Corrective Action Plans

The organization is in the process of updating its policies to ensure the proper calculation of the MTDC in accordance with program guidelines.

The organization is in the process of updating its policies to outline the required documentation on the intake forms and the documentation retention requirements for the intake forms.

Finding No. 2023-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% FPL with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the Federal poverty level (FPL). Patients whose incomes are above 100% and at or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of non-discrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.

Corrective Action Taken: 1. Formalized record retention policies: A formal record retention policy specific to federal grant programs was implemented to ensure full compliance with 2 CFR 200.334. This policy applies regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent complete and accurate records. 2. Auditing timing advocacy and preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, though no fault of the County, as observed during the FY 2023 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal audit readiness reviews: Beginning with FY2025, the County conducts internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Implementation date of corrective action: October 24, 2025 Person Responsible for corrective action: Charles Nickerson, Senior Director of Finance

Reference Numbers: 2023-001 and 2022-001 Federal Program: Direct - USDA Rural Utilities Service award; ALN 10.760, 'Water and Waste Disposal Systems for Rural Communities' (Single Audit / Uniform Guidance).Condition: The Great Northwest Wholesale Water Commission did not complete and submit its reporting package, including the SEFA and the single audit report, to the Federal Audit Clearinghouse within nine months of the fiscal year end. Criteria: Under 2 CFR §200.512, the audit must be completed, and the data collection form and reporting package must be submitted within 30 calendar days after receipt of the auditor's report, or nine months after the fiscal year end, whichever is earlier. Corrective Action Plan: Management acknowledges the finding and has implemented procedures to improve the timely completion and submission of the data collection form to the Federal Audit Clearinghouse. Management has engaged an audit firm to complete the December 31, 2022, 2023, and 2024 audits and will submit the reporting package to the Federal Audit Clearinghouse upon completion. Management will coordinate with the auditors throughout the audit process, monitor applicable reporting deadlines, and establish internal timelines to ensure the audit report and data collection form are submitted within the required time frame prescribed by 2 CFR 200.512(a). Personnel responsible for Corrective Action: Jerri Dearmont, Executive Director Anticipated Completion Date: August 18, 2026

Corrective Action: The University is actively reviewing and updating policies and procedures regarding eligibility and disbursement controls. The University has implemented various new reports for monitoring and correcting over/under award situations. Responsible Person: Matthew Kirksey, Financial Aid Director Completion Date: December 31, 2026

Finding No.: 2023-047 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $28,448,121 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. CMA does not believe the finding fully reflects the Agency's efforts to comply with provider screening and exclusion requirements during the audit period. While documentation supporting certain screening activities was not readily available for auditor review, the Agency has historically performed provider eligibility and exclusion reviews as part of its enrollment and oversight processes. To further strengthen compliance and documentation practices, CMA has developed provider enrollment and screening procedures, conducted retrospective exclusion reviews where documentation was unavailable, and continues to enhance monitoring activities. In addition, the Agency has expanded staffing resources and continues to recruit and assign personnel dedicated Finding No.: 2023-047, continued AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $28,448,121 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: to provider enrollment, compliance, and program integrity functions to ensure federal screening requirements are consistently performed, documented, and monitored. Proposed Completion Date: Ongoing

Finding No.: 2023-044 AL Program: 93.767 – Children’s Health Insurance Program (CHIP) Area: Special Tests and Provisions – Provider Eligibility Questioned Costs: $7,808,322 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. CMA does not believe the finding fully reflects the Agency's efforts to comply with provider screening and exclusion requirements during the audit period. While documentation supporting certain screening activities was not readily available for auditor review, the Agency has historically performed provider eligibility and exclusion reviews as part of its enrollment and oversight processes. To further strengthen compliance and documentation practices, CMA has developed provider enrollment and screening procedures, conducted retrospective exclusion reviews where documentation was unavailable, and continues to enhance monitoring activities. In addition, the Finding No.: 2023-044, continued AL Program: 93.767 – Children’s Health Insurance Program (CHIP) Area: Special Tests and Provisions – Provider Eligibility Questioned Costs: $7,808,322 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: Agency has expanded staffing resources and continues to recruit and assign personnel dedicated to provider enrollment, compliance, and program integrity functions to ensure federal screening requirements are consistently performed, documented, and monitored. Proposed Completion Date: Ongoing

Finding No.: 2023-040 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Eligibility Questioned Costs: $12,490 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: The CNMI CCDF Program respectfully disagrees with this finding. During the audit period, the CNMI CCDF State Plan for FY 2022–2024, Section 3.1.8, Employment Requirements, permitted the acceptance of a USCIS receipt notice (WAC receipt number) as documentation of employment authorization when applicable. Specifically, the State Plan states that a USCIS receipt indicating a WAC number may be requested when necessary and that additional documentation may be requested to identify applicants who meet the long-term employment criteria. Based on the policies in effect during the certification periods cited above, the CCDF Program determined eligibility using the documentation requirements established in the approved CCDF State Plan. Therefore, the questioned costs associated with these cases were incurred in accordance with the Program's established eligibility policies at that time. The issue occurred during a period of increased application volume when eligibility determinations and document reviews were processed manually. In addition, the State Plan language did not explicitly state that USCIS receipt notices would not be accepted as evidence of employment authorization, which contributed to differing interpretations of acceptable documentation requirements. Although the Program maintains that the cited cases were processed in accordance with the policies in effect during the audit period, the CCDF Program has strengthened its documentation requirements to address concerns raised in prior audits. Effective February 1, 2026, the CCDF Program no longer accepts USCIS employment authorization receipt notices as proof of work authorization. This policy change was implemented through CCDF Memorandum Subsidy FY26 No. 1 and serves as a corrective action to ensure consistency and strengthen compliance with employment verification requirements. Program staff have been notified of the revised policy and eligibility determinations will now require approved work authorization documentation rather than receipt notices. Proposed Completion Date: Completed Finding No.: 2023-040, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Eligibility Questioned Costs: $12,490 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 2: The CNMI CCDF Program agrees with this finding. During the audit period, provider payments were processed manually for approximately 1,101 children each month. The manual calculation and entry of subsidy amounts increased the risk of human error, resulting in isolated instances of overpayments and underpayments. To strengthen internal controls and reduce the risk of payment errors, the CCDF Program has been working with a contracted system developer since late 2025 to implement an automated subsidy management system. Once operational, the system will automatically calculate and assign payment amounts based on eligibility factors, including the child's age and approved level of care, thereby reducing reliance on manual calculations. The CCDF Program will continue monitoring payment processes and implementing automated controls to improve payment accuracy and strengthen compliance with program requirements. The Program will initiate recovery of the $390 overpayment identified in Case ID 3040 B through adjustments to provider payments scheduled for August and September 2026. For the underpayments identified in Case IDs 3275 B, 3275 C, and 3600 C, the Program will process payment adjustments and issue the respective amounts owed through the August 2026 provider payment cycle. Proposed Completion Date: September 2026

Finding No.: 2023-028 AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $99,935 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: Condition 1a: The Office of Grants Management (OGM) respectfully disagrees with the finding and questioned cost of $8,337.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Finding No.: 2023-028, continued AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $99,935 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: Condition 1b: The Office of Grants Management respectfully disagrees with the finding and questioned cost of $91,598.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Proposed Completion Date: Ongoing Condition 1c: The Office of Grants Management disagrees with the finding and questioned cost of $68,181.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Proposed Completion Date: Ongoing Condition 1d: The Office of Grants Management disagrees with the finding and questioned cost of $4,500.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. For this particular finding, the client was unemployed and thus could not provide an employment verification. Finding No.: 2023-028, continued AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $99,935 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Proposed Completion Date: Ongoing Condition 1e: The Office of Grants Management disagrees with the finding and questioned cost of $19,614.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Proposed Completion Date: Ongoing

Finding No.: 2023-022 AL Program: COVID-19 17.225 – Unemployment Insurance (UI) Area: Eligibility Questioned Costs: $-0- Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: The CNMI agrees with this finding and acknowledges that a variance exists between the expenditure report details and the listing of payments from the HireMarianas Portal. We are currently reviewing and reconciling both records to determine the cause of the variance. The Expenditure Detail Listing totals $3,057,097.02, while the HireMarianas benefit listing totals $4,112,291.03. During this review, we identified that the HireMarianas benefit listing total includes benefit tax withholdings and child support deductions. However, these amounts are not included in the Expenditure Detail Listing. Therefore, the variance is attributable to PUA tax withholdings ($169,283), FPUC tax withholdings ($150,054), and child support deductions ($202). After excluding these amounts, the adjusted HireMarianas Portal total is $3,792,752.03. Additionally, a review of the MUNIS system identified 19 late entries not reflected in the original Expenditure Detail Listing of $3,057,092.02. These entries represent FY23 expenditures recorded in FY24 and consist of 10 PUA benefit payments totaling $108,937.63 and 9 FPUC benefit payments totaling $110,625.00, for a combined total of $219,562.63. After incorporating these MUNIS late entries into the Expenditure Detail Listing, the adjusted expenditure total is $3,276,654.65. Based on these adjustments, the remaining variance is $516,097.37. Finding No.: 2023-022, continued AL Program: COVID-19 17.225 – Unemployment Insurance (UI) Area: Eligibility Questioned Costs: $-0- Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: CNMI DOL will continue its review and will coordinate with Geographic Solutions, Inc. (GSI), the HireMarianas Portal vendor, and the Department of Finance to further investigate and resolve any remaining discrepancies and to ensure the accuracy and completeness of reported disbursements. Proposed Completion Date: October 2026

2023-007 Tenant Eligibility Material Weakness Recommendation: In general, we continue to recommend a review of the re-certification process to determine areas of weakness. Specifically, we recommend the use of a standard checklist in the re-certification process. We further recommend that each re-certification clerk’s work be routinely audited. We also recommend more standardization in resident files organization of information, and procedures established to make sure all files are maintained adequately in order to be compliant. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

3. Finding 2023-003: Supplemental Nutrition Assistance Program (SNAP), ALN # 10.551, Grant Period 1/1/23 - 12/31/23. Context: Per the Federal OMB Uniform Guidance Circular Compliance Supplement, each individual who receives benefits under the SNAP program should have a completed eligibility determination on file, which is available for audit review. Corrective Action: A substantial number of the identified cases involved 24-month certification renewal periods. As a result, no 2023 application existed for those cases because the recertifications had been completed in 2022 and were not due again until 2024, pursuant to N.J.A.C. 10:87-6.20, Certification Periods. State regulations permit 24-month certification periods for eligible senior citizens and individuals with disabilities. Please see the attached New Jersey Administrative Code provision supporting the applicable 24-month certification period requirements. PCBSS has also implemented additional enhancements to support the DIMS Unit, where files are scanned and electronically stored. The agency increased staffing responsible for document scanning and streamlined the transfer process from worker units to the DIMS Unit. These improvements help ensure that cases are properly identified, organized, maintained, and that supporting case documentation is completed and uploaded timely. Implementation Date: Commenced in 2023 and ongoing.

2. Finding 2023-002: Temporary Assistance for Needy Families (TANF), CFDA #93.558, Grant Period 1/1/22-12/31/22. There were multiple instances where eligibility files selected for review were unable to be presented for audit review. Context: As per the Federal OMB Uniform Guidance Circular Compliance Supplement, each individual who receives benefits under the TANF program should have a completed eligibility determination on file, which is available for audit review. Corrective Action: PCBSS has implemented additional enhancements to support the DIMS Unit, where files are scanned and electronically stored. The agency increased staffing responsible for document scanning and streamlined the transfer process from worker units to the DIMS Unit. These improvements help ensure that cases are properly identified, organized, maintained, and that supporting case documentation is completed and uploaded timely. Implementation Date: Commenced in 2023 and ongoing.

Medical Assistance Program (Medicaid, Title XIX), CFDA #93.778, Grant Period 1/1/23-12/31/23. Context: As per the Federal OMB Uniform Guidance Circular Compliance Supplement, each individual who receives benefits under the Medicaid program should have a complete eligibility determination on file, which is available for audit review. Corrective Action: PCBSS has implemented additional enhancements to support the DIMS Unit, where case files are scanned and electronically stored. The agency increased staffing dedicated to document scanning and streamlined the transfer process from worker units to the DIMS Unit. These improvements help ensure that cases are properly identified, organized, and maintained, and that supporting documentation is uploaded timely and accurately. Additionally, several Medicaid cases identified during the review were initially established by the State of New Jersey and/or third-party vendors contracted by the State prior to being transferred to the county for ongoing case management responsibilities. As a result, PCBSS did not possess the original applications or supporting eligibility documentation because the initial eligibility determination and enrollment process had already been completed before the cases were transferred to the county. Moving forward, PCBSS will provide auditors with system-generated portal documentation identifying the originating agency responsible for the initial case establishment. Implementation Date: Commenced in 2023 and ongoing.

Director of American Rescue Plan (ARP) Programs, Federal program managers, and Chief Financial Officer October 2023 Management remains committed to continuous improvement and has taken corrective actions to strengthen internal controls, ensure proper documentation retention, and maintain full compliance with applicable federal regulations

The County has since implemented corrective actions to strengthen internal controls and ensure compliance moving forward, including: Providing targeted staff training on eligibility requirements, including self-attestation limitations. Implementing a secondary review process for eligibility determinations and payment calculations when clients self-certify income. Establishing ongoing monitoring procedures, including periodic file reviews. Benton County is committed to maintaining strong internal controls and ensuring compliance with all applicable federal and state requirements. These enhancements are designed to prevent recurrence and support consistent application of program guidelines.

Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation

Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation

Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation

Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation

Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation

Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation

Concord’s Compliance Dept has implemented procedures to ensure the tenant security deposits are correctly recorded, tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with HUD’s requirements.

2023-004 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635