Corrective Action Plans

2024-065a: Rhode Island did not participate in the February 2024 PARIS interstate match due to a file issue that has since been addressed in April 2024. The May and August 2024 PARIS matches were suspended at the Federal level for all States due to an outstanding computer matching agreement between the DoD and HHS/ACF. Enhancements to existing PARIS Interstate match logic are scheduled to run as planned for fall/winter 2025. EOHHS completed implementation of an interface on 3/5/24 between The Work Number (TWN) and RI Bridges. Contract and budget actions for TWN services were not completed until fall 2024. The system requirements that Equifax initially communicated to the State and our Integrated Eligibility System implementation partner were incomplete and the original integration configured in fall 2024 did not successfully pass testing. A system modification to correct the original specifications was originally scheduled for February 2025 but was delayed due to the 12/13/24 RI Bridges cyber event. Target date for TWN implementation is July 2025. The Death Match process resumed in Spring 2025. Long-term modifications are scheduled for December 2025. These modifications include connecting RI Bridges to the SSA Death Master File (DMF) and utilizing the data from DMF as the primary source for monthly death verifications. During SFY 2024, several system fixes were deployed to address the findings noted in 2024-065. Specifically, in September 2024, a system fix was put in place to ensure children with verified SSNs were appropriately evaluated for Medicaid/CHIP coverage and excluded from Cover All Kids. The system automatically identifies individuals aging out of Medicaid Expansion prior to their 65th birth month and redetermines eligibility. EOHHS will improve controls of this process and ensure that if the system is unable to accurately remove the member from the Medicaid expansion category, a manual workaround will be implemented. Anticipated Completion Date: January 1, 2026 Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov 2024-065b: EOHHS will proactively work with the system vendor and other State agencies to implement controls over eligibility system and process deficiencies. Corrective actions will include, but are not limited to, manual processes, code fixes, and new system enhancements. Anticipated Completion Date: Ongoing Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov 2024-065c: EOHHS will identify and return any potential ineligible costs by end of the current Federal Fiscal Year (FFY). Anticipated Completion Date: September 30, 2025 Contact Person: Allison Shartrand, Assistant Director, Financial & Contract Management, Executive Office of Health and Human Services allison.shartrand@ohhs.ri.gov

EOHHS amended and updated its guidelines and standard operating procedures leveraging the CMS ‘Delivering Service in School-Based Settings: A Comprehensive Guide to Medicaid Services and Administrative Claiming’ as a source document. In addition to ensuring alignment with CMS requirements, the updated guidelines include a uniform schedule of quarterly submission dates and details the billing responsibilities of participating LEAs. These responsibilities include meeting all Medicaid documentation requirements; submitting the Certification of Local Funds on a quarterly basis; and signing provider agreements and maintaining all other records used to support claims submitted for Medicaid reimbursement. Upon receipt of these submissions a new audit tool will be utilized to ensure each submissions contains the required documentation. Beginning June 2025, EOHHS will initiate on-site reviews of twenty (20) LEAs using a tiered, randomized sample of claims from State Fiscal Year 2023 (SFY23). The sample will include claims with at least 20 claims per LEA, selected to ensure wide geographic representation. If documentation is missing, incomplete, or found to be in error, the LEA and their billing contractor will be notified and corrective action will be implemented. Lastly, EOHHS is also working in partnership with the CMS School-Based Services Technical Assistance Center to ensure continued alignment with federal expectations and the implementation of national best practices in school-based Medicaid claiming and update guidance. Anticipated Completion Date: Administrative Claiming Materials – June 1, 2024; On-site Audit – June 30, 2025 Contact Persons: Tyler McFeeters, Health Program Administrator, Executive Office of Health and Human Services tyler.mcfeeters@ohhs.ri.gov Mark Kraics, Deputy Medicaid Director, Executive Office of Health and Human Services mark.kraics@ohhs.ri.gov

EOHHS has met expectations on aligning the FSR and FDCR reports, has updated files to Milliman, and continues to monitor compliance. EOHHS is currently in a maintenance phase and will continue monthly oversight going forward. Anticipated Completion Date: Current and Ongoing Contact Person: Steven Corvese, Plan Analyst, Executive Office of Health and Human Services steven.corvese@ohhs.ri.gov

2024-056a: During SFY 2024, several system fixes were deployed to address the findings noted in 2024-056. Specifically, in September 2024, a system fix was put in place to ensure children with verified SSNs were appropriately evaluated for Medicaid/CHIP coverage and excluded from Cover All Kids. RI Bridges appropriately determines eligibility for CHIP when TPL data is not present. Once TPL information is known to the system, existing eligibility rules will only evaluate for Medicaid, not CHIP. The TPL exceptions noted by the OAG show a discrepancy between TPL data in the MMIS and the information sent to RI Bridges via the TPL loopback file. EOHHS will work with their vendor to determine the root cause of the discrepancy and establish a corrective action plan if appropriate. Rhode Island did not participate in the February 2024 PARIS interstate match due to a file issue that has since been addressed in April 2024. The May and August 2024 PARIS matches were suspended at the Federal level for all States due to an outstanding computer matching agreement between the DoD and HHS/ACF. Enhancements to existing PARIS Interstate match logic are scheduled to run as planned for fall/winter 2025. Income/Wage Validation: EOHHS completed implementation of an interface on 3/5/24 between The Work Number (TWN) and RI Bridges. Contract and budget actions for TWN services were not completed until fall 2024. The system requirements that Equifax initially communicated to the State and our Integrated Eligibility System implementation partner were incomplete and the original integration configured in fall 2024 did not successfully pass testing. A system modification to correct the original specifications was originally scheduled for February 2025 but was delayed due to the 12/13/24 RI Bridges cyber event. Target date for TWN implementation is July 2025. Anticipated Completion Date: July 1, 2025 for income/wage validation. Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov 2024-056b: The Center for Staff Development and Learning (CSDL) the lead for training at the Rhode Island Department of Human Services (RIDHS) will work towards correction by using a blended approach to learning using formal (classroom or virtual learning sessions) and on the job learning activities. will conduct the following: a. The CSDL Team will continue to include in its Ex Parte Learning Series review of where the system performs an Ex Parte review to determine Medicaid eligibility for age outs ages 19, 26, and 65. In addition, included in the Medicaid Refresher, currently in development, a review will be done of updating income and verification procedures that includes end date and employment segments when household members lost employment. b. The Operations staff supervisors will schedule processing labs that will require the participants to process live cases with guidance from a supervisor. Anticipated Completion Date: The trainings and refresher learnings are ongoing. Processing labs are scheduled as need for this specific topic, we anticipate that processing labs will be scheduled and completed between July – September of 2025. The Medicaid Refresher Learning Series will be released in July. This training will also be ongoing. Contact Person: Zulma Valenzuela, Assistant Director of Administrative Services, Center for Staff Development and Learning, Department of Human Services zulma.valenzuela@dhs.ri.gov 2024-056c: As noted in prior year responses, CMS will not pursue recoveries associated with questioned costs given that recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement program per section 1903(u) of the Social Security Act and regulations at 42 CFR Part 431, Subpart Q. This limits CMS’s ability to recover on most of the SSA eligibility findings. While CMS will pursue the internal control deficiencies noted by the SSA, CMS will not pursue recoveries associated with the questioned costs. Anticipated Completion Date: Not Applicable Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov

RIDE is currently evaluating third-party consultants in order to have the following services performed: • A cybersecurity assessment performed of the overall agency using the NIST Framework • A cybersecurity assessment of our internal applications including CNP Connect & Accelegrants • An updated business continuity plan • A Vendor Risk Assessment Program Development Through the above deliverables from the selected consultant, RIDE will be able to have a better understanding of gaps in IT/ Cybersecurity throughout the agency, as well as the applications cited by the Auditor General. Anticipated Completion Date: December 31, 2025 Contact Person: Brandon Bohl, Finance Director, Department of Elementary and Secondary Educationbrandon.bohl@ride.ri.gov

RIDE’s Office of School Health & Wellness will develop a guidance document for LEAs regarding Paid Lunch Equity calculations and send communication at least annually to ensure LEAs have complied with 7 CFR Sec. 210.14(e). Anticipated Completion Date: June 30, 2026 Contact Persons: Brandon Bohl, Finance Director, Department of Elementary and Secondary Education brandon.bohl@ride.ri.gov Rosemary Reilly-Chammat, Director – Office of School Health & Wellness, Department of Elementary and Secondary Education rosemary.reilly-chammat@ride.ri.gov Jennifer Goodwin, School Health Specialist, Department of Elementary and Secondary Education jennifer.goodwin@ride.ri.gov

Procedures are in process of being reviewed and will be completed prior to the issuance of this report. Underlying reports will be updated with the ERP implementation and corrected to capture all data for all programs in the TSA. Anticipated Completion Date: December 31, 2025 Contact Person: Xiomara Soto, Administrator Financial Management & Reporting, Department of Administration, Office of Accounts & Control xiomara.c.soto@doa.ri.gov

The District will ensure that Additional or Compensatory Special Education or Related Services (ACSERS) funds are not used to fund Substitute Services due to the teacher shortage.

Audit Finding Reference: 2024-002 Comments on the Finding and Each Recommendation: Management agrees with the finding. Corrective Action Planned or Taken: Management will formalize the approval process of HAP voucher requests with documentation and approval occurring via email to ensure evidence of the approval.

Management has reviewed this finding and indicated appropriate corrective action will be implemented.

Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025

U.S. Department of Treasury No. 21.027 – Coronavirus State and Local Fiscal Recovery Funds Grant Period Year Ended December 31, 2024 Corrective Action Plan: In order to ensure future submissions are containing segregation of duties, the organization will ensure there are two people a part of the reporting and submission process. One person will fill out the reporting information and another person will sign off and submit the information to ensure two people are part of the process. Responsible for this plan: Ariel Rodriguez, Executive Director Implementation Timeline: Immediately as of April 22nd, 2025

DCH will review MO 598348 within the Gateway system to ensure the established interface process is functioning properly. DCH will draft additional guidance through a policy memo to revise DHS policy 2750 as it relates to the processing of Ex-Parte members. The DCH policy memo will clarify that upon the completion of the determination by DHS, Gateway will notify GAMMIS of A/R's approval or denial thorough daily interface files sent from Gateway to GAMMIS. The non-confirmation report will be reviewed to determine SOP and validate that the file has been received. Additionally, the DCH policy memo will require Gateway to complete the DMA-962 and submit to Gainwell for manual processing if the file has not been received. DCH is also reviewing current policy to determine if the infinity date established for Ex-Parte members can be revised to a time-limited date.

DCH will develop a reconciliation process between members denied within Georgia Gateway and members removed within GAMMIS. DHS will provide training as outlined within the current contract to address changes and updates to Medicaid policy and the Georgia Gateway system.

The monthly student reconciliations for the Direct Loan programs, including the SAS files, have resumed starting with the October 2024 SAS file. These reconciliations will continue on a monthly basis by the financial aid office, as required, and will be conducted without interruption. The reconciliation process will be closely monitored, reviewed, and approved monthly by management to ensure ongoing compliance. The loan processing team has been trained on the SAS file import process and direct loan reconciliation. They have also been provided with the necessary system resources to identify variances between Common Origination and Disbursement (COD) and Banner at the student level. Additionally, the direct loan reconciliation process documentation will undergo continuous review and monitoring by the loan processing team, with oversight from the Director of Student Financial Aid and Scholarships, to ensure accuracy and adherence to established policies with each new academic year. The loan processing team will have annual refresher training at the beginning of each academic year. Confirmation of employees, date of training, and current training process will be documented.

Grant Overpayments - Criteria: Management was responsible for reviewing and reconciling monthly reimbursement requests from the contractor to the invoices submitted for reimbursement under the grant agreement in a timely manner. Condition: The State of New Hampshire Department of Health and Human Services appointed a contractor to administer, disburse and monitor Flexible Needs Funding (FNF) under this grant from December 20, 2023 through September 30, 2024, which changed how FNF reimbursement requests were processed. As part of this arrangement, the contractor compiled FNF information submitted via the System and submitted to the State for FNF reimbursement. It was determined that the System was reimbursed in error for duplicate invoices and formula errors within the reimbursement spreadsheets used by the contractor totaling $47,273. Of this overpayment, $45,925 was from a reimbursement received in December 2024 from the contractor’s final invoice covering July 2024 through September 2024 FNF reimbursements, which included duplicate invoices already reimbursed. Cause: With this change in process, the System did not implement appropriate procedures to review and reconcile reimbursements received from the State to the underlying FNF requests the contractor submitted via invoice for reimbursement under the grant agreement in a timely manner. This was primarily due to system reporting limitations of the new platform implemented by the contractor in July 2024, which limited the ability to effectively reconcile with FNF requests submitted. Effect: As a result, the System received overpayments from the grant totaling $47,273. Recommendation: Management should notify and refund the grantor for the funds received in duplication. Management should also implement controls to ensure this error does not reoccur. Responsible Party: Scott Sloane, Chief Financial Officer. Corrective Actions Taken or Planned: Management acknowledges the finding and has ensured controls are now implemented to prevent this error from recurring. The agreement with the contractor was not renewed. The System met with the State to review the new process for submission and reimbursement of FNF and reviewed with the State the controls that are now in place to prevent this error from recurring. The System refunded the overpayment to the State totaling $47,273 on March 27, 2025.

Residual receipts were not remitted to the residual receipts account in a timely manner. Residual receipts are required to be remitted within 90 days of year-end. In order to avoid this issue in the future, surplus cash will be calculated prior to the audit.

Plan: We recognize the importance of ensuring timely completion, regardless of turnover at the project level. To address this, we are implementing the following actions: 1. Designated Oversight: The Housing Director, is currently monitoring all major maintenance projects to ensure timely completion and consistency throughout. 2. Clear Reporting: We have established regular progress reports and communication channels to track project timelines and address any potential delays promptly. 3. Accountability Measures: A process has been implemented to ensure that projects are continually monitored and completed as scheduled, even in cases of turnover. Completion Date: 6/30/2025 Contact: Jackie Oliveira-Director of Affordable Housing

Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Management made the deposit.

Corrective Action: We recognize the importance of ensuring that expenses are incurred within the correct reporting period for grant compliance. To address this issue and prevent future occurrences, we are implementing the following corrective actions: - Adjustment of Financial Reporting: We will work with the grantor agency to secure the appropriate federal approvals for any projects that may extend past the end of our fiscal year if necessary. - Enhanced Internal Controls: Our finance team will implement stricter monitoring of expense recognition, ensuring that only incurred costs are included in grant reimbursement requests. - Vendor Coordination: Going forward, we will attempt to implement a more rigorous project timeline review process with contractors to anticipate and address potential supply chain delays before committing grant funds. We remain committed to fully complying with grant guidelines and to strengthening our financial management processes.

Recommendation: We recommend the Agency revise federal award cash draw procedures to ensure compliance with cash management requirements. Such draws should be made solely for immediate cash needs. Action taken: Management agrees with this finding and has implemented corrective actions. Current and future draws are made for immediate cash needs for expenses already incurred.

We recommend the School Board implement a review process to ensure the manually entered meal counts agree to the supporting documentation.

Finding 2024-002 HUD Approval Process for Residual Receipts Withdrawal Program Name/Assistance Listing Title: Supportive Elderly Housing Section 202 Federal Assistance Listing No: 14.157 Corrective Action Plan: To address the issue of withdrawing funds from the residual receipts account without prior HUD approval, we will take corrective actions to ensure compliance with HUD regulations. We will communicate this with HUD to determine if replenishment is required and provide supporting documentation for review. If HUD mandates replenishment, we will explore available funding sources to restore the withdrawn amount. Additionally, we will enhance documentation procedures, implement stricter internal controls to ensure prior approval for withdrawals, and designate a compliance contact to facilitate future HUD communications. A tracking system will also be developed to oversee fund withdrawals and prevent similar occurrences in the future. Proposed Completion Date: 12/31/2025

Finding No.: 2024-002 Internal Control Over Grant Expenditures Federal Program Name: FEMA Feeding Mission CFDA Numbers: 97.036 Federal Agency: U.S. Department of Human Services Finding: During testing of grant expenditures, it was noted that 2 out of 2 reimbursements tested were modified by the State Agency overseeing the grant. Feeding Illinois did not properly calculate the number of expenditures for reimbursement. Questioned Costs: N/A Systemic or Isolated: This instance of noncompliance is systemic. Effect of Finding: The Organization submitted grant expenditures both in excess of amounts reimbursed. Recommendation: We recommend that the Organization perform a more detailed review of the information submitted to verify the accuracy prior to submission for reimbursement. . Corrective Action Plan: All future federal grant programs that require substantial lines of information and calculations to be submitted for reimbursement of allowable costs will be reviewed by at least two qualified persons before submission to the administering agency (e.g. IDHS).. Contact Person Responsible for Corrective Action: Stephen Ericson, Executive Director Anticipated Completion Date: June 30, 2025