Corrective Action Plans

Corrective Action Plan Finding: Finding 2023-002-Lack of Adequate Quality Control Regarding Tenant Procedures-Eligibility Condition: The quality of supervision over tenant file functions, such as calculating tenant rent and Housing Assistance Payments should be timely and sufficient to find errors in calculations or mis-application or mis-understanding of procedures. Corrective Action Planned I am Jedidiah Jackson. I was hired as E.D., effective July 1, 2024. We are in the process of addressing the problems noted in the audit, as well as correcting other issues noted by HUD. Person responsible for corrective action: Jedidiah Jackson, E.D. Telephone: (985) 785-2601 St. Charles Parish Housing Authority Fax: (985) 785-6238 200 Boutte Estates Dr. Boutte, LA 70039 Anticipated Completion Date- October 31, 2024

ST. CHARLES PARISH HOUSING AUTHORITY________________________________________PHONE: 985-785-2601 ·FAX:985-785-6238· 200 BOUTTE ESTATES DRIVE ·BOUTTE, LA 70039-0448 ________________________________________ HOUSING AUTHORITY OF ST. CHARLES PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2023 Corrective Action Plan Finding: Finding 2023-001-Internal Controls Inadequate for Disbursements-Allowable Costs Condition: Good internal controls should be in place to make sure that disbursements are for eligible payments, are correctly classified, and are timely paid. Good controls ensure that there is proper, documented review of all these functions. Records should be maintained in an order that is conducive to efficient and timely summarizing by the outside fee accounting firm. Unaudited financial statements should be produced on a timely basis, and reviewed by the Board of Commissioners. Corrective Action Planned I am Jedidiah Jackson. I was hired as E.D., effective July 1, 2024. We are in the process of addressing the problems noted in the audit, as well as correcting other issues noted by HUD. Person responsible for corrective action: Jedidiah Jackson, E.D. Telephone: (985) 785-2601 St. Charles Parish Housing Authority Fax: (985) 785-6238 200 Boutte Estates Dr. Boutte, LA 70039 Anticipated Completion Date- October 31, 2024

Action Taken: MHA will review and enhance as necessary the program’s existing quality control (QC) file review procedures as well as daily data validation reports to include a measure that cross-checks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. To further mitigate the risk posed by frequent turnover among Housing Specialist-I (HS-I) staff, MHA will increase the frequency of training on rent and income determination for all staff including tenured team members and new hires, alike, to occur quarterly. In 2023, MHA implemented a Housing Specialist-II Team Lead to oversee HS-I staff processing annual reexaminations in accordance with 24 CFR 982.516. This team member is responsible for ensuring families are notified in a timely manner and if they do not comply with the annual reexamination requirement, they receive termination notices in compliance with HUD and MHA Administrative Plan requirements. MHA also implemented two compliance analysts in 2023; we will add another compliance analyst staff person in 2024 to increase the percentage of files undergoing quality control review. These three (3) Compliance Analyst will report to the Operations and Compliance Manager who monitors HUD’s PIC system and analyzes discrepancies between PIC data and MHA data housed in the Yardi system of record. This information is maintained in the program file. Name of Responsible Person: Paul and Magdalene Watkins, Program Administration Team Projected Completion Date: 12/31/2024

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate an internal reviewer to continually review the casefile eligibility determinations throughout the year. Name of the contact person responsible for corrective action plan: Jill Frisell, Finance Director Planned completion date for corrective action plan: December 31, 2024

The County agrees that reinforcing existing policies and procedures to require caseworkers to cite source documents supporting a child’s disability when determining initial Title IV-E eligibility and continuation of eligibility is necessary and will continue to do so.

The Department of Children and Family Services management agrees with the findings and will reinforce existing policies and procedures within the Department to ensure that all documents are properly retained and signed.

The County agrees with the findings and will reinforce existing policies and procedures within the Health Department to ensure that all supporting documents are properly obtained.

Finding Number: 2023-002 Finding Title: Eligibility Program: Medical Assistance Program (AL No. 93.778) Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Director and Karen Syverson, Supervisor Corrective Action Planned: To address the findings from the recent audit, Clay County Social Services will take both immediate and long-term corrective actions. First, the case files identified with discrepancies will be revie.wed in detail, and necessary corrections will be made to ensure that the documentation in both the case files and the MAXIS system aligns with program requirements. Requests for case file numbers have already been submitted to the MA team lead to identify the cases needing correction. This will include reverification of asset amounts, we will match MAXIS's citizenship status with the appropriate documentation within the case file. In addition, one-on-one reviews will be conducted with the staff responsible for administering the affected cases. During these reviews, case-specific feedback will be provided, detailing the nature of the errors and explaining corrective actions to prevent recurrence. For long-term preventative measures, Clay County will implement a more comprehensive and mandatory training program for all staff involved in eligibility determination. This training will focus on key areas such as proper documentation for citizenship, asset verification, and data entry protocols to reduce human errors in MAXIS. We will continue conducting periodic case file audits with increased frequency to detect errors early and provide timely feedback to staff. Audit results will be shared with the entire team to promote learning from errors and reinforce best practices in documentation and data entry. Anticipated Completion Date: The cases found in error will be corrected by November 15, 2024. Case file reviews will continue monthly.

Views of Responsible Officials and Planned Corrective Actions: This condition was primarily the result of a heavy reliance on external subject matter experts (SMEs) for technical aspects of programmatic workplan deliverables, as well as the use of single-sourcing selection carveouts in the interests of efficiency, that are provided for in the organization’s procurement policies & procedures. These instances of single sourcing nonetheless required additional levels of documentation and justification when in use, which was always not the case. Starting in August 2024, all program and compliance staff will be re-trained on federal procurement policy documentation and justification requirements. The Organization will also embark on concerted efforts to expand its pool of qualified and eligible SME vendors, to ensure more reliance on competitive bidding and minimize the future use single-source procurement. A comprehensive review of current Organizational policies and procedures will also be undertaken, to ensure that they are aligned and consistent with current federal procurement guidelines and requirements. Responsible Official: Peter Kiburi, Senior Director of Finance.

Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.

In mid-2024 the organization implemented procedures to collect client intake data at the largest program identified in testing and expects to be following intake guidelines for all programs by the end of 2024.

Corrective Action Plan September 25, 2024 Federal Audit Clearinghouse County of Orleans respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: EFPR Group, CPAs, PLLC 100 South Clinton Avenue, Suite 1500 Rochester, NY 14604 Audit period: January 1, 2023 – December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING – FINANCIAL STATEMENT AUDIT FINDING 2023-001 - Material Weakness in Internal Control Over Financial Reporting - Material Adjustments Condition: The County is responsible for maintaining a proper system of controls to allow for all year end adjustments to be made prior to the preparation of the Annual Financial Report (AFR) and the start of the audit. Criteria: A proper system of controls would result in the County making all required year end closing adjustments prior to the preparation of the AFR and the start of the audit. Cause: Auditors were required to make material adjustments as part of the year end audit process. Effect of Condition: The County does not have the controls in place to make all required year end closing entries which resulted in material adjustments as part of the audit process. Recommendation: The County should re-evaluate the year end close process to ensure all required year end closing adjustments are completed timely. A training should be held with all employees involved with year end closing to review the process. Views of Responsible Officials and Planned Corrective Actions: The County Treasurer has created a written Year End Adjustment checklist for the County Treasurer and Deputy County Treasurer to both check and sign before the Annual Financial Report (AFR) is filed with the State Comptroller to ensure all normal year end adjustments are accounted for, justified and confirmed. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT 2023-002 - CCDF Cluster - Child Care Development Block Grant - Assistance Listing No. 93.575; Grant Period - For the year ended December 31, 2023 Condition: Currently the senior social welfare examiner who handles the child care development block grant program processes the application and determines eligibility. There is no requirement for the documentation of review and approval by a secondary individual over this process. Criteria: Implementing internal controls that provide for segregation of duties over the child care development block grant would involve a secondary reviewer resulting in more than one individual being responsible for the entire process. Documenting this secondary approval process would provide for confirmation that the segregation of duties has occurred. Cause: The County does not have procedures in place to require a secondary review on the application process and eligibility determination. Effect of Condition: The County's internal control system for the child care development block grant was not designed to provide segregation of duties and the related documentation. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Recommendation: The County should consider revisiting the segregation of duties over application and eligibility process to provide for a documented review and approval over the process. Views of Responsible Officials and Planned Corrective Actions: Effective immediately, 100% of new, denied and closed Child Care applications and 10% of recertification applications will be reviewed by a supervisor to verify that: o All required documentation is present in the case file. o All information was correctly entered into the electronic Child Care Time and Attendance system which determines eligibility. o A correct eligibility determination was produced. Contact Person Responsible for Corrective Action: Kimberly DeFrank, Orleans County Treasurer – finding 2023-001 and Holli Nenni, DSS Commissioner – finding 2023-002. Anticipated Completion Date: The corrective action plan was completed by September 27, 2024. If the Federal Audit Clearinghouse has questions regarding this plan, please call Kimberly DeFrank at 585-589-5353. Sincerely yours, Kimberly DeFrank

Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MNSADM and 2305MN5MAP, 2023 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Number: 2305MN5ADM and 2305MNSMAP Award Period: Year-Ended December 31, 2023 Type of Finding: Signiflcant Deficiency in lnternal Control over Compliance Recommendation: lt is recommended the County increase review over casefiles and ensure that there are performed on a periodic basis throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action plan: Barb Dietz, Human Services Director Planned completion date for corrective action plan: December 31, 2024

The Project will follow HUD directives regarding recertification procedures for existing tenants.

Contact Person – Bruce Starkey, County Administrator Corrective Action Plan – The County will review procedures over application filing. Completion Date – 9/30/2024

The Project will properly establish that utility allowance is reported correctly on the lease and Form HUD 50059 per the effective date of the HUD-approved annual utility allowance.

Federal Award Finding: 2023-002 Significant Deficiency in Internal Control and Noncompliance with Special Tests and Provisions in Application of Organization's Sliding Fee Discounts Policy Name and Contact Person: Gina McCullough, Chief Financial Officer 907-733-2273 gmccullough@sunshineclinic.org Corrective Action: The Organization will take steps to ensure that staff are proficient in the completion of the application of the slide adjustments within the EHR system and are working to improve the review process of those adjustments applied to ensure compliance. Proposed Completion Date: June 30, 2024

CORRECTIVE ACTION PLAN September 18, 2024 Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance Listing Number 93.224/93.527) Finding 2023-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in January 2024. As part of our corrective action plan for this finding, the Center hired a consulting firm in September 2023, to perform a comprehensive review of the Center’s Electronic Medical Records systems to ensure that the system setup is correct and that proper reports are being generated. In addition, the Center retained the consulting firm to train all front desk staff, including the director and supervisors. The Consulting firm was also retained to conduct bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. The auditor’s finding for the 2023 audit period reflects issues existing prior to implementing the above corrective action plan at the beginning of the 2024 fiscal year. We are seeing progress in documenting and calculation of the sliding fee discounts. We have hired a new front Desk Director. Her task, on a weekly basis, is to do a comprehensive review of the Center’s compliance with the sliding fee scale program and make corrections, as necessary. In addition, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Name: Daniel Desire Title : Chief Financial Officer

Finding Number: 2023-005 Finding Title: Reporting (DHS 2550 and 2556) Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services fiscal staff will review the new detailed instructions on how to complete the referenced quarterly reports that include recent changes. Staff will correct an resubmit quarterly reports as requested. Anticipated Completion Date: January 20, 2025

Housing Voucher Cluster – Assistance Listing No. 14.871 / 14.879 – Eligibility Recommendation: We recommend management to implement controls and policies to ensure compliance with eligibility requirements. Additional training for housing specialists would also improve accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Monitor and quality control documents as required by HUD. If quality control determines there is a pattern of the same type of discrepancy, then corrective actions will be taken. The finding is based on 2 late reexaminations and failure to automatically identify a client as disabled. This is marked as a repeat finding in the same category, but is not the same type of finding as last year.

The County of Fulton, Pennsylvania, respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: RKL, LLP 1800 Fruitivlle Pike P.O. Box 8408 Lancaster, PA 17601 Audit period: Year Ending December 31, 2023 The findings from the December 31, 2023 Schedule of Fundings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FEDERAL AWARD FINDINGS Finding 2023-001: Eligibility for Individuals and Inventory Records CFDA#10.568/10.569 Food Nutrition Cluster Date for Completion: December 31, 2024 Recommendation: The County should maintain documents and records to ensure compliance with the audit requirements of the OMB Compliance Supplement to demonstrate that they serve predominately needy persons, maintain receipts, usage/distribution, losses and ending inventory, and perform an annual physical inventory observation. County Response: The County met with the subrecipient after the prior finding was issued ot review the OMB Compliance Supplement and requirements for individual eligibility along with requirements to document and maintain inventory records. The County will revisit these requirements with the subrecipient to ensure that changes are made timely to ensure compliance. If there are any questions regarding this corrective action plan, please contact the Fulton County Business Office. Sincerely yours, Michael Lamb, CPA, CGFM Chief Financial Officer

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2023-007 Medicaid and CHIP Eligibility Determination Timeliness Name of the contact person responsible for corrective action: Heather Atkins Anticipated completion date for corrective action: July 31, 2024 Recommendations: The DSS through the MHD and the FSD ensure participant eligibility is determined within the required timeframes. DSS Response: The DSS agrees with this finding. During SFY 2022, DSS experienced significant delays in completing determinations of eligibility at application, resulting in sizable backlogs and applications pending beyond the timeframes permitted in regulation. Due to this, Missouri collaborated with CMS to mitigate the backlog. As of September 30, 2022, DSS had completed processing of all overdue applications. The mitigation plan is located at https://www.medicaid.gov/medicaid/eligibility/downloads/missouri-mitigation-plan.pdf. Since DSS completed the processing of all overdue applications as of September 30, 2022, DSS has continued to receive a substantial increase in applications, both directly from applicants and from the Federal Facilitated Exchange (FFE). Additionally, DSS FSD has encountered staffing shortages, which has contributed to the delay in application processing. To address the continued increase in applications, DSS is leveraging new and available technologies. These technologies are intended to assist the department and participants with necessary actions such as submitting applications, verifying income and resources, and providing required information. Corrective action planned is as follows: The DSS will continue to work towards completing applications within the established timeframes outlined in 42 CFR 435.912(c)(3) and 42 CFR 457.340(d).

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

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2023-005 Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name of the contact person responsible for corrective action: Heather Atkins Anticipated completion date for corrective action: N/A Recommendations: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. DSS Response: The DSS disagrees with this finding. The DSS disagrees there is a significant deficiency in internal controls. As noted in the finding, from the 60 participants selected, the SAO did not identify any participants with previously-established overrides; therefore, no incorrect payments were cited. Section 6008 of the Families First Coronavirus Response Act (FFCRA) required states to provide continuous coverage, through the end of the month in which the PHE period ends, to all Medicaid beneficiaries who were enrolled in Medicaid on or after March 18, 2020, regardless of any changes in eligibility unless the individual voluntarily terminated eligibility, is deceased, or moved out of state. As required by the Centers for Medicaid and Medicare Services (CMS) during the PHE, the DSS had processes in place to terminate eligibility for individuals who were deceased, voluntarily requested closure, or reported they have moved out of state when a current change was reported. The Consolidated Appropriations Act, 2023, signed on December 29, 2022, amended section 6008 of the FFCRA such that the continuous enrollment condition ended on March 31, 2023. During the PHE, the DSS did not conduct reviews of cases that did not report current changes. The DSS developed a report identifying all individuals with manual overrides and their certification dates to complete annual reviews on them. The DSS is actively working the report and have initiated annual reviews on all individuals that have had MO HealthNet eligibility for at least twelve consecutive months. The DSS anticipates completing the review of all individuals by August 31, 2024, to account for the required 90 day reconsideration period as required in 42 CFR 435.916.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Missouri Medicaid Audit and Compliance (MMAC) Audit Finding Number: 2023-003 - Medicaid and CHIP New Provider Eligibility Name of the contact person responsible for corrective action: Dale Carr Anticipated completion date for corrective action: June 30, 2024 Recommendation: The DSS through the MHD and the MMAC review, strengthen, and enforce internal controls to ensure complete new provider enrollment application checklists are prepared and retained documenting that new Medicaid and CHIP provider applications were reviewed and screened as required. DSS Response: DSS agrees with the auditor's recommendation. The Corrective Action Plan includes the department’s planned actions to address the finding. Corrective action planned is as follows: 1. The MMAC Provider Enrollment Unit (PEU) will add a new final check box at the bottom of the provider enrollment verification form where the PEU clerk will verify each required step to enroll a new provider was completed. 2. The MMAC PEU will increase the number of quality control reviews of completed provider enrollment verification checklists by supervisors and managers. 3. MMAC PEU will train the staff that are scanning the completed enrollment files into FileNet to look at the verification checklist and make sure it has all required initials and checks. If they determine it does not, it will be returned to the PEU staff member that processed the enrollment. 4. All PEU staff working new enrollments will be retrained on the importance of checking each step on the verification checklist to indicate whether each step was completed or “not applicable”.