Corrective Action Plans

􀀃 Finding􀀃2023􀍲005􀀃 􀀃 Finding􀀃Subject:􀀃Child􀀃Nutrition􀀃Cluster􀀃–􀀃Eligibility􀀃–􀀃Internal􀀃Controls􀀃 Summary􀀃of􀀃Finding:􀀃Internal􀀃Controls􀀃were􀀃not􀀃in􀀃place􀀃over􀀃direct􀀃certification􀀃of􀀃 students.􀀃 Contact􀀃Person􀀃Responsible􀀃for􀀃Corrective􀀃Action:􀀃Director􀀃of􀀃Food􀀃Service􀀃 Contact􀀃Phone􀀃Number􀀃and􀀃Email􀀃Address:􀀃(260)431􀍲2030,􀀃msnyder@sacs.k12.in.us􀀃 􀀃 Views􀀃of􀀃Responsible􀀃Official:􀀃We􀀃concur􀀃with􀀃the􀀃finding.􀀃 Description􀀃of􀀃Corrective􀀃Action􀀃Plan:􀀃 All􀀃direct􀀃certification􀀃information􀀃shall􀀃be􀀃initiated􀀃by􀀃the􀀃Director􀀃of􀀃Food􀀃Service:􀀃Pulling􀀃the􀀃 information􀀃monthly􀀃from􀀃CNP􀀃Web.􀀃The􀀃list􀀃of􀀃students􀀃to􀀃be􀀃directly􀀃certified􀀃will􀀃be􀀃printed,􀀃 signed􀀃and􀀃dated􀀃by􀀃the􀀃Director􀀃of􀀃Food􀀃Service.􀀃Once􀀃information􀀃is􀀃imported􀀃into􀀃the􀀃student􀀃 management􀀃system,􀀃the􀀃Assistant􀀃Food􀀃Service􀀃Director􀀃would􀀃then􀀃cross􀀃reference􀀃the􀀃printed􀀃list􀀃 of􀀃information􀀃to􀀃benefits􀀃assigned􀀃in􀀃the􀀃student􀀃management􀀃system􀀃to􀀃ensure􀀃accuracy.􀀃The􀀃 Assistant􀀃Food􀀃Service􀀃Director􀀃will􀀃initial􀀃next􀀃to􀀃the􀀃students􀀃they􀀃spot􀀃check􀀃on􀀃the􀀃list.􀀃The􀀃 printed􀀃document􀀃with􀀃signatures􀀃of􀀃both􀀃parties􀀃will􀀃be􀀃retained􀀃with􀀃the􀀃school􀀃years􀀃 applications.􀀃􀀃 Anticipated􀀃Completion􀀃Date:􀀃3/18/24􀀃

Finding Number 2023-004 – Student Financial Assistance (SFA) Cluster – Various ALN Numbers – Enrollment Reporting Management’s Response The UPR concurs with this finding. In the previous three years, cases have been reported in which the change in the student's status was never reported, the change in status was incorrectly reported, or the change in status was reported after 60 days. For FY2023, the auditors only pointed out that the UPR reported the change in the student's status over 60 days. This is evidence that the measures implemented before are achieving their objective. The UPR has implemented provisions to prevent the change in status from ever being reported or the incorrect status from being reported. However, we still must comply 100% to ensure that changes in student status are reported on time. For this, the UPR will issue written instructions and will have meetings with the Deans of Academic Affairs of the eleven (11) campuses to ensure they guide their staff to understand the importance of complying with the academic calendars and the implications of not doing so; including: (a) the importance of submitting grades on time (b) the importance of Bachelor or Master’s degrees being conferred on time. For the four cases of UPR-Bayamon campus, the registrar has evidence that they were reported to the National Student Clearinghouse (NSC) on June 30, 2023. UPR-Bayamon campus will contact the NSC to determine why these cases were reported on August 30, 2023, and will implement the necessary actions to prevent this from happening again. Responsible Person/Office: Executive Vice President for Academic Affairs and Research. Timeline: June 2024, so we will notice their effect during fiscal year 2024-2025.

DCH has implemented the programming changes in Georgia Medicaid Management Information System (GAMMIS) to recoup capitation payments dating back to April 1, 2023 for members who were deemed retroactively eligible for Medicare. For any current Managed Care Organization (MCO) member that gets retroactive Medicare coverage, that member’s MCO capitation payments are recouped back to the day before the effective date of the Medicare benefit or back to 4/1/23 whichever is later. A monthly report entitled MGD-4218-M captures the recoupment activity.

GDOL acknowledges this is a repeated finding from previous years, therefore the Department concurs with this finding and offers the following response preceded by the auditor’s findings: Auditor’s Findings: The Department of Labor should improve internal controls over Employer Filed Unemployment Compensation claims. GDOL Response: GDOL submits the following information as an overview of the employer filed claims program and actions that have been taken and will continue to address the findings as well as incorporate additional safeguards and available technological system controls in the new system: The Employer Filed Partial Claims (EFC) program originated in the late 1960’s and was designed to allow employers with short-term, temporary periods of lack of work for their employees to retain their workforce when work resumes. This is a program that many large manufacturers in Georgia rely on when they have temporary plant shutdowns and have for decades. When GDOL has attempted in the past to limit this program, we have met strong resistance from Georgia’s manufacturers. This program optimizes our ability to process and pay mass numbers of claims more quickly, such as what occurred at the beginning of the pandemic. EFCs may be filed by an employer for any complete pay-period week during which an otherwise full-time employee works less than full-time, due to lack of work only, and earns an amount not exceeding his/her unemployment insurance weekly benefit amount. Such claims shall not be submitted or allowed for vacation days regardless of whether such vacation days were requested by the employee or established by the employer. Effective March 19, 2020, a temporary, Emergency Rule 300-2-4-05(1), containing Rule 300-2-4-.09(1) was signed which required employers to electronically submit EFCs on behalf of their employees whenever it is necessary to temporarily reduce work hours or there was no work available for a short period due to the pandemic. Employers were allowed to file such claims for full and part-time employees whose earnings had been reduced. In July 2020, the Rule was sunset and employers were no longer required to file EFCs. By electing to submit EFCs on behalf of the individuals, the employer is responsible for attesting by an affidavit to the employment status and weekly earnings of the individual for the EFC submitted. The affidavit certifies that the employer has obtained earnings from other employment as well as other requirements must be completed before EFCs can be entered or uploaded for their employees. Individuals for which EFCs are submitted are considered to be still attached to the employer and are exempt from the requirement to register for employment services per Georgia Employment Security Law Rules 300-2-4-.02. Such individuals are not required to be nor certify on a weekly basis to be actively seeking work. Effective December 6, 2021, the EFC process was revised to require individuals (employees) to complete an EFC profile to include a real-time identity verification before payments can be made. Employers are responsible for submitting the request for the payment to certify to the individual’s employment status, but the individuals must certify their identity and personal information for the claim to be processed. Employees are notified when a claim is filed on their behalf and provided instructions for their portion of completing the EFC process. The MyUI Customer Portal dashboard provides all the EFC correspondence sent to the individual as well as the status of the profile setup and identify verification. Before the implementation of the EFC profile requirement, GDOL utilized the Social Security Administration (SSA) crossmatch and Systematic Alien Verification for Entitlement (SAVE) verification processes to verify the identity of claimants where employers submit claims on their behalf. When we identify employer fraud schemes, we follow the guidance issued by the United States Department of Labor (USDOL) and collaborate with the United States Department of Labor Office of Inspector General (OIG) to investigate these cases. Effective June 29, 2023, GDOL implemented additional Employer Filed Claims safeguards and security measures to reflect amended Georgia Employment Security Rule 300-2-4-.09. Employers must now meet the following conditions to submit Employer-Filed Partial Claims on behalf of their employees: • Employer accounts must have been registered with GDOL for more than 5 years. • Employers must be current on all quarterly tax and wage reports. • Employers must be current on all quarterly contribution taxes, assessments, penalties, and interest. • The week ending date on employer filed claims cannot be older than 30 days. The amended Georgia Employment Security Rule also clarifies that part-time employees are not eligible for Employer Filed Partial Claims. Summary: This finding will persist until a system-wide resolution is implemented in the new modernized UI system. GDOL will include a self-certification and dual certification process for employer filed claims in the new solution.

GDOL acknowledges this is a repeated finding from previous years, therefore the Department concurs with this finding and offers the following response preceded by the auditor’s findings: Auditor’s Findings: The Georgia Department of Labor did not have effective internal controls in place to ensure unemployment benefit payments were made correctly and only to eligible claimants. 1) Claimants did not self-certify for benefits in eighteen instances GDOL Response: Employer Filed Partial Claims (EFC) are submitted by employers on behalf of the claimant. The employer is responsible for attesting to the employment status and weekly earnings of the claimant for the EFC submitted. An affidavit certifying that the employer has obtained earnings from other employment as well as other requirements must be completed before EFCs can be entered or uploaded. Claimants for which EFCs are submitted are considered to be still attached to the employer and are exempt from the requirement to register for employment services per Georgia Employment Security Law Rule 300-2-4-.02. Such individuals are not required to be nor certify on a weekly basis to be able, available and actively seeking work. We recognize the state auditor's recommendations to add the self-certification. However, the current unemployment system is obsolete, having been put into production in 1982. This finding will persist until our new modernized unemployment insurance (UI) system is implemented in 2026. 2) Fraudulent employer-filed claims were filed for thirteen claimants GDOL Response: When we identify employer fraud schemes, we follow the guidance issued by the United States Department of Labor (USDOL) and collaborate with the United States Department of Labor Office of Inspector General (OIG) to investigate these cases. Additionally, we have taken the following measures to safeguard the system against fictitious employers: • Effective December 6, 2021, the Employer Filed Partial Claims (EFC) process was revised to require individuals (employees) to complete an EFC profile to include a real-time identity verification before payments can be made. Employers are responsible for submitting the request for the payment to certify to the individual’s employment status, but the individuals must certify their identity and personal information for the claim to be processed. Employees are notified when a claim is filed on their behalf and provided instructions for their portion of completing the EFC process. The MyUI Customer Portal dashboard provides all the EFC correspondence sent to the individual as well as the status of the profile setup and identify verification. • Before the implementation of the EFC profile requirement, GDOL utilized the Social Security Administration (SSA) crossmatch and Systematic Alien Verification for Entitlement (SAVE) verification processes to verify the identity of claimants where employers submit claims on their behalf. • Effective June 29, 2023, GDOL implemented additional employer filed claims safeguards and security measures to reflect amended Georgia Employment Security Rule 300-2-4-.09. Employers must now meet the following conditions to submit Employer Filed Partial Claims on behalf of their employees: o Employer accounts must have been registered with GDOL for more than 5 years. o Employers must be current on all quarterly tax and wage reports. o Employers must be current on all quarterly contribution taxes, assessments, penalties, and interest. o The week ending date on employer filed claims cannot be older than 30 days. The amended Georgia Employment Security Rule also clarifies that part-time employees are not eligible for Employer Filed Partial Claims. BPC and Integrity merit staff continue to establish pseudo claims when fraud is confirmed to relieve victims of liability and the fraudster is unknown. Otherwise, the payments are moved to the fraudsters claim account, if identified. GDOL has procured a vendor to build and implement a modernized UI system. We are also pursuing data analytics tools to expedite the identification and detection of fraudulent activities. These tools will also be incorporated into the modernized solution. 3) Proof of employment or self-employment or a valid offer to begin employment and proof of wages was not submitted by five Pandemic Unemployment Assistance (PUA) claimants. One of these claimants was not eligible to claim benefits in Georgia. GDOL Response: The claimants who established PUA entitlement with a weekly benefit amount greater than the minimum or later determined to not be eligible were based on wages entered by the claimant and/or wages reported by the employer. The Coronavirus Aid, Relief, and Economic Security (CARES) Act only required proof of wages to be submitted. If claimants did not submit proof, federal requirements only allowed for payment of the minimum weekly benefit amount and no disqualification of benefits. Claims established at a higher weekly benefit amount had to be reduced to the minimum amount if no proof was provided. To date, no proof has been provided by the claimants cited. The claims were reduced as appropriate. An overpayment has been established on all five claims identified for the difference in weekly benefit amount for weeks paid over the minimum amount under CARES and for the entire amount for weeks paid under Consolidated Appropriations Act (CAA)/American Rescue Plan Act (ARPA). GDOL’s current UI Information Technology (IT) system was developed in 1982 using mainframe “legacy’ technology. Due to the system’s age and other limitations, many automated processes and corrections cannot be fixed and/or easily implemented. As such, many processes must be handled manually by staff. This includes reviewing all the PUA proof documents submitted to determine the validity and eligibility for each PUA claim. Based on the volume of workload and staff limitations, GDOL has been unable to quickly complete this manual review to correct the finding. It is anticipated this manual review will continue throughout the FY24 audit review period. Summary: GDOL’s limited technology resources will hinder our ability to update our current system to satisfy the state audit’s recommendation. Therefore, we acknowledge that this finding will persist until a system-wide resolution is implemented in the new modernized UI system. The new solution will include a self-certification and dual certification process for employer filed claims and include controls over eligibility determinations for current and future UI programs. GDOL greatly appreciates the feedback and recommendations and will consider this information in our endeavors to modernize our UI system and business processes.

Commodity Supplemental Food Program (CSFP) and The Emergency Food Assistance Program (TEFAP) have developed a tentative 2024 agency review schedule to ensure continued compliance with the annual USDA Food and Nutrition Services (FNS) requirements. The schedule was submitted to FNS as part of the state’s FFY 2022 Management Evaluation (ME) findings response. The State received notification from FNS on January 26, 2024, noting the successful completion and close-out of the FFY 2022 Management Evaluation and its findings.

Our Correction Plan will be to check monthly that loan disbursements correctly match with COD. While progress was definitely made from the prior year, it is important that every student disbursement is correctly shown by the Business Office.

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Mark Ollerton, Business Manager Anticipated Completion Date: Because this has been addressed the completion date is immediate as to the corrective action plan, March 25, 2024. Planned Corrective Action: The process in the District is that two individuals reconcile the number prior to submission of claims. After evaluating what caused the error, the staff did follow best practices in that two separate individuals reconciled the numbers for the claim. After this was completed, the claim was created and submitted to be processed by the Arizona Department of Education Child Nutrition Program. In developing the claim, a number was entered incorrectly on the claim. The corrective action is already in place. The District will continue with the dual review of the numbers. The error has been discussed with staff and they will be more diligent in their part of entering the claim information.

Reviewing all areas of this finding, the District needs to assist with extra help from the district office and ensure that all student records are updated timely based on the review of income eligibility forms or direct certification information, plus additional training.

Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. As such, HUD requires the Authority to comply with special tests and provisions relating to its Housing Choice Voucher program. The Authority must inspect the unit leased to a family at least annually to determine if the unit meets Housing Quality Standards (HQS) and the Authority must conduct quality control re-inspections. The Authority must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). In addition, the Authority must determine that rent paid to an owner is reasonable in comparison to rent for other comparable unassisted units. Population and Items Tested: Testing of twenty-nine family eligibility files revealed two files lacked documentation of rent reasonableness. The Authority did conduct quality control re-inspections during the year ended June 30, 2023, However, the minimum sample size of 7 units (per Table 10.1 of the Housing Choice Voucher Guidebook) was not met. The Authority only conducted 5 quality control re-inspections. Auditor’s Recommendation: The Authority should perform housing quality control re-inspections according to HUD guidelines. The Authority should ensure proper documentation of rent reasonableness is included in each eligibility file. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent, safe and affordable housing to low-income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family’s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following: a. As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. e. Reexamine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary. Population and Items Tested: Testing of thirteen family files revealed the following deficiencies: 1. One file used an incorrect utility allowance. 2. One file failed to allow a disability deduction. 3. Two files calculated an incorrect housing assistance payment Auditor’s Recommendation: This is a repeat finding. A thorough review of tenant files should be performed for the purpose of eliminating the deficiencies. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2024

The Municipality of Caguas PHA will implement internal controls which ensure that the families files conform to the program requirements for the annual recertifications. Each month the Program Manager or the persona assigned by the Director, will select a sample of files of each zone and verify the following: Voucher Size, Family Composition, income., Inspection Documents, Payment Standards, Utilities, and the rent calculation in the Form HUD-50058, Family Report and other required documents. Files without all the required documentation will be assigned to the respective Housing Office (HO). The HO must contact the family and request the necessary documentation in order to complete the tenant file. The HO will be required to complete all corrective actions within 15 days upon assignment. If additional time is needed, the Director or the person assigned will evaluate the case and may provide an additional 15 days for a maximum of 30 days.

FINDING 2023-001 Finding Subject: Student Financial Assistance Cluster - Special Tests and Provisions - Enrollment Reporting Summary of Finding: Although the University had policies and procedures in place over Enrollment Reporting, a process to ensure that system defects did not impact reporting requirements was not implemented. As such, for students who had a reduction or increase in enrollment status during the Spring 2023 term, errors in reporting campus level and program level data went undetected. Students with a status of withdrawn or with no changes during the period were accurately reported. It was recommended that the University's management establish a system of internal controls that includes a review of Banner job processes to verify source data is correctly populated so as to ensure that all data elements required to be submitted to NSLDS are accurate. Contact Person Responsible for Corrective Action: Angel Nelson, Associate Registrar Contact Phone Number and Email Address: (812) 465-1626; angel.nelson@usi.edu Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: While the University of Southern Indiana had internal controls in place to verify the accuracy of our enrollment reporting data, these controls were not effective in discovering system errors. In order to correct this deficiency, the following corrective actions have been implemented: 1. The system defect within our student information system has been corrected by our vendor. 2. All student records affected by the system defect have been corrected in the National Student Loan Clearinghouse database. 3. Beginning in January 2024, the University increased the number of records selected for review from the enrollment file, making sure to review some students who had a reduction or increase in enrollment status, as well as some who had withdrawn. 4. Associate Registrar has subscribed to the e-community for our software vendor to monitor for future system errors. Anticipated Completion Date: The system defect was corrected with the installation of a system patch that was installed on June 4, 2023. All other steps in the corrective action plan have been completed as of January 26, 2024.

Finding No. 2023–002 – Enrollment Reporting Name of Contact Person: Dr. Kendra Ortiz, Registrar Corrective Action Plan UCB recognizes its obligation to report enrollment data to the National Student Loan Data System (NSLDS) at least every 60 days. The Registrar's Office reports enrollment data to NSLDS on a monthly basis. To ensure that the University comply with the 60-day requirement, we have established an additional notification procedure. The Financial Aid Office will forward report of all Title IV student recipients classified as withdrawn to the Registrar's Office, this process consists of a reconciliation of the data. The Registrar's office will report the enrollment change of this cases to NSLDS within 60 days required. Anticipated completion date: Immediately.

Finding No. 2023–001 – Disbursement to or on behalf students Title IV, HEA credit balances Name of Contact Person: Dr. Ismael A. Velez de la Rosa Corrective Action Plan The University affirms its understanding of its obligation to submit disbursement according to the 34 CFR 668.164(h)(2)(i) A title IV, a HEA credit balance must be paid directly to the student or parent as soon as possible, but no later than fourteen (14) days after the balance occurred, if the credit balance occurred after the first day of class of a payment period. Due to an error in the system, within institutional officials in charge of managing this process, one disbursement was not submitted on a timely basis. UCB will reinforce their policies and procedures to satisfy all applicable requirements specified in 668.164 (h) and due a doble verification of the process to make sure every student no later than fourteen (14) days after the balance occurred. As of the date of the auditors’ report, the University request all of the institution’s officials to work in the school premises and the communication between officials has been improve, making easier the tracking of the disbursements on a timely basis to students. Anticipated completion date: Immediately.

Planned Corrective Action: The Director of Financial Aid will document the review of students that change academic status (full time vs part time) and determine if any adjustments need to be made to the students Cost of Attendance as a result of the change. The Director of Financial Aid will document this review and note any changes that were made as a result. If no changes are necessary, this will be documented as well Person Responsible for Corrective Action Plan: Sandra Mitchell Holder, Director of Financial Aid Anticipated Completion Date June 2024

Planned Corrective Action: The Director of Financial Aid will document the calculation of Satisfactory Academic Progress. This calculation has occurred each year but the Seminary didn’t keep the documents that proved that the calculation was done and applied to each student. In the future, the Director of Financial Aid will keep detailed records of the calculation on each student and retain the records for audit purposes. Person Responsible for Corrective Action Plan: Sandra Mitchell-Holder – Director of Financial Aid Anticipated Completion Date: June 2024

Finding Number: 2023-002 – Eligibility Planned Corrective Action: We agree with the finding. It should be noted that this individual received only 30 minutes of services. Nonetheless, to prevent future occurrences, we have established a peer-review process where student records are reviewed by a program coordinator or manager to ascertain compliance with the grant requirements. We have also scheduled a series of trainings for staff in addition to the ones offered by the state to keep staff up-to-date on guidelines and changes to the grants. Person Responsible: Stephen Mack, Chief Financial Officer Expected Completion Date: Immediately

Pell and SEOG Awarding Errors Recommendation: We recommend the College evaluate its procedures for reviewing financial assistance and implement changes to validate the awarding of financial assistance. Views of Responsible Officials and Planned Corrective Actions: When the Department of Education changes Pell Grant eligibility parameters, there is a process that is run to update Pella Grant eligibility in the Datatel processing system. However, when new eligibility parameters increase the number of eligible students due to increasing the estimated family contribution (EFC) eligibility cut-off, there is a separate process that must be run to catch these newly eligible students. This was the scenario in 2022-2023. Six students that were not originally eligible for Pell Grant became eligible. Similar circumstances also occurred in 23-24 and the process was run ensuring all eligible students are being awarded. The additional process has been added to the financial aid calendar to ensure this will not happen in the future. Anticipated Completion Date: September 30, 2023

1. With the 2022-37 Corrective Action Plan, Gainwell activated the termination job within the PMM that automatically ends a provider’s contract with VT Medicaid when no license was obtained by the license end date. This termination job was activated on 06/05/23. 2. With the 2022-37 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. The State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. Completed 2. Completed Contacts for Corrective Action Plan: Deidra Jarvis, DVHA Member and Provider Services deidra.jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

With the 2022-36 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. The State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Deidra Jarvis, DVHA Supervisor of Member and Provider Services deidra.jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for closure and appropriate notice was not sent because a system error caused this member to be classified as a new applicant instead of enrollee. This was likely due to case-specific circumstances of timing and household eligibility (other members were no longer eligible for Medicaid). Further, because they were classified as a new applicant, they received an additional verification notice (even though coverage was already terminated) and were ultimately “denied” for non-response in late July. As corrective action, we reinstated CHIP back to 7/1/2023 through 10/31/2023 after sending proper closure notice for failure to respond. Based on our internal QA process, Medicaid Recon and HCQC unit’s internal case reviews, no other incidents of this condition were found as of 10/2/2023. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Nicole McAllister, DVHA-HAEEU HCAA II nicole.mcallister@vermont.gov Sarah York, DVHA-HAEEU HCAA I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

DCF has updated the eligibility determination procedure document and referenced checklists to ensure that there are additional reviews of the manual data entry and its processing in the data system (SSMIS). There is a process in place by which any cases where manual data entry causes erroneous IV-E draws, the Department will make changes in the data system and return IV-E funds erroneously claimed within one quarter of the mistake being identified. Scheduled Completion Date of Corrective Action Plan: January 1, 2024 Contact for Corrective Action Plan: Gillie Hopkins, DCF-FSD Permanency Planning Program Manager gillie.hopkins@vermont.gov Barbara Joyal, DCF-FSD System of Care Unit Director barbara.joyal@vermont.gov Beth Sausville, DCF-FSD System of Care Unit Director beth.sausville@vermont.gov Ed Dwinell, DCF Business Office, Financial Director ed.dwinell@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

Contact person responsible for corrective action: University Registrar Corrective action: Sacred Heart University implemented a comprehensive corrective action plan in collaboration with the following key stakeholders: Sacred Heart University’s enterprise resource provider (ERP), Ellucian; the Registrar’s Office; and Sacred Heart University’s Department of Information Technology (IT). Sacred Heart University acknowledges the erroneous reporting of graduation effective dates for two students, wherein the effective start date of their first graduate course mistakenly overrode their previously reported correct graduation date. The University took decisive action to address the inaccuracies identified within a summer 2023 enrollment submission to National Student Clearinghouse for Branch 80 and Branch 81. Sacred Heart University conducted a thorough investigation with Ellucian Support to identify the source of these errors. The investigation resulted in a determination by Ellucian Support that the reporting error was caused by a software bug within its software platform, Ellucian Colleague. Ellucian developed a patch, released in October 2023, to rectify the issue. Implementation of this patch by the Sacred Heart University Information Technology department is scheduled for March 2024. Proposed completion date: March 31, 2024

FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Special Tests and Provision – Verification of Free and Reduced Price Applications (NSLP) Summary of Finding: The finding was isolated to school year 2023 in which one employee is to determine the number of applications to be verified, select the required applications and perform verifications of eligibility, with a second employee reviewing the verifications. Contact Person Responsible for Corrective Action: Kathy VanHoosier, ECA Manager Contact Phone Number and Email Address: 812-547-3300; kathy.vanhoosier@tellcity.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The process of selecting and performing verifications of eligibility with a second employee reviewing the verifications was refined and fully implemented for school year 2023/2024. A change in personnel since the 2022/2023 improved this process, and sign-offs were done and initialed by both the initial reviewer (the Central Office manager) as well as the final reviewer (the ECA Manager) on the 2023/24 applications. It is the intent to continue with this improved internal control process going forward. Anticipated Completion Date: Already Done in Fall 2023