Corrective Action Plans

Corrective action plan: In December 2021, HHSC implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Medicaid provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in Medicaid. Of the Medicaid providers requested during the fiscal year 2023 Statewide Single Audit, 47 of 60 samples had been enrolled or revalidated through PEMS and the auditor received all requested documentation. The listed exceptions only apply to Medicaid long-term care (LTC) providers whose enrollment and/or revalidation have not yet been processed through PEMS. The LTC enrollment and revalidation process mirrors the sampled acute care providers which were found to be 100 percent compliant during this review, further supporting that the process is working. HHSC operated under the public health emergency (PHE) between March 30, 2020, and May 11, 2023. In response to the PHE, the Centers for Medicare and Medicaid Services waived exclusion check requirements for provider reenrollments and revalidations. HHSC is in the process of revalidating providers through PEMS; however, as a result of the PHE end date and provider revalidation requirements, the projected completion date for the required revalidation of all LTC providers is January 2027. HHSC continues efforts to enroll LTC providers through PEMS and expects to eliminate errors related to these documents once all LTC providers have revalidated. Implementation dates: December 2021, PEMS implementation January 2027, LTC provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management

Corrective Action Plan: • The University has already implemented significant process enhancements in this area. • The University immediately updated the ECAR to add the School of Veterinary Medicine at Amarillo. • The University has implemented updated procedures requiring both the Primary and Secondary designee to review the ECAR quarterly for any required changes. Implementation Date: August 2023 Responsible Persons: Jamie Hansard and Kyle Phillips

Corrective Action Plan: • The University has already implemented significant process enhancements in this area. • We have implemented an ad hoc report to identify students with canceled loans and loan fees included in their COA. The report is reviewed bi-weekly and loan fees for canceled loans are removed in a timely manner. Training regarding the timely cancelation of loan fees was provided to staff responsible for the review and adjustment. • We have implemented an ad hoc report to review student’s COA budget and the student’s actual enrollment to identify discrepancies between a student’s actual enrollment charges and student’s COA budget. The report is reviewed following our census after the 20th day of classes and COA budgets are adjusted to align with actual enrollment charges. Training regarding post census review of student’s actual attendance and student’s COA budget was provided to staff responsible for the review and adjustments. • We have implemented an ad hoc report to review student’s tuition and fees budget component and the student’s academic program to identify discrepancies between the student’s tuition and fees budget component and the charges associated with their academic program. The report is reviewed monthly, and a student’s tuition and fees budget components are adjusted to align with the student’s academic program. Training regarding review of a student’s tuition and fees budget component and the student’s academic program was provided to staff responsible for the review and adjustments. Implementation Date: January 2024 Responsible Persons: Christina Montecillo and Robert Hamilton

Corrective Action Plan: The University has implemented corrections to this calculation when it was brought to the attention by the State Auditor’s Office. Corrective action was immediately taken by reducing the unsubsidized award for those who received the incorrect amount during the 2022-2023 award year. The University also corrected awards for the 2023-2024 year and updated the awarding rules in it’s Banner system. Implementation Date: August 2023 Responsible Person: Amy Wilson, Director of Financial Aid and Scholarships

Corrective Action Plan: The Office of Scholarships and Financial Aid will create a reconciliation process that will identify all FSEOG recipients for a given aid year. This reconciliation process will include a report/query that can be distributed weekly and on demand to identify any discrepancies that will be worked timely. The office will also assign a staff member to conduct R2T4 quality control. The staff member will be responsible for running a query and creating a report categorizing the type of returns (i.e. – standard R2T4, Post Withdrawal, etc.) with an estimated time for completion on a weekly basis. Implementation Date: March 2024 Responsible Person: Frank Gomez, Associate Director, SFA

Corrective Action Plan: The University now reviews the Cost of Attendance for students as it gets closer to the start of the semester to ensure that there is a variety of Cost of Attendances instead of just mostly full time Cost of Attendance. This will help ensure that the COA amounts are correct before disbursements are made. The University’s Financial Aid & Scholarships Office will also work with the Registrar’s Office to ensure that all online programs are input into the Cost of Attendance formulas before the start of the academic year to further ensure that Cost of Attendance calculations are correct. Implementation Date: 08/2023 Responsible Persons: Scott Lapinski, Assistant Vice President for Enrollment Management/Director of Financial Aid Joe Sanders Assistant Vice President for Enrollment Management/Registrar

Corrective Action Plan: The University has implemented significant enhancements- in its process to grant user access. In addition, to address the specific exceptions noted by the State Auditor’s Office, access for all staff within the SIS has been restricted from disbursing aid. Access is now only granted to the batch user account. Implementation Date: 11/2023 Responsible Person: Scott Lapinski, Assistant Vice President for Enrollment Management/Director of Financial Aid

Corrective Action Plan: The University has implemented significant process enhancements in this area. The policy manual will be revised to include detailed procedures. The steps involved in testing and reviewing Cost of Attendance components for each population of students during aid year roll-over will be expanded to include secondary review of all COA components to show they are assigning correctly for all variations of COA structures. In addition, management will review to ensure we are following federal requirements. Implementation Date: January 2024 Responsible Person: Frankin Foxworthy, Director of Technology, Office of Financial Aid

Corrective Action Plan: In the event that an employee transitions to another University department but needs to retain access for a period of time to facilitate knowledge transfer or to provide backstop support during the transition period, a date will be set for removing that access by setting an expiration date on the authorization, when feasible. If an automated access expiration date is not available, a calendar meeting will be scheduled for at least 2 people authorized to remove that access to remind them to remove the access. Implementation Date: January 2024 Responsible Person: Diane Todd Sprague, Assistant Vice Provost for Scholarships and Financial Aid Corrective Action Plan: The University is currently in the process of replacing its current custom-developed, mainframe-based financial aid management system with a vendor-provided, cloud-based system. The current issue with the mainframe programming library not being under change control will be resolved with the implementation of the new financial aid management system. Implementation Dates: Rolling implementation starting February 2024 through August 2024 Responsible Person: Graham Chapman, Assistant Vice Provost and Director of Academic Information Systems

Corrective Action Plan: The University has implemented significant process enhancements in this area. The policy manual has been revised to include detailed procedures. The University will build Cost of Attendance and place in PeopleSoft Campus Solutions. Before financial aid is disbursed to students the Office of Financial Aid will rebuilt budgets which includes COA to ensure they match all COA’s for all programs. This process will ensure that students are eligible for the aid awarded and disbursed. OIT has implemented new reports to determine PELL, FSEOG, and Direct Loan eligibility and will be reviewed monthly to ensure accuracy of eligible awards and aggregate limits for all financial aid students. Implementation Date: March 2024 Responsible Persons: Laurie Rosenkrantz, Associate Director Karen Krause, Executive Director Lea Anne Sikora, Associate Director

Corrective Action Plan: In response to the current finding of temporary access monitoring, the frequency of reviews for people that have temporary Financial Aid role assignments will be increased from an annual review to quarterly, for a period of two years. Staff training for access control and business owner training has taken place, to increase awareness that roles need timely removal when maintenance tasks are completed. Implementation Date: 1/29/24 Responsible Persons: Karen Krause, Office of Financial Aid Doug Bergere, Office of Information Technology

Corrective Action Plan: • The University has already implemented significant process enhancements in this area. • The University immediately reviewed all Financial Aid security access and removed any access not deemed immediately necessary to the employee’s job duties. • The University has developed Financial Aid security classes based on employee positions. This will allow us to more easily monitor what access an employee has and ensure that it is appropriate to their job responsibilities. Implementation Date: September 2023 Responsible Persons: Kyle Phillips and Robert Hamilton

Corrective Action Plan: After research, it was determined that the issue was limited to our co-enrollment program with Austin Community College (ACC Pathways). Procedures have been updated in our Systems Team to include recalculating the COA for all co-enrollment students after census. As a double check, our Program Specialist Team will also review all co-enrollment students to ensure that the COA was recalculated correctly. Implementation Date: September 2023 Responsible Person: Dede Gonzales, Director of Financial Aid and Scholarships

Corrective Action Plan: The Office of Student Financial Success has worked with the Office of Technology to develop an effective budget rule in the Banner system that accurately calculates books and supplies for students based on hours of enrollment. We have identified and rectified issues with banner that prevented identified students from being recalculated to determine appropriate hours of attendance for books and supplies. The Office of Student Financial Success has developed a new Budget Component report that identifies the correct credit hours from both the student enrollment and financial aid banner modules, which assist with the recalculation process ensuring accurate books and supplies for all students. In addition, we have also increased the number of times we recalculate the budget components at the beginning of each semester. Implementation Date: January 2024 Responsible Person: Dr. Latisha Addison, Executive Director Student Financial Success Corrective Action Plan: The Office of Student Financial Success has created written procedures to include the process for recalculating Federal Pell Grant eligibility after the final student add/drop course deadline. In addition, we have also increased the number of times we recalculate Federal Pell Grant eligibility for students at the beginning of each semester based on add/drop processes. Implementation Date: January 2024 Responsible Person: Dr. Latisha Addison, Executive Director Student Financial Success Corrective Action Plan: The Office of Student Financial Success has added to its written policy a process for determining student loan eligibility manually. The system functions to identify students near aggregate limits based on FAFSA data received. Students who have reached their aggregate loan limits are identified through a newly created loan limit Argos report. Student financial aid counselors review the students on the report and compare them with data pulled from NSLDS to determine any remaining eligibility for each student. The ability to award a student more than they are eligible for is a manual process, and in the case of the student in the finding, it was overridden by a staff member. Policies have been implemented to ensure the accuracy of student eligibility identification by financial aid counselors before awarding a student loan manually. Implementation Date: January 2024 Responsible Person: Dr. Latisha Addison, Executive Director Student Financial Success Corrective Action Plan: The Office of Student Financial Success has ensured staff training as it relates to manual SAP calculations as needed based on student circumstances. The SFS Office has identified that some students who have breaks in enrollment may not be included in yearly SAP run processes. Our policy now states that a student who has not been enrolled for more than a year must have a manual SAP calculation completed before being awarded financial aid to ensure accuracy and compliance. Implementation Date: January 2024 Responsible Person: Dr. Latisha Addison, Executive Director Student Financial Success Corrective Action Plan: During the fall of 2022 and some of the spring of 2023, the Office of Student Financial Success did not have a staff member in place to ensure the accuracy of data being pulled in from the Department of Education. Since then, proper staff has been hired and trained to ensure the accuracy of data files being loaded into the Banner student information system. Implementation Date: January 2024 Responsible Person: Dr. Latisha Addison, Executive Director Student Financial Success

Corrective Action Plan: Through analysis of the exceptions identified in the audit, the University has developed a standard operating procedure to assign employee access based on the principle of least privilege as determined by individual roles. The university is engaged with a third-party vendor to procure and implement an automated role-based access assignment process, to ensure that the University complies with this audit findings requirements. Implementation Date: June 2024 Responsible Person: Mr. Matthew Steimel, Director of Enterprise Applications

Corrective Action Plan: Once the discrepancy was identified in July of 2023, corrections were made for the next satisfactory academic progress review in August of 2023 and going forward. The new procedures put into place in August are as follows: the SAP table used for calculating maximum time frame will be reviewed by the Associate Director and Director over Advising in conjunction with the Registrar’s office to ensure there are no discrepancies in degree program hour requirements. The policy manual has been revised to include procedures. Implementation Date: August 2023 Responsible Person: Delisa Falks, Assistant Vice President

Corrective Action Plan: In a typical academic year, we package prior to the new aid year COA being finalized. This means that we roll the prior year's components when initially packaging students. Once the new aid year's COA is finalized, we re-run COA to update these components on all students prior to disbursement each term. This involves updating the budget component screen in our student information system. In 2022-2023, we rolled the 2021-2022 budget components and did not accurately update the components in Banner, which led to lower COA for students enrolled in Fall 2022 and Spring 2023. This was not identified until the Summer of 2023 when entering the weekly summer budget components. The Office of Financial Aid will implement a new aid year checklist specific to the review of Cost of Attendance that has a sign-off for each step of the process. The Executive Director and Director have responsibility in creation of the annual Cost of Attendance. The COA is shared with the Vice President of Enrollment Management prior to any awarding occurs. After the creation of the COA chart, the Director and Assistant Director will ensure accuracy of the chart in comparison to the COA methodology. The Director of Financial Aid will enter these components into Banner with secondary review by the Assistant Director. We will provide screenshots with the checklist that the COA chart matches Banner. When our IT staff runs COA prior to disbursement, we will test a sample of students to ensure budgets match the COA chart and RORALGS. The policy and procedure will be revised to include these updated procedures. The 2024-2025 aid year cycle is an atypical cycle with the delayed release of the FAFSA. We will not receive ISIR records until at least February 2024. We will not package students until after the 2024-2025 COA is finalized. This means that we will not roll the 2023-2024 COA. We will follow our new updated procedures and checklist to ensure accurate calculations and reporting. Implementation Date: March 2024 Responsible Persons: Kathy Wright, Executive Director of Student Financial Assistance Services Amanda Petrosian, Director of Financial Aid Josiah Mendoza, Assistant Director of Operations

Corrective Action Plan: The user access has been limited to their specific job function. The university will verify user access was appropriately updated/removed. Access review procedures will be reviewed to ensure access is appropriately assigned in the future. To streamline and assure a consistent outcome regarding the approvals for security patches to be introduced to the production environment, the University will convert these normal changes to standard changes. A standard change is “A pre-authorized change that is low risk, relatively common and follows a procedure or work instruction. (ITIL v4 definition.)” Software patching and updates are standard change candidates. Not applying security patches in a timely manner introduces a greater risk to the University than processing these requests as a normal change. A standard change is pre-authorized and will address how IT is testing and/or validating whether the OS patches were successful in an available test environment prior to deployment to production. Test procedures will be documented as a requirement of the Standard Change Model. IT will document that outcome of the testing and/or validating of the OS patch as a Journal entry on the Standard Change prior to implementation. The Change Advisory Board (CAB) will review these changes/procedures on a regular basis to ensure we are in compliance. Policies, Standards and Procedures will be updated to meet any required changes. Implementation Date: January, 2025 Responsible Persons: Michael Dewey, Chief Technology Officer Amy Wilson, Director of Financial Aid and Scholarships

Corrective Action Plan: A process with the Student Aid office exists for aid clean up that is run after Census Day for each part of term identifying students that had a variation in payouts versus packaged budget. In reviewing the 2022-2023 aid year, it appears that these reports and processes were not being worked due to staff turnover. Working the students identified on this report is part of scheduled processes. Student Aid is working with IT to have these reports automated and scheduled out for delivery to ensure that it is received and worked in a timely manner. Implementation Date: February 2024 Responsible Person: Megan Begnaud, Director of Student Aid

Corrective action plan: Program is enhancing processes to reconcile current expenses and ensure only eligible expenses are reported on the applicable funding sources. These actions will result in accurate amounts reported on the schedule of federal award expenditures. To strengthen requirements related to unique disaster funding, DSHS will reevaluate all invoices on this grant to ensure they are on the proper funding source. The State Medical Operations Center Finance staff will coordinate with DSHS Financial Division to communicate FEMA updates impacting expense reimbursement. Implementation date: August 31, 2024 Responsible persons: Wayne Zwart, Disaster Finance Manager, Center for Health Emergency Preparedness and Response’; Amanda Hudson, Budget Director, Financial Division

Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Children’s Health Insurance Program (CHIP) provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in CHIP. Of the CHIP providers requested during the fiscal year 2023 Statewide Single Audit, 59 of 60 samples had been enrolled or revalidated through PEMS and the auditor received all requested documentation. The listed exceptions only apply to one CHIP provider. The provider enrolled with CHIP before the implementation of PEMS. HHSC operated under the public health emergency (PHE) between March 30, 2020, and May 11, 2023. In response to the public health emergency (PHE), the Centers for Medicare and Medicaid Services waived exclusion check requirements for provider reenrollments and revalidations. HHSC is in the process of revalidating providers through PEMS; however, as a result of the PHE end date and provider revalidation requirements, the projected completion date for the required revalidation of all CHIP providers is January 2027. HHSC continues efforts to enroll CHIP providers through PEMS and expects to eliminate errors related to these documents once all CHIP providers have revalidated. Implementation dates: December 2021, PEMS implementation January 2027, provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management

Corrective action plan: The applicant's file date is the date HHSC or an HHSC agent receives an application that contains, at a minimum, the person's name, address and signature. A faxed or electronic signature, if using the online application available through YourTexasBenefits.com, is acceptable. Access and Eligibility Services (AES) must determine eligibility and provide Form TF0001, Notice of Case Action, by the 45th day after the file date for an application requesting health care for children. Federal regulations at 42 CFR 435.912(c)(3) require that HHSC complete an eligibility determination within 90 days for individuals who are applying for Medicaid based on disability and within 45 days for all other applicants. HHSC has made significant investments in its eligibility workforce to address required application processing timeframes. In the last fiscal year, HHSC onboarded more than 2,100 eligibility staff, implemented workforce recruitment and retention initiatives, and augmented its training capacity by leveraging technology, strengthening the quality of the virtual learning products and scheduling, and standardizing On-the-Job Trainings. HHSC is working on cross-training eligibility advisor staff across all programs (SNAP, TANF, Medicaid, CHIP, MEPD). HHSC is actively reviewing existing application processing procedures to ensure all applications are reviewed and an eligibility determination is made within the required timelines. Implementation date: December 31, 2024 Responsible person: Gracie Perez – Interim Associate Commissioner, AES Operations

Corrective action plan: HHSC has made significant investments in its eligibility workforce to meet workload demands. In the last fiscal year, HHSC has onboarded more than 2,100 eligibility staff, implemented workforce recruitment and retention initiatives, and augmented its training capacity by leveraging technology, strengthening the quality of the virtual learning products and scheduling, and standardizing On-the-Job Trainings. HHSC will also continue to create and share guidance and tips with staff to reinforce proper data entry in the eligibility determination system, including entries related to TANF. Implementation date: December 31, 2024 Responsible person: Gracie Perez – Interim Associate Commissioner, Access and Eligibility Services (AES) Operations

Corrective action plan: To rectify the discrepancies in the EA Eligibility Application/Determination section of the IMPACT system, DFPS is implementing the following measures: 1. Research and Analysis: DFPS IT initiated research on 12/12/2023 to investigate the root cause of why the child became eligible upon recertification. This research will be ongoing to comprehensively understand the underlying factors. 2. Database Audit: A database audit table was added in early October 2023 to expedite the identification of similar issues in the future. This enhancement aims to facilitate a quicker determination of the root cause for any inaccuracies related to EA eligibility. 3. Batch Analysis: The EA eligibility batch process will undergo a thorough analysis to ensure it accurately identifies children who should or should not be deemed EA eligible. Insights from this analysis will help optimize the batch process and prevent similar occurrences. 4. Project Review: A review of Project 65700, completed in August 2021, will be conducted to assess if any gaps in the re-certification batch allowed a child to be incorrectly considered EA eligible. The data fix performed during this project will also be scrutinized to ensure it adhered to accurate eligibility criteria. 5. Communication and Training: DFPS commits to ongoing communication and training for INV/AR staff regarding EA and the correct method of answering questions within the IMPACT system. This aims to enhance staff awareness and compliance with federal guidelines and internal policies. 6. Internal Quality Assurance: DFPS will strengthen its internal quality assurance reviews of cases eligible for EA. This proactive approach ensures ongoing compliance with federal guidelines and internal policies, thereby minimizing the likelihood of eligibility-related errors. 7. In Fiscal Year 2023, DFPS Investigations/Alternative Response personnel underwent supplementary training sessions and received revised policy and resource guides pertaining to Emergency Assistance (EA). These initiatives were implemented to address the concerns identified, specifically related to inaccuracies in responding to questions within the EA Eligibility Application/Determination. DFPS remains committed to these corrective actions to address the identified issues and continually improve the accuracy and reliability of the EA eligibility determination process. The effectiveness of these measures will be regularly assessed to uphold the integrity of the system and prevent improper payments. Citizenship: To rectify this situation and to ensure that a child that is not a U.S. citizen, qualified alien, or permanent resident does not receive EA benefits, DFPS is implementing the following measures: 1. DFPS Finance will work with program and IT to determine the best practices when answering citizenship and the Emergency Assistance (EA) eligibility questions and ensure the IMPACT system is reading the responses and applying the logic properly resulting in EA eligibility determination that is in compliance with United States Codes, Chapter 8 Aliens and Nationality, Chapter 14 – Restricting Welfare and Public Benefits of Aliens, §1611. 2. DFPS will review the list of non-citizens and update their eligibility if they are incorrectly deemed EA eligible. 3. DFPS will review the payments issued to non-citizens and process adjustments to ensure EA funds are used only for eligible activities. Implementation dates: IMPACT IT research begun on 12/12/2023 and will be ongoing to determine the root cause of the issue. Ongoing communication to staff. Citizenship: The first item will require a coordination with IT and programs and it’s completion date will be dependent on the efforts required to make the agreed upon changes. Item 2 and 3 is anticipated to be completed by May 31, 2024. Responsible persons: Jerome Green, CPI Deputy Director of Field; Citizenship: Scott Greer, Budget Director

Corrective action plan: The Provider Finance Department (PFD) will take proactive measures to establish and enforce guidelines that guarantee documentation is retained for a minimum of three years from the date of submission of the final expenditure report for each grant. This approach aligns with our dedication to transparency, accountability, and responsible grant management. We will ensure that all the documentation is saved within our documentation repository for a minimum of three years from the date of submission. Implementation date: June 1, 2024 Responsible person: Stacy Kerns – Director, Business Operations and Support Services