Corrective Action Plans

SPECIAL TESTS AND PROVISIONS – INCOME ELIGIBILITY AND VERIFICATION SYSTEM Department of Health & Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The Division of Family Support within the West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA), will send the current desk guides to all WV WORKS (TANF) staff, which includes the Data Exchange desk guide and the Viewing Data Exchanges by Exchange Type desk guide. The BFA Division of Family Support will also work with the BFA Division of Professional Development to create a blackboard course for supervisors and community service managers [who supervise WV WORKS (TANF) staff] to assist the supervisors and management in identifying deficiencies regarding the IEVS system.

SPECIAL TESTS AND PROVISIONS – SATISFACTORY ACADEMIC PROGRESS Blue Ridge Community and Technical College, Bluefield State University, Fairmont State University, Marshall University, New River Community and Technical College, West Liberty University, West Virginia Northern Community College, West Virginia School of Osteopathic Medicine, and West Virginia University at Parkersburg Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364 Blue Ridge Community and Technical College (BRCTC) response BRCTC agrees with the auditor’s comments that the internal control process regarding the Satisfactory Academic Progress (SAP) Policy can be improved by maintaining documentation of an annual formal review of the SAP policy and its publication on the website, internal policy manuals and the student catalog. Effective January 2024, BRCTC’s website has been updated to appropriately reflect the SAP policy. Bluefield State University (BSU) response Effective January 2024, internal controls are in place to perform the Review of the Standards of Satisfactory Academic Progress Policy to comply with federal regulations 2-CFR 200.303, 34 CFR 668.16 (e) and 34 CFR 668.34. The current SAP policy was reviewed in June of 2023, but a signature was not maintained. The SAP policy will be reviewed annually prior to the new academic year that begins each August. The review will consist of the Director of Financial Aid, Chief Financial Officer and Provost reviewing all aspects of the current policy at first and then maintaining any changes annually along with retaining signatures of the annual review. The policies and procedures will be given a new review date each year to reflect the process.   Fairmont State University (FSU) response Effective January 2024, the following has been placed into the Satisfactory Academic Progress policy and will go into effect in Spring 2024 - Institutional Documentation Retention. Prior to the Satisfactory Academic Progress policy being applied to students at FSU, the Director will be responsible for the following: 1. Download the most current Satisfactory Academic Progress regulations from studentaid.gov. This documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 2. Review, compare, and update the current Satisfactory Academic Progress policy at FSU with the most current federal regulations. The most current version of the policy will be signed off and dated by the Director of Financial Aid & Scholarship. This documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 3. The Director of Financial Aid & Scholarships will provide any updates to the policy to the Information Systems Specialist by email in order for the Banner system to be updated with the updates. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 4. The Information Systems Specialist will update the Banner system in TEST. 5. The updates will be ran in TEST by running the ROPSAPR process for the future fall and future summer terms. 6. The TEST data will be reviewed and evaluated to ensure all policy updates have been captured and the students have been appropriately evaluated according to federal regulations. 7. The Information Systems Specialist will notify the Director of Financial Aid & Scholarships by email the status of the TEST system to determine if additional updates need to be made. 8. If the Director approves the data from the TEST system, they will notify the Information Systems Specialist by email that the updates are ready for production. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 9. Updates will be applied to the production system by the Information Systems Specialist and the ROPSAPR process will be run on all current students for evaluation. 10. The Information Systems Specialist will notify the Director of Financial Aid & Scholarships by email once the process is complete for one final review of the data to ensure all federal regulations are being met and the students have been evaluated accordingly. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 11. The Director of Financial Aid & Scholarships will sign off on the completed process by email to the Information Systems Specialist. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. Marshall University (MU) response MU updated the website in February-March which included a review of SAP Policies and Procedures. MU did not update the Revision Date as there were no updates to Satisfactory Academic Progress federal regulations for the 2023-24 aid year. The policy did not change but was reviewed when updates were made to the website. This policy was updated and also added to the website. Effective February 2024, MU will document and retain all reviews and approvals for compliance with federal regulations. New River Community and Technical College (NRCTC) response NRCTC will continue to review policies and procedures at least once, and sometimes twice a year when the catalog is reviewed. NRCTC will continue doing this review and maintain documentation to ensure compliance with federal regulations. West Liberty University (WLU) response Effective January 2024, to comply with internal control over federal awards, WLU will ensure that SAP policies are compliant with the US DOE standards and retain evidence of the review before the SAP procedures are completed annually. If there are no changes, the policy will be approved to move forward. A signed sheet of the SAP policy approval will be retained in the office and an email of no updates will be sent to others in the Financial Aid Office. If changes are necessary, a financial aid committee would meet to make the appropriate updates. Once the policies and procedures are updated, a signed copy of the update will be retained in the FA Office and an email of the updates will be sent to the Financial Aid Office and communicated to all faculty, staff and students. West Virginia Northern Community College (WVNCC) response Effective December 2023, a new internal control process has been added to validate WVNCC’s processes (including SAP) with any changes to the Dept of Ed regulations, as available for the upcoming school year. WVNCC begins creating the new policy and procedure manual as the new year financial aid setup begins. The Director of Financial Aid will be creating a task force which meets two times per year to review the procedures. As WVNCC’s policy and procedure manual is a live working document, updates will be made as needed with a revision date denoted where applicable. WVNCC had an initial conversation with NASFAA on their policy and procedure information available and has created a sign off form to verify the review of the policy each academic year. This process is being implemented during the 2023-2024, prior to this year, as with the 2022-2023 documents, changes in regulations or college policy changes were made in the policy and procedure manual but may not have had a revision date as it done during the manual creation. This process will be fully implemented for the new 2024-2025 policy and procedure manual as it is being created. The new control will formalize this process, a review of applicable review is in process. West Virginia School of Osteopathic Medicine (WVSOM) response WVSOM did not have adequate internal controls in place surrounding the satisfactory academic policy (SAP) policy. A new SAP policy will be written and published to the public website to include reasonable standards for measuring whether eligible students are maintaining SAP in the educational program in our published SAP policy. The new policy will provide notification to the students of the results of an evaluation that impacts the students’ eligibility for title IV program funds. WVSOM will retain sufficient documentation that the procedures are performed and reviewed by the Financial Aid Director and a second review performed by the Associate Director of Financial Aid. The review will provide two signature sign-offs. West Virginia University at Parkersburg (WVU-P) response Financial Aid employees review all financial aid policies and procedures at minimum once per academic year. The Satisfactory Academic Progress (SAP) policy was reviewed and updated by financial aid staff throughout the spring and was approved by the Executive Vice President in June 2023, the updated SAP policy was forwarded to the President’s office to be filed and posted in the appropriate places, including online. WVU-P agrees that the updated and most recent SAP policy was not posted to the website prior to June 30, 2023. There was a college-wide policy review this spring, and the volume of that caused a delay in the policy’s posting. The resolution for this issue is to complete our policy review process earlier, and ensure if updates are necessary then the Marketing and Communications staff are aware of a deadline prior to June 30 to post the updated policy. WVU-P believes that there is sufficient documentation to show that the review of the SAP policy occurred within the academic year. The policies themselves have footnotes to document that Heather Skidmore reviewed the policies, and then the secondary review completed by Alice Harris before submission to the President. WVU-P will retain all communication that occurs related to future review processes to avoid a repeat finding on this issue.

ALLOWABILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 The West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA), analyzed the condition that led to this finding and hereby offers more details into the condition and cause of the finding. The $463.00 cost in question was a supplemental Emergency Assistance payment from July 2022. The SNAP Assistance Group was due for recertification review for the month of July 2022. A review document was mailed to the client in June 2022. The client failed to return the review in a timely manner, which resulted in a late review interview. The SNAP household eventually submitted the review document on July 11, 2022, whereby the interview was conducted the same day. As the household was then required to submit updated income verification, the case was still pending on July 11, 2022. On July 28, 2022, the case comments document that the client submitted paystubs, but the paystubs were outside the period of consideration (POC); the SNAP benefit failed on this date. On August 2, 2022, the household submitted additional documentation and the BFA reopened the SNAP benefit retroactively for July. The Emergency Assistance (EA) supplements were not to be initiated until the second month of SNAP issuance (i.e., the month following active SNAP approval). Therefore, the $463.00 payment in question was ineligible because the SNAP Assistance Group was not receiving SNAP at the time of the July 2022 EA supplemental issuance. The condition is due to the household reporting new income prior to the start of the recertification, which caused the BFA to need or request additional payments immediately following. Client confusion added to this issue. On December 29, 2022, the U.S. President signed into law the Consolidated Appropriations Act, 2023. Division HH, Title IV, Section 503(b), of the Act ended the SNAP EA that was provided by Section 2302(a)(1) of the Families First Coronavirus Response Act (FFCRA). The law terminated EA after the issuance of February 2023 benefits. Therefore, the last benefit month that may include EA was February 2023. If future EA or related programs become available for SNAP, the BFA will work with its contractor to develop stopgap measures within the eligibility system that will require an additional review to process supplemental EA payments when a household is due for recertification.

SPECIAL TESTS AND PROVISIONS – ADP SYSTEM FOR SNAP Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 Management within the DHHR, Bureau for Family Assistance (BFA), appreciates and shares the auditors’ concern with SNAP program integrity as it relates to the Recipient Automated Payment and Information Data System (RAPIDS) ADP system. The BFA notes that 7 CFR § 272.10 begins with, “(1) Purpose. All state agencies are required to sufficiently automate their SNAP operations and computerize their systems for obtaining, maintaining, utilizing, and transmitting information concerning SNAP. Sufficient automation levels are those which result in effective programs or in cost effective reductions in errors and improvements in management efficiency, such as decreases in program administrative costs...” Within the RAPIDS ecosystem for SNAP administration, this automation includes data matching measures undertaken, in compliance with related federal rules as specified in 7 CFR § 272.8, 7 CFR § 272.16, etc., to automate the validation of client-provided, worker-input information while mitigating the additional administrative burden of secondary review for all worker interactions with a client’s case. Policy regarding state and federal data matching is laid out in Chapter 6 of the State’s Income Maintenance Manual (IMM) at https://dhhr.wv.gov/bfa/policyplans/Documents/ Binder4.pdf. The primary data exchange system detailed in IMM Chapter 6 that is applicable to SNAP is the Income and Eligibility Verification System (IEVS) required by 7 CFR § 272.8. Systems mandated federally for inclusion in the IEVS include those operated by WorkForce WV, the Internal Revenue Service (IRS), and the U.S. Social Security Administration (SSA). A variety of other sources may also be queried for the purpose of validating client-provided information entered into RAPIDS by a worker, including Veterans Affairs (VA), Beneficiary and Earnings Data Exchange (BENDEX), Beneficiary Earnings and Exchange Record System (BEERS), National Directory of New Hires, and Prisoner Matching with the Department of Corrections as well as the Federal Data Services Hub (FDSH). IMM Chapter 6, page 2 describes the purpose of data matching through the IEVS thusly: Information obtained through IEVS is used for the following purposes: • To verify the eligibility of the assistance group (AG). • To verify the proper amount of benefits. • To determine if the AG received benefits to which it was not entitled. • To obtain information for use in criminal or civil prosecution based on receipt of benefits to which the AG was not entitled. IMM Chapter 6, pages 2-3 further detail the points at which a match with the IEVS must take place: A data exchange in the eligibility system occurs: • When a new case is created; • When a new person is added to a benefit; • When a person’s demographic information is changed; and, • On a periodic basis for all individuals in the eligibility system, depending on the type of benefit being received. Requirements for independent verification of information when automated data matches fail or report a discrepancy with client-provided, worker-input information are spelled out in IMM 6.4.4. The BFA believes that these automations, while perhaps not foolproof, are in keeping with both the word and intent of 7 CFR § 272.10, 7 CFR § 272.8, 7 CFR § 272.16, etc., which aim to automate processes in order to reduce administrative burden and associated costs, such as those that would be associated with a secondary review of all worker interactions with a client’s case. Furthermore, page 4-10.551-9 of the Compliance Supplement 2023, which lays out the suggested audit procedures for this topic, recommends the use of the USDA-FNS SNAP System Integrity Review Tool (SIRT) to ensure that the State’s ADP system is in alignment with USDA-FNS requirements and ensure that automated processes within RAPIDS continue to comport with federal requirements for ADP systems. To our knowledge, the auditors neither utilized that tool to guide their work nor requested verification from the State that the SIRT had been completed and previously employed. To support this response, management advocates a review of the SIRT submitted to FNS on October 26, 2023 in preparation for the go-live stage of the West Virginia People’s Access to Help (WV PATH) Family Assistance pilot program; as there is no significant difference in system functionality between the Family Assistance module of WV PATH and the existing eRAPIDS system, the responses/comments/replies from both FNS and the State that are included in this version of the SIRT generally apply both to eRAPIDS and to PATH. Throughout 2023, the BFA Division of Performance and Quality Improvement continued its ongoing SNAP case reviews, as well as its efforts to report compliance with monthly requirements for expanded supervisor case reviews conducted and tracked through the Rushmore case review system, as mandated in a December 7, 2022 memorandum to supervisors and made available to the auditors last year. Furthermore, the BFA developed additional worker training, including the reinstatement of face-to-face Statewide Payment Accuracy Conferences (held throughout the summer of 2023), with the aim to ensure that client information is accurately captured in RAPIDS so the APD can perform its automated functions with integrity.

DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, COVID-19 93.777, 93.778 The DHHR is currently phasing in a new information technology system for determining eligibility, making payments, maintaining documentation, etc. The name of the new system is WVPATH (West Virginia People's Access to Help). The WVPATH system will replace the Family and Children's Tracking System (FACTS) and the Recipient Automated Payment Information Data System (RAPIDS), which are currently referenced in the finding. The WVPATH system will have additional controls and levels of review as compared with the FACTS and RAPIDS systems. Due to the timing of the phase-in process, the DHHR anticipates the finding will be resolved for the year ended June 30, 2024.

We propose to implement the following actions to ensure this doesn’t happen again. a. Audit existing patient records and patient registrations to identify missing documentation. We will start with the oldest patient files that likely started off with paper charts prior to being on the centralized electronic health record system. We will audit for: proof of IHS benefits, official identification card or other proof of identification, as well as reviewing 3rd party payor sources. For any missing items, we will be sure to request those from the patients and/or parents, if a minor child. b. Monthly - double check new registrations and have our central registration perform audits on those for completion. c. Perform immediate training with the registration and front desk team; stressing the importance of documentation. Send registration lead and primary care administrator to the Alaska Native Tribal Health Consortium ‘s Alaska Statewide Tribal Business Office Conference for Billing and Coding and Outreach and Enrollment April 2-5, 2024. Adopt any missing best practices. d. Adopt signage for patients necessary to understand that if they don’t submit the required documentation, they will be expected to pay for services provided. e. Adopt monthly registration and scheduling meetings with the front desk team to ensure the above tasks are coming along and address any known issues with acquiring documentation. f. Transfer supervision of front desk employees from the Medical Director to the newly hired, Primary Care Services Administrator. Thank you for giving us the opportunity to address and correct this important issue and improve our processes. It’s always our intent to comply with our federal programs.

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this finding. Caseworkers will be reminded of appropriate signatures needed within the application process. Training and refresher training on voice and telephonic signatures will be provided to Energy staff. Supervisors and/or Quality Assurance staff will continue to perform monthly second party reviews. Emphasis will be placed on forms requiring applicant signatures to ensure all signatures are secured and documented accordingly. Proposed Completion Date: The above procedures are currently in place and will be monitored on an ongoing basis.

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this finding. Caseworkers will be reminded of appropriate documentation techniques and when IV-D referrals are necessary within the eligibility determination process. Supervisors and/or Quality Assurance staff will continue to perform monthly second party reviews. Emphasis will be placed on documentation and IV-D referrals to ensure compliance with NC Medicaid policy. Proposed Completion Date: The above procedures are currently in place and will be monitored on an ongoing basis.

Caseworkers are to review and verify income and deductions by policy standards. Food and Nutrition Lead workers and Supervisor will conduct second-party reviews on caseworkers. The Food and Nutrition Supervisor will go over errors found by second parties during their team's monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisor due to performance and 4 for applications workers and 3 for redeterminations workers per month. The supervisor and lead workers will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisor and/or Lead workers will conduct monthly meetings which include mini trainings on errors found in second parties. Refresher training will be held quarterly and annually for in-depth training regarding policy areas in which the Supervisor and lead workers identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest training needed to the Supervisor to ensure that policy/procedures are being implemented accordingly. The supervisor will schedule and hold a meeting each month to inform Program Administrator, Heather Hayes, of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisor and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator monthly and at quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training will be held on Food and Nutrition policy sections 340 Deductions, 310 Budgeting New/Change/Terminated Income, and 315 Special Budgeting Income on January 24, 2024.

Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. The supervisor will go over errors found by second parties during their team monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisor will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2352 on November 29, 2022. Plan was discussed on November 17, 2023 with Lead Workers Michelle Ogle and Delta Elliot on a new team procedure regarding SSI terminations. Meeting will be held on November 28, 2023 discussing new procedure and a Training will be held by December 29, 2023 regarding SSI Expartes.

Caseworkers are to review the determinations tab and policy manual to properly ensure that the case is showing correctly. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. Family and Children Medicaid Lead Workers and the Supervisors will conduct second-party reviews on caseworkers. Both Adult Medicaid and Family and Children Medicaid supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisors will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisors due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisors will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. Supervisors will schedule and hold a meeting each month to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2250 on November 29, 2022, DSS Terminial Message regarding Admin Letter 11-22 dated 12/12/2022 on COLA procedures was provided to Adult Medicaid team members on 12/12/2022. Meeting held regarding COLA income on 12/29/2022. Update meeting regarding the COLA increases will be held by December 31, 2023 when policy guidelines are provided by state. Family and Children Medicaid sections MA-3300 was held on November 30, 2022 regarding income. Meeting regarding Incorrect income will be held on by November 30, 2023.

Corrective Action: Proposed completion date: Finding 2023-005 Inaccurate Information Entry Name of contact person: Kim Grissom, Family and Children's Medicaid Supervisor, Shelia Morton, Family and Children's Medicaid Supervisor, and Vanness Taylor, Adult Medicaid Supervisor To ensure that the caseworkers do not repeat these errors, the following will happen: Adult Medicaid Documentation Templated was updated November 13, 2023. Training was held on July 6, 2023 for Recertifications for Adult Medicaid. Adult Meeting will be held on November 28, 2023. Family and Children held team meetings on November 30, 2022, January 26, 2023, and May 23, 2023. Family and Children meeting will be held by November 30th, 2023. State mandatory Training was held for all Medicaid Staff on July 25, 26, or 27, 2023 for Mastering Medicaid Policy , MAGI Recertifications and NCFAST 20020, and September 26, 27, or 28, 2023 Authorized Representatives and NCFAST 20020 Reminders. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. Family and Children Medicaid Lead Workers and the Supervisors will conduct second-party reviews on caseworkers. Both Adult Medicaid and Family and Children Medicaid supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisors will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings.

Corrective Action: Proposed completion date: Finding 2023-004 Inadequate Request for Information Name of contact person: Caseworkers are to review the determinations tab and policy manual to properly ensure that the case is showing correctly. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. The supervisor will go over errors found by second parties during their team monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly.The Supervisor will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator Staff Development Specialists and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2230 on Janaury 31, 2023, July 6, 2023 and September 28, 2023. Documentation Templates were recently updated as of November 13, 2023. Meeting regarding the cited errors will be held on November 28, 2023.

Finding 2023-002 IV-D Cooperation with Child Support Name of contact person: Corrective Action: Proposed completion date: Finding 2023-003 Inaccurate Resources Entry Name of contact person: For the Year Ended June 30, 2023 Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings July 1, 2023 Stephen McNally, Finance Director The Finance Department will attempt to make all necessary transfers of funds between Forfeiture accounts in the current period. However, this correction notification from US Treasury was not sent to the Finance department until after the reporting period in which the transaction took place. Kim Grissom, Family and Children's Medicaid Supervisor and Shelia Morton, Family and Children's Medicaid Supervisor Family and Children Medicaid Lead Workers and Supervisors will conduct second-party reviews on caseworkers. The supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisors will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisors due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisors will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisors will schedule and hold a meeting to inform the Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invites to Program Administrator, Staff Development, and Human Services Planner Evaluator, for monthly and at quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on November 30, 2022, for Family and Children Medicaid section MA- 3365. Documentation Template was last updated on November 3, 2023, which includes IVReferral reminder. Family and Children meeting will be held by November 30, 2023.

Over Award Review and Correction Action Taken – Kansas Health Science Center (KHSC) Identifying Number: 2023-001 Finding: Eligibility – Determining Federal Direct Student Loan Awards Applicable Regulation: Per 34 CFR 686.203(b)(iii), in the case of a graduate or professional student for a period of enrollment beginning on or after July 1, 2012, the total amount the student may borrow for any academic year of study under the Direct Unsubsidized Loan program may not exceed $8,500. Per 34 CFR 685.203(c)(2)(v), the additional amount that a student described in paragraph (c)(1)(i) of this section may borrow under the Direct Unsubsidized Loan Program for any academic year of study may not exceed the following: in the case of a graduate or professional student, $12,000. Finding: During testing of eligibility, 7 out of 7 students selected for testing were over awarded Unsubsidized Federal Direct Loans. KHSC improperly awarded 61 out of 61 students Unsubsidized Federal Direct Loan in excess of the maximum amount for one academic year, amounting to [$4,445] per student, for a cumulative over award of [$271,146]. Summary: Prior to the commencement of the independent audit conducted for the fiscal year ended May 31, 2023, the institution discovered that it had over awarded Unsubsidized Federal Direct Loan funds to its students. Specifically, the institution awarded additional Unsubsidized Federal Direct Loan funds based on 12-month academic calendar instead of prorating the award based on a 10-month academic calendar. This error resulted in an over award of [$4,445] per student. The institution conducted a file review and refunded all amounts owed to the Federal Student Aid programs because of the file review. The institution also informed the auditor of this error. Corrective Action Taken or Planned: Once the above noted error was discovered, the institution conducted an audit of all student aid packages for students enrolled in the 2022-2023 academic year. It was determined that 61 current students had been over awarded by a net amount of $4,445, for a total of $271,146. Findings were compiled and a plan was created to return over awarded funds and communicate the error to students. The institution also consulted with the Department of Education to confirm its revised calculation was appropriate. The institution returned the funds between July 5-July 20, 2023. Further, the institution made students whole by forgiving any student balances that would have been paid by the over award amount. Emails were sent to all impacted students on July 3, 2023 notifying them of the error. The institution also subsequently notified students that any account balance that remained based on the reversal of the over award would be forgiven. Students who received an estimate financial aid award with the incorrect figures, but who had not yet received aid, were notified of the error and provided updated award information. To ensure this does not happen again the institution has updated their internal student finance audit to include a review of all aid eligibility in conjunction with the next year’s academic calendar for each class of students. Upon any determination that future aid should be prorated, calculation(s) will be completed and reviewed with leadership before implementation. An internal review and approval process will then be enacted and documented. The institution informed RSM of this error and the corrective actions taken. Contact Person Lawrence McGhee, Associate Vice President of Financial Aid, lawrencemcghee@tcsedsystem.edu Completion Date July 20, 2023

Finding: 2023-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2024

Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name(s) of the contact person(s) responsible for corrective action: Nancy Siddens, Director of Financial Aid. Planned completion date for corrective action plan: November 1, 2023.

Pell Awards Planned Corrective Action: We have engaged an outside vendor to provide knowledgeable staff augmentation to help us improve our processes and the timeliness of verifying students’ enrollment status. Person Responsible for Corrective Action Plan: Cathy Morgan Anticipated Date of Completion: March 1, 2024

Item 2023-002 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken 1. To train all staff involved with the calculation of sliding fees on the policies and procedures to ensure: ► The sliding fee guidelines document is known. ► Understanding of the methodology for calculating fees, including how family size and income are considered. ► Documentation required to support income and family size information provided by clients. This may include tax returns, pay stubs, or other relevant documents. ► To use the standardized form (checklist) to ensure all necessary information is collected and verified. 2. To perform a monthly audit review, utilizing a selected sample to identify any discrepancies and make necessary corrections in a timely manner. 3. To ensure the sliding fee scale is clearly communicated to clients. Responsible Party: Director of Patient Services/RCM Director Target Completion Date: 04/30/2024 If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Hewart Tillett, CFO at 1-314-882-1463, or email at htillett@phcenters.com.

The Office of Academic Achievement Programs will update their procedures to ensure that all appropriate documentation is maintained when making eligibility determinations for each student.

Incorrect Pell Calculations Planned Corrective Action: The University will provide oversight and review of Pell calculations on a weekly basis. Person Responsible for Corrective Action Plan: Donnie Purvis, Director of Financial Services Anticipated Date of Completion: Effective Immediately, February 15, 2024

The District will continue to enhance procedures and controls over the verification compliance requirement with adequate oversight and will identify and train additional individual(s) to ensure appropriate back-up is in place, that is also knowledgeable of its requirements. Responsible official: Cory Kaisler, Data Systems Coordinator – ckaisler@shawanoschools.org Anticipated Completion Date: June 30, 2024

The District will continue to enhance procedures and controls over the eligibility requirements with adequate oversight of both manual and electronic processes and will identify and train additional individual(s) to ensure appropriate back-up is in place, that is also knowledgeable of its requirements. Responsible official: Cory Kaisler, Data Systems Coordinator – ckaisler@shawanoschools.org Anticipated Completion Date: June 30, 2024

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: Material Weakness Condition and Context There was no evidence that the Direct Certifications were correctly and properly included in the software system, or that there was an oversight, review, or approval process over the Direct Certifications. Contact Person Responsible for Corrective Action: Lori Boyce Contact Phone Number and Email Address: 765-653-3148 lboyce@sputnam.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Food Service Director will have the Guidance Secretary check and initial that the Food Service Director has completed the Direct Certification correctly. Anticipated Completion Date: 2/2024

in 2024, the Vilalge will implement processes and conrols to ensure the completeness of underlying records and accuracy of HAP and utility allowance calculations. The Village will sample case files to help ensure compliance.