to ensure that requests for reimbursement are for appropriate program expenditures. Implementation date - Anticipated completion August 28, 2025. Persons responsible for the implementation - The Board of Directors and Head of School.

COVID-19-Coronavirus State and Local Relief Funds (CSLRF)-Assistance Listing No. 21.027 Allowable Activities/Costs Recommendation: The Town should review and enhance controls and procedures where necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town will continue to review and enhance controls where necessary to ensure that all State and Local Fiscal Recovery Funds (SLFRF) expenditures support an eligible COVID-19 public health or economic response. Name(s) of the contact person(s) responsible for corrective action: Tyler Home, Director of Finance Planned completion date for corrective action plan: 07/01/2024