Corrective Action Plans

FINDING 2025-001: PELL GRANT AWARD We concur with the finding and will follow established procedures more closely to ensure that, in the future, Pell Grant awards are calculated and disbursed in accordance with the federal regulations. The following corrective actions have been implemented: • The institution has strengthened internal controls to ensure that all Pell Grant awards are calculated and disbursed in strict compliance with federal regulations. • A reconciliation process for Pell Grant awards has been implemented. Pell Grant awards and scheduled credits are now reviewed and reconciled at the conclusion of the institution’s add/drop period to ensure accuracy before any disbursement occurs. • The institution has discontinued the practice of early disbursements. Beginning with Winter quarter, Pell Grant funds will not be drawn down or disbursed prior to the close of the add/drop period.

Finding Number: 2024-043 Audit Type: Single Audit Finding Title: Use of Unapproved Federal Funds to Satisfy Required Local Match Related Finding: 2024-022 (Yellow Book) 1. Contact Person Responsible for Corrective Action Name: Shannah Weaver Title: City Clerk Department: Finance Department2. 2. Planned Corrective Action The City will revise its grant accounting procedures to ensure only eligible local funds are used for matching requirements. 3. Anticipated Completion Date September 30, 2026 4. Management's Response Management concurs and will coordinate with granting agencies to confirm match eligibility. 5. Status of Prior Year Finding This is a new finding.

Federal Program Name: Federal Transit Cluster Assistance Listing Numbers: 20.507, 20.526 State Program Names: State Urbanized Area Formula Program; State Formula Grants for Rural Areas Contact Person: Ted Ross, Executive Director Updated Corrective Action Plan: The District has revised its procurement procedures to meet Uniform Guidance requirements. Enhancements include: Mandatory documentation of quotes for applicable procurements Verification and documentation of suspension and debarment checks for all covered transactions Centralization of procurement records in accordance with best practices Policy training and practices are already in place and are being followed. Certification The Gulf Coast Transit District affirms that all corrective actions noted above are actively corrected or are being addressed. Additional documentation or clarification will be provided to auditors upon request.

Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Rudd & Company, PLLC 3805 Valley Commons Drive, Ste. 7 Bozeman, MT 59718 Audit Period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below: Federal Award Findings and Questioned Costs Finding 2024-001 Department of Health and Human Services Libby, Montana’s Public Health Emergency, Asbestos Health Screening, CFDA #93.534 5NU61TS000295-05 Finding Summary: Final Financial report for the grant period end was not submitted by the due date. Responsible Individuals: Executive Director, Tracy McNew and Financial Officer, Janine Price Corrective Action Plan: Management has added all report due dates to their calendars beginning two weeks before the due dates to ensure reports are filed in a timely manner even if difficulties are encountered with the filing process. In addition, case numbers with PMS’s help desk will be recorded and other communications will be saved to ensure that proper documentation is maintained for any reports rejected and refiled at a later date. Anticipated Completion Date: Ongoing

Corrective Plan of Action: Silver Key Senior Services has had review and approval processes in place since early 2024; however, gaps arose in consistent documentation. Going forward, all compliance procedures will be followed and documented, including documenting verbal communications. All Controller (new role in lieu of CFO) approvals will be maintained in writing, and transactions by the Controller will continue to be reviewed by the CEO. Quarterly spot checks will be conducted to confirm compliance. Anticipated Completion Date: Corrections were made as soon as the issue was identified; procedures are now in place to ensure consistent documentation

ALLOWABLE COSTS - MEDICAL ASSISTANCE Recommendation: It is recommended that the County implement procedures to ensure that all disbursements are reviewed and approved prior to payment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will train employees to ensure that all disbursements are reviewed prior to payment. Name of the contact person responsible for corrective action plan: Tesa Tomaschett, Administrator Planned completion date for corrective action plan: December 31, 2025

The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management which expanded the scope of the financial review. As a result of these monitoring efforts, the Corporation identified ineligible and questioned costs, and efforts are underway to recapture ineligible and unsupported costs. The Corporation has put the following policies and procedures in place to mitigate future risk: 1. Biennial Risk Assessment with Annual Updates 2. Annual Project Compliance Report (APCR) required by subrecipient agencies (with the exception of subrecipients receiving only Department of Energy and LIHEAP grants for the Weatherization Assistance Program, which are governed by separate monitoring procedures). 3. Enhanced Draw Monitoring and draw documentation requirements 4. Expansion of the Corporation’s Compliance and Training Team Given the policies, procedures, and changes outlined above, the Corporation feels confident it will be able to comply with its Compliance Monitoring Plan going forward and identify any concerns with subrecipient compliance in a timely manner. Curtis Stauffer, Managing Director, Housing Contract Administration, and applicable compliance staff will implement by October 1, 2024.

Correction action • Finance team is in the process of implementing a new financial accounting (Grants Management System, Sage) system to ensure that coding for grants are accurately tracked. Internal reports will be built to provide monthly analysis of individual grants. Finance will work with program staff to ensure timely and accurate budget to actuals review and reconciliations. • Finance will contact Grant Manager responsible for each grant to develop plan of action for returning any overdrawn funds. Responsible Person • Associate Director - Finance Anticipated completion date • September 30, 2025

The entity has implemented wording in their vendor contracts that they will not honor invoices that are more than 90 days out.

Title: Capital Fund Program Grant Draws Program Name: Public Housing Capital Fund ALN:14.872 Description: During our audit procedures over revenue recognition for the Capital Fund Program (CFP), we identified drawdowns of federal funds for which the client was unable to provide adequate supporting documentation. Specifically, the expenditures associated with the draw requests lacked invoices, contracts, or other substantiating records to demonstrate that the costs were allowable, allocable, and incurred in accordance with applicable federal requirements. Planned Corrective Action: Today’s Marlboro County Housing Authority management acknowledges the auditor’s finding that documentation to support certain CFP drawdowns was incomplete or missing and concurs that this represents a failure to comply with Uniform Guidance documentation requirements under 2 CFR §200.302 and §200.403. The Authority recognizes the importance of maintaining complete and accurate supporting records—such as invoices, contracts, and payment documentation—to substantiate costs charged to federal programs and ensure allowability and allocability under the Capital Fund Program. Effective October 1st, 2024, all draw requests under the Capital Fund Program ARE supported by: • Approved contracts or purchase orders • Invoices or other source documents • Proof of payment (e.g., canceled checks, ACH confirmations) • Documentation clearly linking each expense to an approved activity in the CFP Annual Statement

The METRO Vanpool Department, in collaboration with the Grant Programs Administration Division, has initiated actions to strengthen internal controls and improve compliance with federal cost principles. These actions include: • Updating existing policies and procedures related to grant-funded expense transactions; • Developing guidance to ensure transactions are appropriately reviewed for allowability, allocability, and reasonableness; • Enhancing training for relevant personnel to reinforce understanding and application of award-specific terms and conditions; • Ensuring compliance with 2 CFR § 200.403 and § 200.303. These process improvements and control enhancements will be finalized and implemented no later than December 31, 2025, under the direction of the Director, Commuter Services. METRO believes these steps will ensure compliance and mitigate recurrence of similar findings in future audit periods.

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

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

Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the birth certificate was identified and the youth was determined to be Title IV-E eligible. MDHHS will reclassify the funds to the appropriate funding source, allowing the department to claim Title IV-E for the eligible placement. For those cases in which Title IV-E funding is denied initially based on lack of a birth certificate or other documentation of citizenship, the Child Welfare Funding Specialists will continue to monitor the case for updated documentation in order to complete a redetermination of funding. Child Welfare Funding Specialists will be reminded to monitor cases for updated documentation during a Child Welfare Funding conference call in June 2025. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Nancy Berger, MDHHS

Finding 2024-045 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine the reason for the incomplete application by September 30, 2025, and implement a solution to correct the issue, if needed. If potential system modifications are needed, MDHHS will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. MDHHS will also send a memo and template of the application to the local offices to highlight the required questions on the application to help ensure all required questions are appropriately answered. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solution identified. Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schulze, MDHHS Brian Sanborn, MDHHS

Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notification to adult services staff, communicating that medical needs forms should be uploaded into EDM. MDHHS issued an Adult Services Notification to adult services staff during May 2025 to communicate the exceptions identified and remind them of the medical needs form requirements. MDHHS will develop a procedure to monitor the expiration of medical needs forms using the MiAIMS Plan of Care by August 2025. In addition, MDHHS will research potential options to automate monitoring of the medical needs forms in MiAIMS and determine if any necessary system changes are needed by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Elaina Brown, MDHHS

Finding 2024-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates a monthly hospitalization report and distributes to adult services workers as part of the post-payment review process. MDHHS enhanced the report query to improve the data used to identify overlaps in services and timely recover payments. MDHHS implemented the updated query during June 2025. Also, MDHHS issued an Adult Services Notification to managers and directors during February 2025, informing them of the audit finding and reminding local office management of the expectation to thoroughly monitor and review the hospitalization reports to ensure timely and accurate action is taken by adult services workers. In addition, MDHHS reissued the Home Help Recoupment Process training and procedural resources during February 2025 to adult services workers who manage Home Help cases to ensure process steps are consistently followed. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown, MDHHS Michelle Martin, MDHHS

Finding 2024-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing these overpayment issues, as well as developing mitigation strategies to temporarily address the overpayment concerns while the more permanent system solutions are developed. MDHHS expects all remaining synchronization issues to be resolved once the remaining larger system changes are implemented in December 2025. Anticipated Completion Date December 31, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS

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

Finding 2024-033 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MiLEAP and MDHHS ESA will continue to work together to help ensure compliance with client eligibility requirements by providing guidance on updated policies, processes, and noted trends to local office and BSC staff. On October 1, 2024, MDHHS ESA distributed an ESA memo to BSCs and local offices requiring a Child Development and Care eligibility checklist to be completed and uploaded to the electronic case file at the time of each Child Development and Care application and redetermination to help ensure the authorized hours of care in Bridges does not exceed the client's documented need for hours of childcare services. The ESA memo also requires local offices that have not yet achieved compliance to review a sample of cases monthly and ensure the Child Development and Care eligibility checklist is properly uploaded to the electronic case file. The BSCs receive the monthly results from the local offices and also monitor progress to help ensure compliance. Anticipated Completion Date Ongoing Responsible Individual(s) Lisa Brewer-Walraven, MiLEAP Mariah Schaefer, MDHHS Gayle Vail, MDHHS

Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Party: Cynthia Rogers-Ellickson, Director – Housing & Community Development Planned Implementation Date: June 13, 2025

Corrective Actions Taken Commons has taken the following actions to protect against such fraudulent incidents in the future: • Engaged a firm to assist with managing the incident; • Opened a new bank account; • Added account verification services with our banking partner, which will be utilized to verify account updates; • Limited the amount of per vendor/subrecipient daily payments to our insurance limits, with verifications prior to releasing additional funds when the total payment exceeds the insurance limits; • Subrecipient payment receipt is verified by both the subrecipient and the Commons grants team; • Updated our policy and procedures to direct our subrecipients to request banking changes through our procurement system and not through email; and • Expanded implementation of our Kissflow procurement system across the organization, which includes new vendor process as well as a change of vendor information module. Vendor changes would be approved first by the program/department that works with the vendor prior to Finance approval. Completion Date With the exception of implementing the change of vendor information module in Kissflow, the above actions have all been completed by the date of this report. The projected completion date for Kissflow change of vendor information module is April 30, 2025. Responsible Party Dana Thomas, Chief Financial Officer Angela Allen, Vice President of Finance

Recommendation: The county staff and management should review roles and responsibilities related to the annual reporting requirements and develop controls to ensure that regardless of position turnover, the required reporting is able to be submitted in a timely manner. This may include ensuring multiple county personnel are aware of deadlines and required reporting. Views of Responsible Officials and Planned Corrective Actions: The county understands and concurs with this finding. The county will employ a system to ensure timely reporting that includes additional oversite of the program by the County administration. The position responsible for reporting has also undergone turnover and the new employee responsible for such reporting will be informed of the required deadlines.

Views of Responsible Officials: All Astraea staff members are required to complete timesheets. Astraea’s internal processes were reviewed and overhauled in December 2021 (midway through FY2022) with department heads determining how their direct reports would spend time on various Astraea work streams and projects. This information is detailed in a level of effort (LOE) spreadsheet tracked against timesheets and budgets regularly. However, the processes for instituting regular updates to the LOE spreadsheet and timesheet allocations remained time-consuming and highly manual in FY2023 – which we believe resulted in misallocations. Astraea is currently reviewing internal processes to ensure, 1) that review and revision of the LOE spreadsheet and timesheet allocations can happen in a timely manner with less administrative burden, and 2) allowance of a more detailed review of the payroll allocation approval and entry process. As of January 1, 2025, a new finance system was implemented allowing for greater sophistication, consistency and automation of these processes. We do not expect to see this finding upon completion of our FY25 audit.

Pursuant to federal SNAP regulations at 7 CFR 272.4(g) and corresponding state regulations, the Department is required to establish and operate a fraud detection unit, which is responsible for the detection and investigation of SNAP fraud. The Office of Internal Audit (OIA) at the Department of Administration, Office of Management and Budget, through a Memorandum of Understanding (MOU), provides DHS with fraud detection, investigation and prevention services across DHS’s public assistance programs, including SNAP. DHS staff refer to OIA SNAP cases in which staff suspect fraud. OIA, in turn, investigates the allegation. If OIA determines that the household has committed an intentional program violation of SNAP, they pursue disqualification of the individual(s) from the program, either through an administrative disqualification hearing (ADH), a waiver of ADH, or refer the case to the state police for criminal prosecution. If the individual is found to have committed the IPV, and received SNAP benefits they were not entitled to, DHS establishes an overpayment claim against the household’s liable individuals. The liable individuals are required to make payment agreements to return to DHS, the benefits they received, but were not entitled to. If the fraud is referred for criminal prosecution, the amount of overpaid benefits is determined by the Court through an Order for Restitution. DHS followed the established and required protocols in the case cited in this finding. DHS referred a case to OIA in which identity fraud was suspected. OIA, with DHS assistance, and collaboration from the USDA Office of Inspector General (OIG), conducted the investigation, which revealed, not only fraudulent actions, but also criminal behavior and a significant estimate of overpaid SNAP benefits. The case was referred to the U.S. Attorney’s Office for prosecution. The criminal case is currently pending. Once a disposition is issued, DHS will take the appropriate sanction actions(s), including any disqualification from the SNAP, as well establishing an overpayment claim for any restitution ordered. Pursuant to federal regulations, any collection by DHS of any overpaid SNAP benefits will be returned to the Food and Nutrition Service (FNS), with DHS retaining 30% as provided for in the regulations. Should the liable individual not pay the ordered restitution in a timely manner and the claim becomes delinquent, DHS will pursue all other available collection actions to recoup the overpaid benefits. OIA and DHS also engage in fraud prevention activities, mainly by utilizing data analytics and identifying case issues that are indicative of fraudulent activities. Once an issue is identified, OIA, in conjunction with DHS, review the impacted case population and determine actions that should be taken to mitigate the issue as well as educate customers on actions they can take to safeguard their benefits, including changing EBT card PINs, freezing cards or limiting access to out-of-state or internet transactions. Other prevention actions that may be taken include changes to the card security through vendor options, as well as widespread communication to customers and the public on new fraud trends, etc. OIA and DHS also provide training to DHS staff to spot fraud in cases, including identifying fraudulent/altered documents, use of invalid identification cards, and identity fraud trends, etc. Approximately 60% of DHS staff have completed or are in the process of completing the fraud training. Anticipated Completion Date: The criminal case is ongoing. Contact Person: Iwona Ramian, Deputy Chief Legal Counsel, Department of Human Services iwona.ramian@dhs.ri.gov