Corrective Action Plans

The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds.

1. Finding 2023-001 a. Comments on the Finding and Each Recommendation We accept finding and recommendations made b. Action(s) Taken or Planned on the Finding A review of policies and documentation will be undertaken, and training with an emphasis of appropriate documentation handling will be applied to those who handle the leasing information.

FINDING 2023-001 Finding Subject: Child Nutrition Cluster – Eligibility Summary of Finding: The Food Service Director was responsible for running the direct certification match report monthly from the Indiana Department of Education and uploading it to the school lunch point-of-sale system. The School Corporation did not have a proper system of oversight or review to ensure that all students on the direct certification match report were entered accurately into the point-of-sale system. We recommended that the School Corporation's management establish a system of internal control to ensure compliance and comply with the Eligibility compliance requirement Contact Person Responsible for Corrective Action: Nick Alessandri Contact Phone Number and Email Address: 219-962-7551 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: River Forest Community School Corporation is now part of the Community Eligibility Provision (CEP) and therefore the direct certification process will no longer take place. In the event that we are no longer CEP and begin the direct certification process, we will implement a process of internal controls that ensure proper oversight and review to ensure all students are entered accurately into our point-of-sale system. Anticipated Completion Date: July 1, 2023

Audit Period: June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. FINDING – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Health Center Cluster Programs (Assistance Listing Number 93.224/93.527/COVID-19 93.224) SIGNIFICANT DEFICIENCY Item 2023-001 –Special Tests and Provisions Recommendation: We recommend that proper training be given to employees and that sliding fee discounts be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Action Taken Management will be training all registration personnel in teams meetings or one on one training sessions. The staff will be trained on how to appropriately monitor and use the sliding fee discounts. Staff will be shown how to maintain the applicable documentation to support the maintenance of the sliding fee discounts. In addition, a team of management and billing staff will be assigned to periodically review the process to ensure the Center always complies with the sliding fee regulations. Completion Date: July 1, 2024 If the Health Resources and Services Administration has questions regarding this plan, please call Tamisha McPherson, Executive Director of URAM at 212-803-2850.

2023-001: Incorrect Pell Disbursement - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended August 31, 2023 Condition Found During our student file testing we noted one student out of forty was not disbursed the correct Pell Grant. The student was enrolled as three-quarters time but was awarded as being a full-time student resulting in an over award of $574. We consider this error to be an instance of noncompliance relating to the Eligibility Compliance Requirement. This finding was repeated from last year, see Prior Year finding 2022-002. Corrective Action Plan Financial Aid Office will make sure to disburse the accurate Pell Grant amoutn according to the students' enrollment status. EWU will return the over awarded Pell to reflect the correct amount for the student. We have never had a finding for awarding full time Pell to a three-quarters attending student. This was an isolated incident. Responsible Person for Corrective Action Plan Director of Financial Aid Cesar Campos Implementation Date of Corrective Action Plan February 15, 2024

2023-002 Incorrect Direct Loans Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended August 31, 2023 Condition Found During our student file testing we noted two students out of forty were disbursed the incorrect Direct Loan amount. Based on the student’s enrollment status and need the students were over awarded $4,500 in Subsidized Loans and under awarded $4,500 in Unsubsidized Loans. We consider this error in awarding to be an instance of noncompliance of the Eligibility Compliance Requirement. Corrective Action Plan Financial Aid office will make sure the correct amount is awarded based on the student enrollment status and need of the student. EWU will make the proper adjustments to the Direct Subsidized Loan and Direct Unsubsidized Loan to reflect the correct amount foer the two students. Responsible Person for Corrective Action Plan Director of Financial Aid Cesar Campos Implementation Date of Corrective Action Plan February 15, 2024

Major Program: 10.558 - Child and Adult Care Food Program (Grantor - Department of Agriculture) Condition: We tested 18 provider files and identified two billing errors within the May 2022 claim submissions. For each instance of error, the number of meals served was incorrectly determined and submitted for reimbursement. Corrective Action Plan: Catholic Charities Program Manager, Joanne Varnes, conducted a training on December 19, 2023 with all staff involved in the CACFP that included income eligibility/enrollment categorization and meal count accuracy. Catholic Charities staff will review each income form/enrollment and double check that children’s reimbursement rate is properly categorized based on their family’s income. Staff members will review each claim before it is entered for reimbursement to ensure the claim is accurate. Program Manager, Joanne Varnes, will oversee this process and conduct case record reviews quarterly for all providers under Catholic Charities Sponsorship. Contact Person Responsible for Corrective Action: Samantha Wallace, Interim Executive Director Anticipated Completion Date of Corrective Action: Immediately

PDE agrees with the portion of the finding pertaining to the lack of required signature on an expenditure report. To address this error, PDE will retrain staff and update “Tool Tips” in PEARS so that it is clearer for field advisers. PDE disagrees with two of the conditions of the finding, as stated by the auditors. First, regulation 7 CFR 226.6 (o), cited and summarized by the auditors as requiring PDE to resolve and close reviews within a specific timeline, does not include this requirement in the text. The regulation requires that subrecipients resolve any issues with a timeframe specified in their corrective action. Second, the first bulleted condition, states that “these reviews did not include any complex findings that would have required more time to close.” PDE procedure for closing reviews states that “any exception must be communicated and approved by the Supervisor…” The procedure does not qualify or limit these exceptions to “complex findings.” Accordingly, PDE will continue to follow its procedures as written. Anticipated Completion Date: 06/30/2024 Contact Names: Vonda Ramp, Chief, Div. of Food & Nutr., Bur. of Bdgt. & Fiscal Management; Clayton Carroll, Audit Coord., Bur. of Bdgt. & Fiscal Management

PDA, Bureau of Food Assistance (BFA) has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. BFA, in coordination with our contractor, Hunger-Free Pennsylvania, has developed a mechanism to track the reviews of all 16 lead subrecipient agencies for the Commodity Supplemental Food Program (CSFP). This tracking mechanism will help to ensure that CSFP monitoring reviews are scheduled and completed in a timely manner, in accordance with federal regulations pertaining to CSFP. 2. BFA has scheduled a comprehensive monitoring review of Food Helpers (formerly known as Greater Washington County Food Bank). The review is scheduled to begin March 2024, and should be completed no later than April 30, 2024. Anticipated Completion Dates: 1 - Completed; 2 - 04/30/2024 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance

Auditee Contact Person: Paula Powers Title of Contact Person: Food Service Coordinator Phone Number: 812 347-3905 Findings 2023-002-Child Nutrition Cluster-Eligibility Views or Responsible Official: We concur with the findings. Description of Corrective Action Plan: With future processing of free and reduced applications, the Food Authority will process the application. A second person will review and sign the application in order to maintain proper checks and balances. Anticipated Completion Date: March 2024

Program: AL 17.225 – Unemployment Insurance – State – Allowability & Eligibility Corrective Action Plan: The Department has worked with its vendor to implement changes to the wage crossmatch process. The Department has increased the size of its Benefit Integrity Unit and implemented further fraud prevention tools. The Department is working with the unit and individuals to properly prioritize workloads. The Department continues to work extensively with their vendor to address and resolve the issues related to separation information requests. The Department has also revised its adjudication process to manually address issues related to separation information requests pending the vendor completion of the needed corrections. The Department been working to improve its quality and has coached the adjudication team on ETA requirements for follow-up with employers. The Department also implemented a new work model in consultation with a vendor. Since implementing the new process, the Department has met first payment timeliness and nonmonetary determination timeliness for October, November, and December 2023 and January 2024. Separation issues as a cause of improper payment decreased from 6.245% in FFY 2022 to 3.173% in FFY 2023, and overall improper payment rate for FFY is down from 16.014% to 14.862%. Contact: Andi Bridgmon, UI Director Anticipated Completion Date: Ongoing – overall adjudication quality is an ongoing focus of the Department and will be continuously reviewed for continued improvement.

Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program – Allowability & Eligibility Corrective Action Plan: User guides and training materials will be reviewed and updated if deemed necessary for clarity. Individual staff who made the errors will be followed up with to ensure they understand the policies going forward. Contact: Catherine Gekas Steeby Anticipated Completion Date: 6/30/2024

Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program - Allowability Corrective Action Plan: DHHS will work in collaboration with the APA to improve prevention of improper payments and to implement processes to improve the identification of and actions taken against potential fraud, waste, and abuse. In addition, DHHS has established recurring meetings to review each of the conditions in depth and identify mitigation strategies to implement. This could include a combination of policy, business rules, and technology changes, as well as interim and long-term mitigation strategies. Contact: Kathy Scheele Anticipated Completion Date: 12/31/2024

Program: AL 93.575 and 93.596 – CCDF Cluster – Allowability & Eligibility Corrective Action Plan: The CCDF program team will continue to review monthly reports with high billed hours. Resource Developers staff will increase initial and annual billing trainings with subsidy, and assist with any billing needs providers may have. A new provider handbook was launched in October 2023, which also has billing resources in it. DHHS changed the current billing structure from hours and days to partial days and full days, this launched July 2023. This should simplify billing and calculation errors. DHHS also launched a new billing portal in January 2024. Contact: Nicole Vint Anticipated Completion Date: 06/30/2024

Program: AL 93.566 – Refugee and Entrant Assistance State/Replacement Designee Administered Programs – Allowability & Eligibility Corrective Action Plan: Re-training will occur for the Eligibility team working with RCA and RMA benefits. The Eligibility team will follow existing policies and procedures to gather documentation needed from SAVE. Contact: Sara Bockelman & Dinah Wetindi Anticipated Completion Date: 6/2/2024

Program: AL 93.558 – Temporary Assistance for Needy Families (TANF) – Allowability & Eligibility Corrective Action Plan: The TANF program will request the Program Accuracy Team send out a "Quick Tip” ADC memo to Economic field staff to remind them to verify that a dependent child aged 16 to 18 attends school attendance regularly. Contact: Will Varicak Anticipated Completion Date: 03/01/2024

Program: AL 93.558 – Temporary Assistance for Needy Families (TANF) – Allowability & Eligibility Corrective Action Plan: The Agency is working on a new process to ensure that only eligible claims are charged to the Federal grant. Contact: Snita Soni, Will Varicak Anticipated Completion Date: 6/30/2024

Corrective Action Plan The Inter American University of Puerto Rico (IAUPR) will implement the following actions to strengthen compliance with the 30-day reglementary period for the R2T4 determination: 1. IAUPR will also prepare compulsory online or face-to-face training sessions which all full and part-time faculty will be required to take in August and January of each year. The training sessions will review grading policies and any other procedures required for compliance with Federal Regulations. The primary executives of each academic unit, through the Deans of Academic Affairs, will be responsible for ensuring and certifying to the Vice President of Academic and Student Affairs that all faculty participated in the training. 2. The Deans of Academic Affairs or their designees at each academic unit will monitor the entry of final grades in the Banner System and report any suspicious grades and suspected cases of noncompliance with Federal Regulations to the chairs of the academic departments for immediate follow-up and correction. 3. IAUPR will develop a course of action whereby a department chair or dean of academic affairs may correct or update a grade in the Banner System, based on the academic information available, when a faculty member is unable to do so because of a force majeure. 4. In recurrent cases of noncompliance, the primary executives of each academic unit will send a written communication to faculty that do not comply with established procedures and include a copy of the communication in the professors' academic/administrative files.

Finding 2023-001: Student Financial Assistance Cluster, Department of Education Programs Program Name: Federal Direct Student Loans CFDA Numbers: 84.268 Corrective Action Plan: The University will update written procedures to clearly identify a step to manually do enrollment testing following all conferral of degrees. For those regularly scheduled graduation periods and following the submission of both the degree and last of term enrollment files, we will randomly sample 10% of graduated students and manually verify their statuses. For degrees conferred outside of the regularly scheduled graduation periods, each record will be manually verified. This will ensure recorded graduation records will be verified within the National Student Clearinghouse to ensure alignment between degree history and enrollment history. The error was found to be a bug in the reporting software that happened in the current fiscal year. The University’s processes in previous years were correct as this error was not present. Completion Date: Estimated March 2024

FINDING 2023-005 Information on the federal program: Subject: Title I Grants to Local Educational Agencies - Eligibility Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies CFDA Number: 84.010 Federal Award Numbers and Years or Other Identifying Numbers: S010A210014, SA10A20014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Regin Johnson, Title I Director Contact Phone Number and Email Address: (219) 838-1819 rjohnson@lakeridgeschools.net Condition: This finding addresses two issues. First, an effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. Second, The School Corporation has established a process of receiving and reviewing the listing of students from the Private Schools in order to be entered into the Title I application. However, the internal controls were determined not effective since the School Corporation only requested to receive eligible students listing and not enrolled students. Context: The School Corporation has not established a process of review of the Eligibility Summary in the Title I application for the student enrollment and poverty. Real time report October 1 count is used for the eligibility summary in the Title I application. Additionally, the examiner could not determine if the enrolled private school number was correct because the School Corporation did not request the information. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Title I Director will review and sign off on the Real Time October 1 report to ensure that the student enrollment and poverty numbers reconcile with what is submitted in the Eligibility Summary. Additionally, the Title I Director will solicit both eligible and total enrollment figures from private schools that wish to participate in Title I. Anticipated Completion Date: The Corrective Action will be implemented immediately and completed upon the filing of the next Real Time report and Eligibility Summary.

Finding Number: 2023-003 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: Title I, Part A Assistance Listing: 84.010 Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201310-01 (7/1/19 – 9/30/21) 231095-01 (7/1/22 – 9/30/24) 211116-01 (7/1/20 – 9/30/22) 211303-01 (7/1/20 – 9/30/22) 221499-01 (7/1/21 – 9/30/23) 221769-01 (7/1/21 – 9/30/22) Compliance Requirement: Special Test Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend that the Board revises the Student Participation process to include a step that includes matching the student grade level to the corresponding school type and a step to include a second review of the Title I School eligibility address and school type by a second staff member. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: BCPS revised their procedures on Title I Equitable Services: Student Participation in early Fall 2023. Revisions outlined below will lessen the risk of potential audit findings in the future: - Revise the Student Participation process to include a step that includes matching the student grade level to the corresponding public school type. - Revise the Student Participation Process to include a second review of the Title I School eligibility address and school type by a second staff member. Name(s) of the contact person(s) responsible for corrective action: Michele Stansbury, Director of Title I Planned completion date for corrective action plan: For immediate implementation and ongoing.

FINDING 2023 - 003 Finding Subject: Child Nutrition Cluster – Internal Controls Summary of Finding: The School Corporation had not properly designed or implemented an effective system of internal controls, which would include segregation of duties, that would likely be effective in preventing, or detecting and correcting, material noncompliance over eligibility and suspension and debarment. We recommended that management of the School Corporation design and implement a proper system of internal control, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Contact Person Responsible for Corrective Action: Steven Boyer Contact Phone Number and Email Address: 574-936-3115 sboyer@plymouth.k12.in.us Views of Responsible Officials: The Corporation concurs with the finding. Description of Corrective Action Plan: As part of month-end procedures and the documents sent to the Business Manager, the Food Services Director will include the list of students newly certified for free or reduced meals from CNPweb, Indiana’s portal for the Child Nutrition Program. The Food Services Director will also include the list of students newly certified for free or reduced meals from NutriKids. The Business Manager will review and verify the list when balancing the food program’s monthly receipts, expenditures, and reimbursements. Before contracts are awarded to vendors, the Food Services Director shall use SAM.gov to verify that vendors have not been suspended or disbarred from contracting with Indiana public schools. The Business Manager shall review and verify that the vendors have not been suspended or disbarred, and once verified, contracts will be awarded. Anticipated Completion Date: The Food Services Director and Business Manager have collaboratively reviewed and modified the month-end procedures to ensure that they prevent, detect, and correct eligibility errors, and the new procedures were implemented for February 2024 and will be used for subsequent months.

FINDING 2023-003 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program COVID-19 - National School Lunch Program Assistance Listings Numbers: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): SY22, SY23 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Eligibility, Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP), Special Tests and Provisions - Non-Profit School Food Service Accounts Audit Finding: Material Weakness Condition and Context The School Corporation had not established effective internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance. Eligibility The School Corporation's policy is to have the Treasurer review and initial paper applications processed by the individual school treasurers to ensure that the eligibility determination was correct. However, six of the ten applications tested lacked documentation of this review. In addition, there was no internal control in place over applications submitted online. INDIANA STATE BOARD OF ACCOUNTS 18 BORDEN-HENRYVILLE SCHOOL CORPORATION SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) The Treasurer performed the verification of free and reduced price applications without a documented review or oversight process in place to ensure that applications selected for verification were in compliance with requirements related to the program. Special Tests and Provisions - Non-Profit School Food Service Accounts The School Corporation did not have an internal control in place to ensure that reimbursements for meals served were properly credited to the School Lunch fund. The lack of internal controls for Eligibility and Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) was isolated to the second year of the audit period. The lack of internal controls over Special Tests and Provisions - School Food Accounts was systemic throughout the audit period. Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). . . ." Cause A proper system of internal controls was not designed by management of the School Corporation, which would include segregation of key functions. Embedded within a properly designed and implemented internal control system should be internal controls consisting of policies and procedures. Policies reflect the School Corporation's management statements of what should be done to effect internal controls, and procedures should consist of actions that would implement these policies. Effect Without the proper design or implementation of the components of a system of internal controls, including policies and procedures that provide segregation of duties and additional oversight as needed, the internal control system cannot be capable of effectively preventing, or detecting and correcting, material noncompliance. Questioned Costs There were no questioned costs identified. INDIANA STATE BOARD OF ACCOUNTS 19 BORDEN-HENRYVILLE SCHOOL CORPORATION SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Recommendation We recommended that management of the School Corporation design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.

FINDING 2023-004 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirements. Context: During testing of eligibility, we noted that a formal documented control for the review of online student applications was not in place. Management indicated that the free and reduced parameters are updated annually in the Titan system, however, there was no documented review that the updated parameters were reviewed. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will document a formal review of student applications for free/reduced lunch. Management will also document a review over the thresholds for free/reduced meals within the Titan system to ensure they accurately input into the system this will be done by way of signature on the state published eligibility guidelines. This will be kept for record keeping. Responsible Party and Timeline for Completion: Beginning July 2024

Finding 2023-003 Finding Subject: Child Nutrition Cluster-Eligibility Summary of Finding: (suggestion: The School Corporation had not properly designed or implemented internal controls over eligibility.) Contact Person Responsible for Corrective Plan: Dr. Tracy Lorey, Monica Young, April Hopf Contact Phone Number and Email Address 812-482-1801 tlorey@gjcs.k12.in.us myoung@gjcs.k12.in.us ahopf@gjcs.k12.in.us Views of Responsible Officials: We agree with the Finding. Description of Corrective Action Plan: The corporation meets virtually each year with the software vendor to set up all free/reduced lunch applications, federal income guidelines and forms. A certified and signed copy of the income guidelines will be kept on file to show the match between the guidelines and point of sale. The applications that are flagged by the system will be reviewed for approval or denied and a copy will be maintained for The State Board of Accounts for audit. Anticipation Completion Date: February 2024