Corrective Action Plans

Finding No. 2023-001- Section 8 Housing Choice Vouchers Program CFDA#14.871 Eligibility: Tenant Compliance The agency acknowledges that all tenants are required to have their income verified with current EIV Income Reports, as required by HUD regulations. Due to new staff and management changes, all staff did not always have access to EIV. Going forward management will ensure that all staff members have appropriate access to EIV and income verification methods. The PHA will also implement greater oversight over HCV compliance and train employees on procedures mandated by HUD regarding tenant income verification and annual recertification. Planned Implementation Date of Corrective Action: 12/18/2023 Person responsible for corrective action plan implementation: Interim Housing Choice Voucher Program Manager, Janice Spellman and staff. Best Regards, Navonya Thomas Director of Property Management Charlottesville Redevelopment & Housing Authority.

We will review tenant’s files for the deficiencies identified above and implement new internal control procedures to correct these conditions. We will also provide increased supervision and training over this area. We anticipate a complete resolution of this type of error by February 29, 2024.

Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend management should designate one person to review a sample of the new files entering the program to determine if files were prepared and processed in accordance with internal policies and compliance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The compliance officer will ensure that at least 3 of the 15 files selected for review each month are new intakes to determine if files were prepared and processed in accordance with internal policies and compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Regla Exavier and Ruchelle Hobbs Planned completion date for corrective action plan: January 1, 2024.

Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The compliance officer will review at least 15 files monthly and 30 SEMAP files annually to determine if the participant files were prepared in accordance with internal policies and follow up until the compliance deficiencies have been corrected. The HCVP Director will ensure that HCV staff has corrected all files within 10 days of receipt. Name(s) of the contact person(s) responsible for corrective action: Regla Exavier and Ruchelle Hobbs Planned completion date for corrective action plan: No later than 1/1/2024

FORCED ELIGIBILITY Supervisors/Lead Workers and staff will pull case management reports weekly to ensure all recertifications are actively being completed. Staff will proactively use desk or Microsoft calendar to keep up with all recertifications. Staff will complete refresher courses for timely notices. Supervisors will disburse vacant caseload timely after employee leaves to ensure all recertifications are accounted for, distributed and worked. Supervisors will ensure that staff run eligibility checks even if the recertification is rolled over by the system/state. In an effort to prevent the system from automatically rolling the case over, staff will process (recertify and terminate) all cases by the 8110 cutoff date. Staff will implement these changes for the January 2024 recertification period. Staff will be informed on changes and changes will be implemented on December 4, 2023.

Finding Number: 2023-001 Condition: The Hospital's controls in place for submitting expenses did not identify that several invoices and related expense amounts were duplicated in the addendum to the period 1 submission. As a result, period 1 addendum submission included expenses that were deemed unallowable as they had already been utilized to support funding received. Reimbursement for, the original period 1 submission contained retention bonus costs that exceeded 20% of total funds awarded. Planned Corrective Action: The Hospital will review its processes surrounding submission of expenses to MHA and implement additional layers of review. Contact person responsible for corrective action: Brenda Winn and Alex Roehling Anticipated Completion Date: 9/30/2023

2023-003 Condition: Deficiencies Noted in Examination of Low-Rent Public Housing Tenant Files Steps to resolve: We will review the internal control procedures over tenant file re-certifications and documents. Management has implemented procedures along with staffing changes in order to clear this finding in FY 2023. Individual responsible for correction: Ms. Denise Brooks-Jones, Acting Executive Director Timeframe: As of March 31, 2024

2023-001 Condition: Deficit in COCC Steps to resolve: The Authority's continued conversion to private based ownership via tax credits and Rental Assistance Demonstration will ease the burden of capital need. Once all our properties are converted this issue will not exist. Individual responsible for correction: Ms. Denise Brooks-Jones, Acting Executive Director Timeframe: As of March 31, 2024

2023-101 Eligibility Recommendation: The Authority should establish policies and procedures to ensure that tenants' eligibility determinations will be reviewed and approved by an employee that is independent of the initial eligibility determination. Action Taken: Authority concurs and has implemented the recommendation. Anticipated Completion date: Fiscal year 2024

2023-01 - Section 223(f) Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, ALN #14.155 Statement of Condition: The Project does not have sufficient internal controls in place over eligibility Response: Developac, Inc., Management Agent, will immediately implement the following corrective actions to cure said deficiency: 1. Management Agent will be solely responsible for updating housing software with the annual income limits provided by HUD 2. Management Agent will periodically review tenant move-in files for eligibility verification

2023-002 Contact Person Myra Pearson, (Acting) Director Corrective Action Plan An internal audit within the corporation will be conducted and reviewed quarterly until the finding is corrected and satisfactorily completed. Has been implemented with checkl.ist in each tenant file and will be noted as incomplete until all steps are followed and listed as complete. Planned Completion Date for CAP Immediate utilization of CAP with completion date for the endoffiscal year if completed according to plan.

Responsible Party Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedures to ensure tenant eligibility and establishing and maintaining security deposits for tenants moving out and we will review the accuracy / completeness of the documentation being processed in the tenant files on a periodic basis. Anticipated Completion Date December 31, 2023

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers, Mainstream Vouchers, Emergency Housing Vouchers Assistance Listing Numbers: 14.871, 14.879, 14.EHV (the “Housing Voucher Cluster”) Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 8,789 units. Of a sample size of eighty-seven (87) tenant files, the following was noted: • HUD-9886 Authorization for Release of Information was missing in 8 files • Annual 50058 form was missing in 7 files • Verification of income and assets was missing in 10 files • Annual inspection report was missing in 2 files Our sample size is statistically valid. Known Questioned Costs: $216,820 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor on the inspection of tenant files and has made arrangements to comply with the compliance requirements of the Housing Voucher Cluster. The added controls will consist of additional training that will be completed by Continued Eligibility staff related to the Electronic File Protocol and the procurment of an IT vendor that will develop reports to identify missing SharePoint attachments within electronic tenant files. Ingrid Layne, the Director of Assisted Housing will be responsible to implement this corrective action by March 31, 2024.

Finding 2023-007 Special Tests and Provision – Child Nutrition Cluster Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The District does not have an internal control system designed to review and maintain documentation for verification of eligibility status. Responsible Individuals: Shannon Hunstad, Superintendent Corrective Action Plan: The District will review and strengthen the controls to ensure the required verification process is being completed and ensuring proper eligibility status for the Child Nutrition Cluster program. Anticipated Completion Date: June 30, 2024

Finding 2023-006 Eligibility – Child Nutrition Cluster Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The District does not have an internal control system designed to review and maintain documentation for eligibility of program participants. Responsible Individuals: Shannon Hunstad, Superintendent Corrective Action Plan: The District will review and strengthen the controls surrounding the review and approval of eligibility applications for the Child Nutrition Cluster to ensure they are supported, approved, and accurate. Anticipated Completion Date: June 30, 2024

Finding 2023-002 – Housing Choice Voucher Program – Internal Control over Waiting List – Noncompliance and Material Weakness - Housing Choice Voucher Program - subsidy ALN #14.871 Corrective Action Plan: Finding 2023-002 correctly identifies the same underlying cause (recruiting and retaining qualified staff) as well as alluding to another underlying problem—antiquated software and IT systems—as contributing factors. Our detailed analysis of the issues giving rise to Finding 2023-001 and the strategic and comprehensive remedies being pursued will result in better outcomes in implementing RHA’s waiting list policies and procedures. For example, a new eligibility unit under an eligibility manager, will bring focus to sound waiting list management. However, another critical underlying cause is the system of waiting list preferences and having a waiting list that remains open regardless of the size. RHA proposes to do away with all preferences except that of giving higher priority to residents of Wake County and those who are employed in Wake County. An applicant’s preference can change multiple times while they are on the waiting list. Anytime one applicant provides new information that changes their preferences and position on the waiting list, the waiting list changes. Greatly simplifying RHA’s waiting list by eliminating most preferences will result in a more manageable waiting list going forward. An additional remedy RHA has implemented is closing the HCV waiting list for the first time in its history. This will greatly reduce the administrative burden of adding new applicants on a continual basis and then annually updating (purging) an unnecessarily large waiting list. Staff in the eligibility unit will have more time to focus on better management of the waiting list. These additional changes in RHA’s program management will complement the other changes discussed under Funding 2023-001. Person Responsible: HCV Director Priscilla Batts and her Eligibility Manager Anticipated Completion Date: The system of closing and opening waiting lists based on the adequacy of the size of the waiting list has been implemented on October 1, 2023. It is anticipated that the list will reopen on April 1, 2024, RHA’s go-live date for the new software. The elimination of most preferences will be implemented at the same time—April 1, 2024.

Finding 2023-001 – Housing Choice Voucher Program Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Material Weakness - Housing Choice Voucher Program - subsidy ALN #14.871 Corrective Action Plan: Finding 2023-001 for the most part correctly identifies the cause of this finding: “We noted that the Authority has experienced difficulty in hiring, training, and retaining quality staff. This is the cause for each of the instances of noncompliance referenced.” The “Great Resignation” during the pandemic affected the HCV Program significantly as staff began to search for other opportunities and potential staff did not find RHA’s compensation competitive. Other negative impacts related to the pandemic included the moratorium on evictions and termination of assistance. Participants had fewer incentives to comply and became lax, resulting in increased levels of work to counter this lax attitude towards program rules. Later in 2022, the end of moratoria resulted in RHA’s voucher utilization rates plummeting as landlords exercised their rights to evict and terminate as well as pursuing rapidly increased market rents instead of renewing leases of voucher participants or renting to voucher holders for the first time. The efforts to retain landlords and issue hundreds of vouchers strained the departments’ staffing resources. The underlying cause of the findings was not just the pandemic effects. RHA recognized that it had underinvested in program operations. First, compensation levels were not close to being competitive. Second, RHA did not invest enough in staff training, a key factor in retention. Third, RHA had also underinvested in technology, using inefficient systems and paper-intensive operations. Fourth, in addition to underinvesting in compensation, RHA also did not allocate resources to staffing, resulting in an understaffed department—managers and line staff. And fifth, these areas of underinvestment led to an organizational structure and staffing model that resulted in staff roles being very narrow. Multiple staff were involved in individual aspects of processes like annual recertifications. It did not require much training, and it relied on staff to do narrow repetitive tasks in a conveyor-belt fashion without anyone being accountable for an entire process. For example, between one and two staff were responsible for doing calculations for participants’ rent portion and subsidy amounts for 3,800 or so annual recertifications and scores of interim recertifications. Four “client specialists” were each responsible for facilitating almost 1,000 participants’ compliance with recertification requirements prior to the two account specialists’ calculation work. In 2023, RHA started to address the root cause that led to this and other findings—underinvestment: 1. RHA’s Human Resources issued an RFP for a firm to do an analysis of compensation levels and make recommendations for classification of positions and competitive compensation. The study was completed and implemented effective the first pay period in December 2023. Individual compensation increases averaged more 10 percent, with staff in the operating departments like HCV benefiting from even higher salaries. These increases were on top of a five percent increase in all salaries effective July 1, 2023, in anticipation of the results of the study. 2. The Director of HCV immediately, upon direction to increase training, contracted with Nan McKay to provide HCV Specialist Certification training to all staff responsible for any part of the eligibility and ongoing occupancy processes. Prior to this effort, only one HCV staff member had been certified. All but one staff person failed the certification class. Going forward, all new staff will be required to pass Nan McKay’s HCV Specialist Certification class by the end of probation. 3. The HCV Director also contracted for Manager and Supervisor Training by Nan McKay for all supervisory staff. All completed certification requirements. 4. The HCV Director also recommended and implemented proposals to reorganize the department by ensuring that managers had a manageable supervisory load of not more than six staff per manager. The new structure created an eligibility unit headed by an eligibility manager (for the first time) as well as two units of ongoing eligibility staff of 12 HCV specialists overseen by two managers. These actions represent a significant increase in staffing and supervision. This reorganization also entails the implementation of a “case management” model in which each HCV Specialist is responsible and accountable for an initial case load of 300 voucher participants. Managers will be responsible for mentoring, training, quality control (file audits) and evaluation of the work of their staff. This reorganization of the department reflects multiple strategies to address some of the root causes that gave rise to the audit finding. 5. By the time the new CEO came on board on April 17, 2023, RHA had completed the evaluation of bids for new software and selected YARDI’s Voyager, Rent Café portals, and other applications to replace antiquated systems. Contract negotiations between RHA and YARDI were completed in July 2023. This initiative represented both a commitment to far greater efficiency and accuracy as well as a willingness to invest in program operations. Implementation and setup are well underway and April 1, 2024, is the “go-live” date. Needless to say, this commitment of resources and countless hours of staff time over nine months has had short-term impacts on RHA’s ability to address identified weaknesses. However, RHA is committed to long-term benefits while enduring short-term pain. These investments in a comprehensive strategic plan for long-term improvements in customer service, compliance, and performance will yield positive results without necessarily making major progress over the short term. To effect improvements over the short term, RHA has implemented the following measures: 1. The HCV director contracted with Nan McKay to assist RHA with catching up on compliance work that has stalled as a result of short staffing and lack of trained staff. Nan McKay’s own difficutly in retaining trained staff and hiring and training new staff delayed their assistance. This delay was further exacerbated by cyber event at the beginning of May 2023. RHA’s computers and systems were locked down by a threat actor requiring ransom. This event reduces RHA operations to manual processes and lack of access to key information to perform compliance work.Nan McKay’s efforts to assist are increasing over time. 2. HCV managers are increasing their efforts to perform qualify control efforts, focusing their staff’s attention on enforcing participants’ compliance with program requirements, including deadlines, and using what they learned from their training. Person Responsible: Priscilla Batts, HCV Director, is principally responsible and accountable for focusing her team on the strategic initiatives outlined above. Anticipated Completion Date: Some of the corrective actions above have been implemented, for example, competitive compensation, training, and outsourcing some of the compliance work. However, these are mainly system changes that will be fully implemented in 2024, for example, new software, with significant improvements that will be evidenced by December 31, 2024.

Finding 2023-003 – Low-Income Public Housing Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The underlying causes of Finding 2023-03 include many, if not all, the causes underlying Finding 2023-01: 1. Pandemic effects on staffing and resident habits. 2. Underinvestment in staff compensation. 3. Underinvestment in training. 4. Underinvestment in adequate staffing levels. 5. An organizational structure that diffuses accountability for compliance, including timeliness of annual recertifications. In the Housing Management Department, all rent calculations are centralized and completed by one Central Office employee. A management system that does not hold property managers accountable for compliance and relies on one employee doing rent calculations for over 1,200 residents is likely to result in lack of compliance when other negative factors (1 to 5) come into play. RHA’s action plan includes: • Competitive compensation to attract and retain qualified staff. • Increasing senior management staff so that portfolio managers will have manageable supervisory loads of no more than five property manager each. • Reorganizing property staffing by upgrading office assistants to Housing Management Specialists, who will perform all recertication tasks, reviewed by their managers. • All Housing Management Specialists will receive certification training on rent calculation as well as property manager certification for high-performing staff who will become eligible for promotion. • Sites with complex social and other problems will have dedicated property managers, instead of splitting managers between sites. • New state-of-the-art software will greatly improve efficiency in communications with residents, paperless processes, and allow managers and their staff to gauge their performance, including timeliness on an ongoing basis. More qualified and talented property managers, supervised, mentored, and held accountable by portfolio managers, as well as supported by trained and higher qualified housing management specialists will work as a team to ensure compliance, including timely completion of recertications. Person Responsible: Sonia Anderson Director of Housing Management, portfolio managers, and property managers. Anticipated Completion Date: Implementation of all remedies will be completed by June 30, 2024.

Condition: All AmeriCorps participants did not undergo the correct eligibility testing before starting the program. Response: Management identified accountability issues with the implementation of the AmeriCorps grant. The supervisor immediately responsible for the recruiting, determining eligibility, retaining records, and supervision of the AmeriCorps members, was terminated for cause. Management self-reported issues of noncompliance with the AmeriCorps grant to Volunteer Louisiana as it began to correct the issues. Management has hired a new supervisor for the grant. Management has also initiated a new plan with multiple checks and balances to ensure that all new AmeriCorps members complete the required components of the process prior to beginning service with the program. Management has completed all of the required steps outlined by Volunteer Louisiana to be in compliance with the terms of the grant as of the end of the year. Implementation Date: December 1, 2022 Contact: Jayne Wright-Velez, Executive Director

Recommendation: We recommend that the Authority reviews its internal controls over review of annual income calculations to ensure compliance with eligibility requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Huntsville Housing Authority (HHA) is restructuring the Public Housing Department to add additional management positions and implement comprehensive standards and operating procedures. These procedures will include clearly defined eligibility processes and enhance quality control measures. Management will conduct oversight of key functions, data entry, and maintain a consistent review of regulatory compliance. Management will complete more targeted and a higher number of quality control audits. Additionally, HHA will increase staff training on key public housing operation functions. HHA is committed to ensure that all employees have proper training in all components of the Public Housing program. Name(s) of the contact person(s) responsible for corrective action: Turkessa Coleman Lacey, Deputy Executive Director Planned completion date for corrective action plan: As of December 15, 2023 the correction action plan is complete and on-going.

State Agency: Office of Children and Family Services Single Audit Contact: Bonnie Hahn Title: External Audit Liaison Telephone: 518-486-1034 E-mail Address: Bonnie.Hahn@ocfs.ny.gov Federal Program(s) (ALN # [s]): Rehabilitation Services-Vocational Rehabilitation Grants to States (84.126) Audit Report Reference: 2023-010 Anticipated Completion Date: January 15, 2024 Corrective Action Planned: New York State Commission for the Blind (NYSCB) is updating the Internal Controls and Data Validation policy for the RSA 911 report to implement an additional control to ensure the accuracy of the key elements including ‘Start date of Employment in Primary Occupation’ #350. The Senior Vocational Rehabilitation Counselor (VRC) will review the start date for employment during their review of cases when the Individualized Plan for Employment (IPE) is approved and at the time of successful closure. The Senior VRC will also verify that the employment start date is entered and accurate on the employment information form in the case management system. Training on this additional internal control will be provided to the Senior Vocational Rehabilitation Counselor’s and District Managers virtually on December 11, 2023. State Agency: State Education Department Single Audit Contact: Jeanne Day Title: Auditor 3 Telephone: 518-474-5919 E-mail Address: Jeanne.Day@nysed.gov Federal Program(s) (ALN # [s]): Rehabilitation Services - Vocational Rehabilitation Grants to States (84.126) Audit Report Reference: 2023-010 Anticipated Completion Date: December 2023 Corrective Action Planned: Adult Career and Continuing Education – Vocational Rehabilitation (ACCES-VR) will continue to implement and document review processes and methods. The implementation of the Aware electronic case management system is complete and will enhance the agency’s review process. A review process memo is currently in development related to Testing and will clearly document the scope and requirements associated with the review process.

State Agency: Higher Education Services Corporation Single Audit Contact: Dora Diaz-Crowe Title: Director, Audit Division Telephone: (518) 474-8893 E-mail Address: dora.diaz-crowe@hesc.ny.gov Federal Program(s) (ALN # [s]): Federal Family Education Loans (Guaranty Agencies) (84.032) Audit Report Reference: 2023-008 Corrective Action Planned: To ensure the timeliness of Teacher’s Loan Forgiveness (TLF) application review, eligibility determination, and the denial or payment of the claims, Higher Education Services Corporation (HESC) staff implemented a control in 2022 to monitor and track the claims through a TLF tracking spreadsheet. Applications were supposed to be logged into the spreadsheet when received by HESC; they were then reviewed, followed by a determination of eligibility or denial of a payment, and the date claim processed was entered into the spreadsheet. A Claims Unit supervisor was assigned the responsibility of monitoring the process, reviewing the spreadsheet, and following up on any outstanding TLF applications that did not capture payment or denial dates and were approaching the 45-day deadline. Unfortunately, due to loss of the supervisor position the review was not performed regularly. Moreover, due to staff turnover in 2022-23 driven by HESC’s exit from FFELP, the TLF payment monitoring procedures were not followed consistently in all cases.i While we recognize that this is a repeat finding, we note there was significant improvement, decreasing the number of late payments in the sample from 23% last year to 5% this year. We would also note that as of May of 2023, HESC transferred the majority of its FFELP loan portfolio to a successor Guaranty Agency, the Trellis Company. With this transfer, HESC no longer holds loans that would qualify for the TLF program and as of April 2023, no longer performs work on the TLF program. As such, the recommendation will not be implemented as indicated in the audit report. i On December 1, 2021, HESC provided notification to the Education Department (ED) of its intent to exit the Federal Family Education Loan Program (FFELP).

State Agency: Department of Labor Single Audit Contact: Donald Temple Title: Director of Internal Audit and Control Telephone: (518) 457-7332 E-mail Address: Donald.Temple@labor.ny.gov Federal Program(s) (ALN # [s]): Unemployment Insurance (17.225) Audit Report Reference: 2023-007 Anticipated Completion Date: 6/1/2024 Corrective Action Planned: New York State Department of Labor (NYSDOL) continues to reduce pandemic era backlogs with ongoing and evolving strategic planning. In addition, staff training and internal workflow procedures have been updated to ensure staff and supervisors communicate clearly on cases well in advance of case closure deadlines. Furthermore, staffing the unit to the allowable fill level will be sought if sufficient funding permits new hires.

Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Health Center's final expenditure listing identified as eligible and claimed under the federal program were not reviewed and approved by a separate individual outside of the preparer. Responsible individuals: Crystal Richter, Chief Financial Officer Corrective Action Plan: If future reports are required, a secondary review of the summary spreadsheet prepared from the underlying supporting spreadsheets will be documented. No further are reports anticipated relating to this federal program. Anticipated Complete Date: 11/30/2023.

For ALN 93.959, a Financial Assessment Form was not properly completed for 1 of the 60 clients tested. Additionally, 1 of the 60 clients tested did not have the Financial Assessment Form properly signed. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. Our internal tracking of completion of the financial assessment form indicates that compliance with this requirement occurs about 98% of the time. Obtaining the client signature on the form has been challenging, particularly during recent years as use of telehealth services has expanded. As a corrective action, SMA will include completion of the assessment form compliance results to be reviewed at the monthly Process Improvement Committee. Program managers are required to present a corrective action plan when results are out of compliance with the standard. In addition, SMA will develop a procedure to allow staff to document receipt of verbal approval of the completed financial assessment form when the client is unable to be present at service location site.