Corrective Action Plans

Finding 2025-005 Lack of Internal Control over Special Tests and Provisions- Character Investigations Name of Contact Person: Alexis Russell, Human Resource Director Corrective Action: Background check verification will be added into the employee onboarding process for all Annette Island Service Unit employees to ensure required character investigations are completed and documented for all positions subject to Indian Child Protection and Family Violence Prevention Act requirements. In addition, Human Resources will conduct periodic internal reviews of personnel files to indentify and address any missing background check documentation for current employees Proposed Completion Date: Implemented in FY2026, ongoing monitoring in place.

Finding 2025-009 – HQS Re-Inspections Management agrees with the finding regarding quality control HQS re-inspections. The Housing Authority is implementing procedures requiring periodic quality control re-inspections of units inspected under the Housing Choice Voucher Program. These re-inspections will be documented and reviewed to ensure inspection consistency, compliance with HUD standards, and accuracy of inspection determinations. Management will maintain written records of all quality control reviews and establish schedules to ensure compliance with applicable HUD regulations. Responsible Party: Executive Director and Maintenance Supervisor Expected Completion Date: July 31, 2026

Reference Number: 2025-002 Description: Special Tests and Provisions Corrective Action Plan: Guest House has implemented stronger process controls to ensure that Rent Reasonableness forms are completed prior to executing lease agreements. Staffing changes have been made to support compliance, and enhanced review procedures have been put in place. In addition, all previously outstanding Rent Reasonableness forms are in the process of being completed. Anticipated Corrective Action Plan Completion Date: July 1, 2026 Contact Information: For additional information regarding these corrective actions, contact Stephen Bauer, CEO at 414.345.3240. Stephen Bauer CEO Guest House of Milwaukee

2025-005: WAGE RATE REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Pass-Through Agency: Direct award Grantor Number: Not applicable Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: N. Special Tests and Provisions – Wage Rate Requirements Repeat Finding: Yes. Same as finding 2024-001 and 2023-002. Criteria or Specific Requirement: Federal regulations require that contractors and subcontractors performing work on federally funded construction projects pay laborers and mechanics wages at rates not less than those prevailing on similar projects in the locality. These requirements are established under the Davis-Bacon Act and incorporated into federal grant compliance requirements under 2 CFR Part 200. Adequate monitoring of compliance with these wage requirements is required to ensure that workers are being paid correctly per 29 CFR 5.5 compliance provisions. Per 2 CFR section 200.303(a), a non-Federal entity must establish and maintain effective internal control over Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should comply with guidance in “Standards for Internal Control in Federal Government” issued by the Comptroller General of the United States or the “Internal Control-Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our testing for one of 2 contractors that were tested and funded under the Impact Aid program, we noted that the District did not obtain or review certified payroll reports from contractors to verify compliance with federal prevailing wage requirements. As a result, the District could not demonstrate that contractors complied with required wage provisions for the sampled projects. Corrective Action: The District will ensure wage rate requirements are maintained for all vendors as appropriate under Uniform Guidance and the provision of the Davis Bacon Act. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Kay Morris, Superintendent

Public Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority strengthen internal controls over income determination and rent calculation by: • Enhancing procedures to ensure all sources of tenant income are properly identified, verified, and included in calculations • Providing additional training to staff on HUD income determination and rent calculation requirements • Implementing or strengthening supervisory review controls to detect and correct errors in a timely manner Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PBCHA staff responsible for eligibility determinations will be scheduled for rent calculation training through available resources over the next FY. The PBCHA will continue to conduct internal training for program staff on eligibility documentation requirements and program rules to reinforce compliance standards. Through the implementation of intakes, interims and annual recertifications utilizing Yardi’s online workflows, the PBCHA expects to see increased improvement through automated application and documentation processes. The PBCHA will utilize available dashboards, internal audits and formal monitoring protocols to ensure continued compliance and to minimize the risk of recurring deficiencies. The PBCHA will continue to assess current staffing levels and evaluate the feasibility of restructuring, hiring outside consultants and/or increasing staffing to support consistent and compliant eligibility determinations while being cognizant of current funding uncertainties. Name(s) of the contact person(s) responsible for corrective action: Carol Jones-Gilbert Planned completion date for corrective action plan: September 30, 2027

Finding summary – Patients received sliding fee discounts that were inconsistent with the stated sliding fee discount categories under the Organization’s policy. Corrective Action Planned – 1. Crossing has implemented a billing workflow to automatically apply sliding fee scale discounts to all eligible self-pay accounts during the billing process, eliminating manual charge adjustments and improving consistency with established guidelines. 2. All billing staff have received retraining on the correct manual posting procedures for sliding fee scale adjustments after insurance payment, ensuring compliance with patient income verification and applicable percentage guidelines. 3. We will continue ongoing monitoring and review of accounts receiving sliding fee scale adjustments to ensure accurate and compliant application of the approved discount and percentages. Anticipated Completion Date – Completed 4/1/2026 Responsible Contact Person – Margret Guy, Director of Revenue; Julie Brilley, CEO Management Response - Management concurs with the auditor's finding. The Organization acknowledges that patients received sliding fee discounts that were inconsistent with the stated sliding fee discount categories under the Organization’s policy. The corrective action plan has been successfully implemented and will be monitored regularly to ensure compliance.

Dear Katelyn, Please see below the Corrective Action Plan, number referenced above: New Tenant: 1. Gather intake information 2. Identify apartment close to the Fair Market Value that tenant seeks to sign a lease with. 3. . Gather information about that apartment, enter into the Affordable Housing .com form. 4. Submit the form to Affordable Housing.com. 5. Affordable Housing returns the results to us, showing comparable properties in the area. This form indicates whether the rent is or is not reasonable based on the prevailing market conditions. 6. If the rent is both Reasonable and within the Fair Market Value guidelines, approve the lease. Existing Tenant: 1. Rent reasonableness forms have been added to every chart. 2. Any time there is a change in the rent due, we gather the information again and re-submit it to Affordable Housing for a new comparable analysis. 3. Quarterly review will be done to verify all rents are correct and Rent Reasonableness has been done if warranted. Responsible Staff 1. Patricia Skinner, Assistant Director of Housing and Care Coordination 2. John Lent, Director of Corporate Compliance Expected Date of Correction: already in place

a. Administrator: V.P. Finance/ CFO ................... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ....... Jennifer Scott-Gilmore 601-857-3250 Student Financial Assistance Cluster: The District did not properly calculate the total amount disbursed or to be disbursed which lead to incorrect calculation of funds to be returned to Title IV. Additionally, the District did not provide evidence of date of determination used in calculation. Corrective Action Plan: The District is an attendance taking institutional and has reviewed its internal controls on how total days in the semester are calculated correctly and timely disbursements are made. The District understands that it should be using the Last Day of Attendance in the calculation of earned aid and made that modification Spring 2025 in collaboration with the U.S. Department of Education and outlined the calculation variables to align with that calculation change. Management has revised its Policy and Procedures accordingly and was submitted to the Hinds Board of Trustees for final approval December of 2025. The correction implementation date was June 2025 and finalized December 2025. With the corrected action initially taking place June 2025, this will be a continuation into this FY2025 audit. The correction implementation date was June 2025 and finalized December 2025. With the corrected action initially taking place June 2025, this will be a continuation into this FY2025 audit.

a. Administrator: V.P. Finance/ CFO ................... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ....... Jennifer Scott-Gilmore 601-857-3250 Student Financial Assistance Cluster: The District did not report timely and accurate student status information to the National Student Loan Data System (NSLDS). The District did not ensure internal controls were in place to ensure timely and accurate reporting. Corrective Action Planned: The Management has implemented additional organizational and internal controls to ensure students' enrollment statuses are reported timely and accurately. In reviewing the causation of the finding, it was determined that it was a personnel error and as of June 2024, there is a new Registrar for Hinds Community College charged with compliance of this requirement. During the AY2024-25, the Registrar worked within the new student information system (SIS) to generate the required student data on a monthly cycle to be submitted to the National Clearinghouse which is then transmitted to NSLDS. This update in internal controls should satisfy future reviews. The correction date was July 2024. With the corrected action taking place July 2024, this will be a continuation into this FY2025 audit.

a. Administrator: V.P. Finance/ CFO ................... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ....... Jennifer Scott-Gilmore 601-857-3250 Student Financial Assistance Cluster: The District did not properly update the student verification process in COD and the District's internal controls related to verification did not ensure verification status was properly updated in COD. Corrective Action Planned: The Management has reviewed the District process of verifying student status in COD by evaluating student status information in both the District Student Information System (SIS) and COD concurrently. Reporting allows these functions to be compared, flagged, and corrected for any variation of student status information. The correction was implemented August 2025 and will be validated June 2026.

Student Financial Assistance Program Cluster – Department of Education Federal Financial Assistance Listing/CFDA #84.268 Federal Direct Student Loans - 2024/2025 P268K211430 Federal Financial Assistance Listing/CFDA #84.063 Federal Pell Grant Program - 2024/2025 P063P201430 Special Tests & Provisions: Enrollment Reporting Material Weakness in Internal Control over Compliance and Noncompliance not Considered Material Finding Summary: Fourteen instances were identified where the enrollment status reported to the National Student Clearing House did not match the student’s actual enrollment status. Responsible Individuals: Robert Hoover, Director of Financial Aid and Kristi Bagstad, Registrar Corrective Action Plan: The University will strengthen controls over enrollment reporting by implementing a reconciliation process that includes sampling of enrollment statuses prior to submission. In addition, procedures will be updated to ensure reports are submitted within required timeframes. A secondary review of enrollment files will be conducted prior to submission, and staff will receive training on reporting requirements. Periodic reviews will be performed to monitor ongoing compliance and accuracy. Anticipated Completion Date: August 1, 2026/ongoing

Student Financial Assistance Program Cluster – Department of Education Federal Financial Assistance Listing/CFDA #84.268 Federal Direct Student Loans - 2024/2025 P268K211430 Federal Financial Assistance Listing/CFDA #84.063 Federal Pell Grant Program - 2024/2025 P063P201430 Special Tests & Provisions: Return of Title IV Funds Material Weakness in Internal Control over Compliance and Noncompliance not Considered Material Finding Summary: Two instances were identified where the amount of Title IV funds to be returned was not remitted correctly, and two instances were identified where the funds were returned in the correct amount but not in a timely manner. Responsible Individuals: Robert Hoover, Director of Financial Aid and Ashley Hantelmann, Associate Director of Financial Aid Corrective Action Plan: The Financial Aid Office will continue strengthening its Return of Title IV (R2T4) procedures to ensure accurate and timely processing. The secondary review process has been expanded and formalized, now including the Associate Director of Financial Aid to provide additional oversight. The R2T4 checklist has been updated to better align with compliance standards and ensure consistent documentation. Staff will receive ongoing training, and periodic internal reviews will be conducted to monitor compliance. Anticipated Completion Date: August 1, 2026

The City has taken steps to strengthen internal controls over the CDBG program. The City will additionally implement formalized procedures requiring, centralized project files containing procurement documentation, cost support, and project eligibility records, document procurement procedures consistent with Uniform Guidance requirements, including cost/price analysis and justification for contractor selection, collection and review of Davis-Bacon documentation, including wage determinations and certified payrolls, when applicable, verification that required permits are obtained prior to construction and retention of inspection and completion documentation, and secondary review by City staff to ensure all required documentation is complete prior to project closeout. Additionally, the City will provide training to staff involved in CDBG program administration. Responsible Persons: Community Development Director Date of Implementation: Initiate FY 2025-26 with ongoing monitoring into FY 2026-27

2025-006 - Student Financial Aid Cluster - (a) Federal Supplemental Educational Opportunity Grants (b) Federal Work Study Program (c) Federal Pell Grant Program (d) Federal Direct Student Loans, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.063 (d) 84.268 - Year Ended June 30, 2025 Criteria: 34 CFR 690.83 (b)(2) which states the institution shall submit “in accordance with deadline dates established by the Secretary, through publication in the Federal Register, other reports and information with Secretary requires and shall comply with the procedures the Secretary finds necessary to ensure that the reports are correct.” 34 CFR 685.309(b)(1-2) which states a school shall “upon receipt of a student status confirmation report from the Secretary, complete and return that report to the Secretary within 30 days of receipt; and unless it expects to submit its next student status confirmation report to the Secretary within the next 60 days, notify the Secretary within the next 60 days, notify the Secretary with 30 days if it discovers that a Direct Subsidized, Direct Unsubsidized, or Direct PLUS Loan has been made to or on behalf of student…” Condition: The College did not correctly report enrollment status changes for 21 out of 40 students tested (52.5%). We consider this condition to be a material weakness of the Special Tests and Provisions compliance requirement and is a repeated finding shown in Section IV of this report as prior year finding 2024-004. Statistical sampling was not used in making sampling selections. Responsible Person: Director, Financial Aid and Veteran Affairs, Director, Admission and Registration, and Administrative Information Systems (AIS) Corrective Action Plan: The Director of Financial Aid and Veteran Affairs will work with the Director of Admissions and Registration to review and update enrollment procedures, evaluate system configuration and reporting process related to the recent transition to Jenzabar One and Jenzabar Financial Aid, and establish a secondary review process to verify enrollment status changes prior to and after submission through the National Student Clearinghouse. Periodic internal monitoring will also be conducted to ensure compliance and strengthen internal controls. Implementation Date: May 2026

2025-005 - Student Financial Aid Cluster - (a) Federal Supplemental Educational Opportunity Grants (b) Federal Work Study Program (c) Federal Pell Grant Program (d) Federal Direct Student Loans, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.063 (d) 84.268 - Year Ended June 30, 2025 Criteria: 34 CFR 668.22 (a)(1) states “When a recipient of title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of title IV grant or loan assistance that the student earned as of the student's withdrawal date in accordance with paragraph (e) of this section.” 34 CFR 668.22 (e)(2) states, “The percentage of title IV grant or loan assistance that has been earned by the student is - (i) Equal to the percentage of the payment period or period of enrollment that the student completed (as determined in accordance with paragraph (f) of this section) as of the student's withdrawal date, if this date occurs on or before - (A) Completion of 60% of the payment period or period of enrollment for a program that is measured in credit hours; or…” 34 CFR 668.22(j) notes, “(1) An institution must return the amount of title IV funds for which it is responsible under paragraph (g) of this section as soon as possible but no later than 45 days after the date of the institution's determination that the student withdrew as defined in paragraph (l)(3) of this section. The timeframe for returning funds is further described in § 668.173(b).” Condition: We tested 19 drop students and found one incorrect refund calculation (5.3%). We consider this finding to be an instance of noncompliance in relation to Special Tests and Provisions and is not a repeated finding. Statistical sampling was not used. Responsible Person: Director, Financial Aid and Veteran Affairs Corrective Action Plan: The responsible party will thoroughly review each Return to Title IV (R2T4) calculation to ensure that it was accurately completed. Additionally, the responsible party will review current R2T4 procedures, implement a secondary review process for R2T4 calculations, and will conduct periodic reviews to ensure each R2T4 calculation was accurately completed. Lastly, the Financial Aid and Veteran Affairs Office will evaluate whether the recent transition to Jenzabar Financial Aid and Jenzabar One can strengthen compliance and internal controls. Implementation Date: May 2026

Management agrees with the finding and recommendation regarding sliding fee discount compliance and has taken corrective actions to address the identified issues. For non-pharmacy in-scope services, a portion of the exceptions identified resulted from the implementation of the Organization’s new OCHIN Epic electronic health record system effective January 1, 2025. During the initial system build and configuration process, certain CPT codes that should have been designated as eligible for sliding fee discounts were not appropriately mapped as “slideable” services within the EHR. Upon discovery, a ticket was submitted to OCHIN Epic on March 15, 2026, to correct the system configuration. Affected patient accounts were subsequently identified and corrected retroactively. Additionally, during the EHR setup process, the adjustment code title “SFS Discount” was inadvertently applied to employee discount adjustments rather than the correct “Employee Discount Adjustment” designation required under Organization policy. While there was no financial impact to patient balances or charges, certain employee discounts may have been incorrectly reflected within reporting categories. Upon identifying the issue, a correction ticket was submitted to OCHIN Epic on May 21, 2025, to update the system configuration. At the time, billing staff believed the system correction would apply both prospectively and retroactively; however, during the audit process it was determined that historical transactions existing prior to the EHR correction also required manual retroactive adjustment within the system. Since that time, affected accounts have been reviewed and corrected retroactively, and management has implemented additional procedures to ensure future system correction tickets are evaluated for any required historical manual corrections. For in-house pharmacy dispensing fees, the Organization implemented Pharmacy Policy PH-113, In-House Sliding Fee Policy, which was approved by the Board of Directors in July 2025 as part of corrective actions related to the prior year audit process. Staff training on the revised policy and procedures was completed during July and August 2025. The Organization notes that all pharmacy exceptions identified during the fiscal year 2025 audit related to prescriptions dispensed prior to implementation of PH-113. Based on external audit testing of post-implementation prescriptions and ongoing internal self-audits, management believes the revised policy, training, and monitoring processes have substantially corrected the identified issues. Management will continue performing periodic internal audits, staff education, retroactive corrections when necessary, and ongoing monitoring of sliding fee discount application within both the EHR and pharmacy systems to ensure continued compliance with Health Center Program requirements. In addition, following HRSA program guidance and discussions communicated in March 2026 regarding application of sliding fee discounts to pharmacy dispensing fees, the Organization is evaluating revisions to Pharmacy Policy PH-113 to align future dispensing fee practices with current HRSA guidance and operational best practices. The Organization will continue maintaining internal monitoring, periodic self-audits, and corrective action procedures to identify and remediate potential issues timely. Anticipated Completion Date: Corrective actions related to identified fiscal year 2025 sliding fee discount exceptions, retroactive account corrections, EHR configuration updates, staff training, and implementation of enhanced monitoring procedures were substantially completed by May 31, 2026. Ongoing internal audits, monitoring, and policy evaluations will continue as part of normal compliance operations. Responsible Individuals: CFO, Pharmacy Director, Billing Supervisor, Revenue Cycle Staff, Clinical Leadership, and Information Technology/EHR Support Staff

Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater error rate are receiving focused retraining and ongoing monitoring, with audit results shared with leadership to promote accountability. Two mandatory training sessions for CARs, AR staff, and administrators are being conducted to reinforce consistent and compliant program implementation. Persons Responsible: Steven Hansen, President & CEO; Pearl Lujan, Central Billing Office Director Estimated Completion Date: December 31, 2026

Views of Responsible Officials and Planned Corrective Actions – Description of Finding: Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Health Center’s policy. Statement of Concurrence: Shasta Community Health Center (SCHC) management acknowledges the finding and agrees that there were instances where the approved sliding fee policy of SCHC was misapplied. SCHC also recognizes that this is a repeat finding and recognize the need to strengthen controls to ensure full compliance with HRSA requirements. Root Cause: The identified errors were primarily due to: - Staff inattention in recognizing sliding fee discount expiration dates - Lack of clear guidance from management on sliding fee discounts related to nurse only or other generally unbillable patient visits - Lack of guidance in policies and procedures related to treatment of sliding fee discounts on nurse visits Corrective Action: - Management will reinforce through re-training of front office staff the importance of ensuring that sliding fee eligibility is carefully reviewed at each patient’s appointment. - Billing staff will be retrained in proper application of sliding fee discounts related to nurse-only visits. - Policy will be reviewed for any necessary changes and clarifications to nurse-only visits. - Electronic Health Record (EHR) system will be updated to correctly provide discounts based on patient’s sliding fee eligibility. Responsible Parties: - Front Office Retraining – Director of Informatics and Training - Billing Staff Retraining – Senior Director of Revenue Cycle Integrity and Billing Manager - Policy Revision – Chief Financial Officer and Senior Director of Revenue Cycle Integrity - EHR System Updates – Director of Informatics and Senior Director of Revenue Cycle Integrity Timeline: - Front Office Retraining – Next “All Staff Meeting”, currently scheduled for May 5, 2026. - Billing Staff Retraining – Billing meeting on April 29, 2026, to identify logistical issues and develop a plan to work through necessary EHR process revision. Full correction planned by June 30, 2026. - Policy Revision – Bring revised policy to board meeting in May 2026. - EHR System Updates – Full correction planned by June 30, 2026.

Action taken in response to finding: The Club will implement procedures to periodically review and update internal policies to ensure compliance with current regulatory requirements including requesting auditor review on procurement policies prior to approval. Name(s) of the contact person(s) responsible for corrective action: Julie Adelmund Planned completion date for corrective action plan: 05/28/2026

Finding 2025-005 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications to return Title IV funds within the required timeframe as outlined in the Federal Direct Student Loans Program. Anticipated Completion Date The corrective action plan is anticipated to be completed on or before August 31, 2026. Names of Contact People Responsible for Corrective Action Jeanne Cavalieri-Grover –Director of Fiancial Aid Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Karen West – Coordinator of Student Billing Jade Jackman – Registrar

Finding 2025-004 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications so that credit balances are paid to the students or parent borrowers within the required timeframe as outlined in the Federal Direct Student Loans Program. The corrective action plan is anticipated to be completed on or before August 31, 2026. Names of Contact People Responsible for Corrective Action Jeanne Cavalieri-Grover –Director of Fiancial Aid Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Karen West – Coordinator of Student Billing Jade Jackman – Registrar

Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return federal reimbursements for unallowable expenditures claimed under Medicaid and SNAP. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. DSS staff is in the development phase of implementing new automated procedures to ensure timely and accurate action is taken to discontinue benefits of deceased clients when date of death information is received and matched to the Connecticut Department of Public Health’s State Vital Records Office. Action has been taken to correct the errors cited, including discontinuing the benefits of the individuals that were verified as deceased, and recouping the overpayments as appropriate. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080

Recommendation: The Department of Social Services should amend the contract with its Medicaid recovery audit contractor to comply with federal regulations. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department will review the payment methodology at the next contract renewal. Anticipated Completion Date: October 1, 2027 Department of Social Services Contact Person: John Jakubowski, Director of Quality Assurance (860) 424-5855

Recommendation: The Department of Public Health should strengthen internal controls to ensure compliance with federal Medicare and Medicaid survey requirements. Corrective Action Plan as Reported by the Department of Public Health: The Facility Licensing and Investigations Section (FLIS) continues to recruit and train surveyors to fill vacancies. DPH is working to ameliorate the backlog of recertification surveys before the end of FFY 2026, and the complaint project is continuing. The Department’s efforts are dependent on several staffing and training variables, including hiring, turnover, and other extenuating circumstances (e.g. the need to respond to emergent issues). Department of Public Health Anticipated Completion Date: September 30, 2026 Department of Public Health Contact Person: Jennifer Olsen-Armstrong, Section Chief, Facility Licensing and Investigation Section (860) 509-7520 Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding and the response provided by the Department of Public Health. Department of Social Services Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Nicole Godburn, Fiscal Administrative Manager 2 (860) 424-5393

Recommendation: The Department of Social Services should comply with the long-term care facility auditing procedures in the State Medicaid Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. With more than 1,200 long-term care and boarding home providers, the Department is unable to audit every facility on a biennial basis. Facilities are primarily chosen for audit based on the risk of misstatement. The Department operates with limited resources and while it is neither possible nor feasible to conduct a field examination for every facility, the benefit of utilizing the desk review process must be considered when discussing the risk of incorrect payments. The Department ensures that a desk review is conducted on each facility's cost report annually. During the desk review process the auditors submit requests to providers for additional information to resolve questions which arise from significant risk areas identified and follow up on prior year findings. These procedures are conducted to mitigate and reduce the risk of incorrect payments. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Nicole Godburn, Fiscal Administrative Manager 2 (860) 424-5393