Corrective Action Plans

2023-044 Oregon Housing and Community Services Ensure that the nature of program applicants' financial hardship is documented MANAGEMENT RESPONSE: The agency agrees with this finding. OHCS completed research to better isolate the problem and verified the nature of hardship fields are required to submit an application in the homeowner application portal. Review of the hardship fields are now required, and program underwriters and housing counselors will request hardship statements where none exist in an application. The HAF team will review funded applications to determine if any deficiencies exist related to attestations of the nature of financial hardship. OHCS will request that those applicants supplement any missing information to adhere to regulatory standards. OHCS will also implement sampling quality assurance, compliance, and data report reviews to check for attestations of the nature of financial hardships. Anticipated completion date: September 30, 2024 Contact person: Ryan Vanden Brink, Grants, Loans, and Program Manager

Finding 2023-066 – Corrective Action Plan This audit finding refers to retroactive Medicaid billing from BHDDH for dates of service in 2022 and 2023 once the IMD status was removed from ESH. That provider type currently does not require the Medicare information to be submitted to EOHHS for processing. They bill with a type of bill and if there is eligibility on file for Eleanor Slater, the claim is paid. EOHHS will pursue a project to correct this finding. Anticipated Completion Date: To Be Determined – State Fiscal Year 2025 Contact Person: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health & Human Services hector.l.rivera@ohhs.ri.gov

Finding 2023-065 – Corrective Action Plan 2023-065a – EOHHS and DCYF have been working with St. Mary's on the submission of the SFY 23 cost report which EOHHS needs in order to set a FY 23 rate pursuant to the State Plan and reprice the previously paid claims. EOHHS has provided extensive support on allocation methodology and requirements to which St. Mary's must adhere in order to meet State Plan requirements. Once aligned with the SPA that was approved in July of 2023 for SFYs 23 and 24, EOHHS will prospectively establish rates to remain compliant with the approved methodology. Anticipated Completion Date: June 30, 2024 2023-065b – EOHHS requires that St. Mary's direct bill through the MMIS and the facility began billing in October 2023. EOHHS and DCYF are currently working on a plan to ensure all allowable medical services provided by DCYF providers are directly billed to the MMIS. Anticipated Completion Date: July 1, 2025 Contact Person: Dezeree Hodish, Assistant Director, Financial & Contract Management, Executive Office of Health & Human Services dezeree.hodish@ohhs.ri.gov

Finding 2023-064 – Corrective Action Plan 2023-064a – Death reporting: Permanent system fix will deploy 28 June 2024; enhancement will trigger a 1A code from RI Bridges to send date of death to MMIS when date of death is added on a case with closed eligibility. This fix should remedy audit finding plus financial impact in the MMIS when members are not closed properly. Anticipated Completion Date: June 28, 2024 2023-064b – Death reporting addressed in response to 2023-064a. Residency/Out of State: State resumed PARIS residency verifications and is pursuing secondary residency checks with Accruint/Lexis Nexis data and automation of manual NCOA database verification process. Additionally, State will benefit from future use of The Work Number Employee Address data to verify residency. Anticipated Completion Date: August 1, 2024 Contact Person: Brian Tichenor, RIBridges Medicaid Administrator, Executive Office of Health & Human Services brian.tichenor@ohhs.ri.gov 2023-064c – EOHHS will identify and return any potential ineligible costs by end of the current Federal Fiscal Year (FFY). Anticipated Completion Date: September 30, 2024 Contact Person: Allison Shartrand, Assistant Director, Financial & Contract Management, Executive Office of Health & Human Services allison.shartrand@ohhs.ri.gov

Finding 2023-063 – Corrective Action Plan Each health plan reports TPL recoveries to EOHHS in its quarterly financial report (FDCR). These recoveries are used as a direct offset to medical expenses. As such, claims paid by the plans on behalf of a member with TPL will remain in the EOHHS encounter data warehouse. Health plans do not void claims that have previously been paid to account for any TPL liability. Rather, they seek to recover from the third party any amount owed and report that amount to the state. In each of the last two fiscal years, this reduced medical expenditures by just under $8 million. EOHHS sent the MCOs a full TPL file in July 2023. EOHHS will start the process for a new file in June 2024. Anticipated Completion Date: Ongoing Contact Person: Jeffrey Schmeltz, Chief of Family Health Systems, Executive Office of Health & Human Services jeffery.schmelts@ohhs.ri.gov

Finding 2023-061 – Corrective Action Plan EOHHS has met expectations on aligning the FSR and FDCR reports, has updated files to Milliman, and continues to monitor compliance. EOHHS is currently in a maintenance phase and will continue monthly oversight going forward. Anticipated Completion Date: Current and Ongoing Contact Person: Bill McQuade, Chief of Program Analytics, Executive Office of Health & Human Services bill.mcquade@ohhs.ri.gov

Finding 2023-060 – Corrective Action Plan Rhode Island Medicaid’s Provider Enrollment project went live on 2/01/2024. Any provider that isn’t screened and enrolled with the State Medicaid Agency will have claims deny. Additionally, MCOs have terminated providers in their network who are not screened and redirected members to fully screened and enrolled providers. Rhode Island Medicaid continues to work with its fiscal agent and MMIS contractor, Gainwell Technologies, to ensure all edits are systematic. Anticipated Completion Date: Implemented February 1, 2024 Contact Persons: Kimberly Tebow, Senior Medical Care Specialist, Executive Office of Health & Human Services kimberly.tebow@ohhs.ri.gov Chantele Rotolo, Assistant Administrator for Family & Children Services, Executive Office of Health & Human Services chantele.rotolo@ohhs.ri.gov

Finding 2023-057 – Corrective Action Plan 2023-057a – Residency/Out of State: Rhode Island resumed PARIS residency verifications and is pursuing secondary residency checks with Accruint/Lexis Nexis data and automation of manual NCOA database verification process. Additionally, the State will benefit from future use of The Work Number Employee Address data to verify residency. Income/Wage Validation: EOHHS completed implementation of an interface on 23 March 2024 between The Work Number (TWN) and RI Bridges. Contract and budget actions for TWN services are in progress with a goal of initiating TWN wage verifications in July-August 2024. Anticipated Completion Date: September 1, 2024 2023-057b – EOHHS will return any potential ineligible costs by end of the Federal Fiscal Year (FFY). Anticipated Completion Date: September 30, 2024 Contact Person: Brian Tichenor, RIBridges Medicaid Administrator, Executive Office of Health & Human Services brian.tichenor@ohhs.ri.gov

Finding 2023-056 – Corrective Action Plan Management agrees with the finding. Regulation 4.5.1, RIW approved families are categorically eligible for CCAP services when they have an acceptable need for services related to fulfilling RIW program requirements. The determination of employment plan components including any combination of education and work-related activities in the approved plan are determined by RIW Regulations, section 2.11. The need for services in an RIW CCAP case is based on the employment plan. In situations where an applicant parent does not comply with the RIW employment plan, CCAP services would not be approved. Once CCAP services are approved based on an employment plan for an RIW recipient, the approval is for a 12-month certification period and would not be terminated, per ACF federal requirements, for a subsequent change in employment plan participation or change in income (unless in excess of 85% SMI). It should be noted that in all cases, the decortications were documented in Bridges. CCAP training has also been enhanced in many ways. CCAP training is delivered along with RIW training on a bi-monthly basis for new hires and/or existing ETs The CCAP training module was revised to include topics specific to improper payments. Office of Child Care also holds monthly CCAP office hours for operations staff to connect with program admins, policy and training specialist to answer/troubleshoot questions from the field. Monthly analysis by error type now includes location and worker ID for analysis of more targeted training. DHS also continues to look at system and process improvements. Weekly CCAP theme meetings are ongoing to identify and solution Bridges related incidents. The CCAP Regulations have been reviewed and were opened Q1 2024 for policy updates to streamline and simplify verification processes where possible. Anticipated Completion Date: July 1, 2024 Contact Person: Nicole Chiello, Assistant Director – Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov

Finding 2023-055 – Corrective Action Plan Management agrees with the finding. 2023-055a – DHS has subsequently reviewed the SOC 2 report and will submit to Accounts & Control. 2023-055b – Passwords have already been changed to meet the ETSS policy. 2023-055c – DHS will review user access every 60 days or 90, respectively and terminate users as necessary. Anticipated Completion Date: June 30, 2024 Contact Persons: Deirdre Weedon, Chief Program Development, Low Income Home Energy Assistance Program (LIHEAP), Department of Human Services deirdre.weedon@dhs.ri.gov Ben Quattrucci, Associate Director, Financial & Contract Management, Department of Human Services benjamin.a.quattrucci@dhs.ri.gov

Finding 2023-054 – Corrective Action Plan 2023-054a – The State (EOHHS) receives quarterly user access reports from the MMIS fiscal agent. Anyone identified on the reports that have not logged in for a period of 60 days will have their access deleted. Currently, they are locked out and cannot access the system without first requesting a password reset, which is reviewed and approved/denied by EOHHS systems group. In addition, when a user leaves state service or moves to another agency, their access is deleted. 2023-054b – The State (EOHHS) collaborates with system vendors (MMIS/Gainwell and Deloitte/RI Bridges) Maintenance & Operations (M&O) and Security teams and to ensure annual risk assessment/vulnerability best practices and lessons learned are integrated into annual planning and scope of work for future FYs. Anticipated Completion Date: Current and Ongoing Contact Persons: Brian Tichenor, RIBridges Medicaid Administrator, Executive Office of Health & Human Services brian.tichenor@ohhs.ri.gov Hector Rivera, Interdepartmental Project Manager, Executive Office of Health & Human Services hector.l.rivera@ohhs.ri.gov

Finding 2023-051 – Corrective Action Plan Management agrees with the finding. DHS completed the scope of work in order to hire an outside contractor to evaluate the work and redefine the workflow distribution to improve timeliness and performance. At this time an outside contractor has not been identified. An additional staff has been added to the RIW policy unit and assigned as the liaison with CSDL to ensure written instructions are clear and accurate. Another meeting between the RIW policy unit and operations has been added as another avenue to address concerns and make corrections. The system vendor is sampling cases to identify missing components. Anticipated Completion Date: October 1, 2024 Contact Person: Donna M. Rook, Ph.D, MSW, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov

Finding 2023-046 – Corrective Action Plan As a result of the USDOE review, RIDE has made the necessary changes to the redistribution of unspent funds. Anticipated Completion Date: The corrected process for redistributing unspent funds from prior years was communicated to the field during the FY24 Perkins Launch Webinar on June 8, 2023. The, corrected calculation redistribution was calculated and implemented on November 27, 2023, when the FY23 funds were redistributed. Contact Person: Mark Dunham, Chief Financial Officer, Department of Elementary & Secondary Education mark.dunham@ride.ri.gov

Finding 2023-045 – Corrective Action Plan This error was identified with the USDOE as part of the monitoring in May 2023. All prior years were correct – this was a one-time error in the calculation spreadsheet. As a result, the USDOE did not believe this occurrence rose to the level of a finding – but rather a procedural suggestion to have the calculation spreadsheet reviewed as part of an internal control procedure. Although the issue was discovered in May 2023, the USDOE did not feel the corrections was necessary to be implemented prior to June 30, 2023, as suggested by RIDE. The rationale was due to a projection of a large amount of unexpended FY23 funding - prior to redistributing the unexpended funds, the correct allocation calculation would be applied which would correct most of the previous allocations. Anticipated Completion Date: The correct allocation calculation was applied to the FY2023 Perkins Secondary funds on June 6, 2023. Contact Person: Mark Dunham, Chief Financial Officer, Department of Elementary & Secondary Education mark.dunham@ride.ri.gov

Finding 2023-034 – Corrective Action Plan The auditee does concur with the few exceptions found; however, the auditee feels that these exceptions are not the result of a lack in compensating controls. These exceptions are de minimis in the full scope of the UI program. Nonetheless, future enhancement and modernization of technical systems will reduce instances of these exceptions even further. Furthermore, under the UI PERFORMS Core Measures, the acceptable level of performance for improper payments is 10% or less. The above percentages are well within this ALP. Anticipated Completion Date: Not Applicable Contact Person: Philip D’Ambra, Director, Income Support, Department of Labor & Training philip.l.dambra@dlt.ri.gov

Finding 2023-032 – Corrective Action Plan RIDOH agrees with the finding and recommendation. This finding is centered around some local agency staff being inactive for longer periods of time (60+ days) and the security risk around them not being terminated or made inactive in our Crossroads system. While RI WIC is routinely notified of terminations and transfers of local agency staff, there are instances of people with varying degrees of access going over 60 days without accessing the system. It is sometimes due to a local agency staff person who is in more of an administrator role and not routinely working in the Crossroads system. RI WIC will review policies and procedures regarding user access to the Crossroads System and will work to strengthen and monitor controls for system access. Policies and procedures will be updated as needed, and internal controls will be implemented and documented. Anticipated Completion Date: December 31, 2024 Contact Persons: Ann Barone, Chief, Office of Women, Infants & Children, Rhode Island Department of Health ann.barone@health.ri.gov Anthony Manzi, WIC Fiscal Manager, Rhode Island Department of Health anthony.manzi@health.ri.gov

Finding 2023-031 – Corrective Action Plan RIDOH agrees with the finding and recommendation. The RI WIC Program was cited by USDA for this issue over a year ago. The issue was caused by the Crossroads MIS system rounding up the calculation for converting formula upon issuance, resulting in over issuance in certain situations. RI WIC immediately changed the calculation and responded to the USDA finding with implementing an updated policy and changes to the system. On December 15, 2023, RI WIC received a response from USDA stating that the finding was closed. Anticipated Completion Date: Completed December 15, 2023 Contact Person: Anthony Manzi, WIC Fiscal Manager, Rhode Island Department of Health anthony.manzi@health.ri.gov

Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record

Our agency has implemented a scanning system which prints bar codes on each document that automatically goes to the correct tenant file. After documents have been signed they are scanned in. This will help alleviate misplaced documents/files. Staff has also been instructed to always put any type of correspondence with tenants in the electronic tenant file.

Department of Housing and Urban Development Housing Voucher Cluster - ALN Number 14.871 Recommendation: We recommend that the Authority implement procedures to ensure all required Income verification and other supporting documentation is obtained when completing the HUD-50058 forms, and to the extent they are not, that action be taken to resolve any issues, and that this action be documented Action taken: Updated "How To" and the file guides. The entire file will be reviewed at all Interims and Re certifications. The Operations Manager/Compliance Officer will review each file for quality control. I have attended training provided by Nelrod and will continue to do so.

Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Views of Responsible Official: There is no disagreement with this finding. Action taken in response to finding: On a monthly basis, the Deputy Director/General Counsel will run a LegalServer report on PAI time, including missing activity details, and will follow up with each person to correct their time records as needed. We will also provide additional training to staff on requirements for classifying time as PAI, and the importance of accuracy in timekeeping detail.

Finding Number: 2023-005 Assistance Listing, Federal Agency, and Program Name 10.558, U.S. Department of Agriculture, Child Care and Adult Food Program Federal Award Identification Number and Year 15-016-271P-00 Pass through Entity Illinois State Board of Education Finding Type Material weakness Repeat Finding No Criteria Per 2 CFR 200.303(a), the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal 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). Other requirements include: a) Per 7 CFR 226.10(c)(1), prior to submitting its consolidated monthly claim to the State agency, each sponsoring organization must perform edit checks on each facility's meal claim; per 7 CFR sections 226.16(g) and (h), a sponsoring organization must disburse advance and meal reimbursement payments to centers and day care homes under its sponsorship within five working days of receiving them from its state agency. b) Per 7 CFR 226.15(f), each sponsoring organization of day care homes shall determine which of the day care homes under its sponsorship are eligible as tier I day care homes c) Communication from the passthrough entity to return to pre COVID 19 monitoring, as required under 7 CFR 226.16(d)(4)(iii), effective October 1, 2022, where sponsoring organizations are required to perform onsite monitoring of each of its facilities three times every year, which includes requirements to ensure the amount of time between reviews does not exceed six months (unless review average is used). Condition A lack of documented controls as evidence of supervisory review and segregation of duties to ensure compliance with Federal program requirements, specifically over: a) monthly expenditure reports submitted to the passthrough entity b) tier (day care home eligibility) determinations c) subrecipient monitoring Questioned Costs None Identification of How Questioned Costs Were Computed N/A no instances of material noncompliance noted that would result in questioned costs Context a) During testing a sample of 5 monthly expenditure submissions, we noted no formally documented supervisory review in place. Additionally, during testing of 40 disbursements to providers, we noted no formally documented supervisory review to ensure disbursements to providers are made within 5 working days of receipt from the State passthrough entity. b) While gaining an understanding of controls over tier (day care home eligibility) determinations, we noted no controls established to ensure supervisory review of these determinations. c) While testing a sample 40 provider monitoring visits, we noted 3 visits without evidence of supervisory review and 6 visits where the visit was completed and validated in the software by the same individual. Additionally, we noted 16 day care homes and 2 day care centers with less than the required 3 annual on site monitoring visits for the year, and 15 day care homes and 2 day care centers where onsite monitoring performed were more than the required 6 months apart. Cause and Effect A lack of effectively designed, implemented, and operating controls in any of these areas could result in a material noncompliance with program requirements or Uniform Guidance. Recommendation We recommend management formalize documentation of a supervisory review of: a) monthly expenditure submissions before submitting to the passthrough entity, including documented supervisory controls to ensure disbursement timeliness is met within 5 working days as part of this review; b) of data used in making tier/eligibility determinations for accuracy and completeness; and c) of subrecipient monitoring. Additionally, we recommend management work with its passthrough entities to confirm compliance requirements, especially when compliance requirements change as the result of ending or expiring waivers and flexibilities. Planned Corrective Action Plan –Organization will document process that is used for second review of the monthly expenditure submissions by 04/30/2024. There are no instances of the Organization not providing funds to provider within the mandated 5 days, however, the Organization will document the process for provider payments within 5 days by 04/30/2024. The software required to be used by the funder for management of the program does have limitations on how the data input for making tier/eligibility determinations second review is documented. Organization will design process to document this second review has occurred by 04/30/2024. Staffing shortages coming out the COVID-19 waivers resulted in the inability to perform all required Subrecipient monitoring. This staffing shortage was rectified by 08/31/2023. Contact person responsible for corrective action: Loukisha Pennex, Chief of Youth and Family Potential, Anjanette Brown, CFO and Teresa Rodriguez, Senior Director of Grants and Contracts. Anticipated Completion Date: April 2024

Corrective Action Plan: I am in receipt of the draft finding letter for the audit that was recently conducted for the Housing Authority of McDonough County. Of the 15 tenant files randomly chosen to review, 7 were not in compliance. Discrepancies include: • Failing to gather proper income verification; • Failing to properly calculate annual income; • Failing to maintain EIV documentation; • Failing to maintain birth certificates or social security cards; and • Failing to maintain Declaration 214s. As I am Executive Director, I am responsible for the Corrective Action Plan that will include rental calculation and HOTMA training for a property managers and me. I am scheduled to attend a rent calc/HOTMA training seminar the week of March 18th. The managers are scheduled to attend a rent calc/HOTMA training seminar the week of April 3rd. In addition, a Quality Assurance program to monitor tenant files will be in effect by April 30, 2024. Anticipated Completion Date: April 30, 2024. Person Responsible: Annette Carper, Executive Director

2023-001 - Non-Compliance with Timely Student Enrollment Change Submissions to the National Student Loan Data System (NSLDS) Management View and Corrective Action Plan February 9, 2024 Inaccurate Graduated Student Enrollment Reporting Management View and Opinion NYU Registrar reports a student's enrollment, withdrawal and graduation status to the National Student Clearinghouse (NSC) weekly, per term, which includes a few weeks before and after the term has ended. NSC transfers this data to the National Student Loan Data System (NSLDS). During the degree/graduation reporting period to NSC, the graduation records for some students are not processed prior to NSC's calculated withdrawal which occurs at the start of the subsequent enrollment reporting period. As such, some students are reflected as withdrawn from a term, when in fact they graduated. This impacts the accuracy of student data reported to the National Student Loan Data System. Corrective Action Plan Currently, students self-identify when their loan servicer reflects an incorrect enrollment or loan repayment status. In these cases, the Office of Financial Aid or Registrar manually adjust the NSLDS/NSC file. NSC procedural timelines impact and limit NYU staff’s access to make manual adjustments. Going forward, the Office of Financial Aid and Registrar will collaborate to upload an NYU Graduated Student file directly to NSLDS to update the records of all students to ensure their graduation status are reported accurately and in a timely manner. This upload will be done through the Enrollment Spreadsheet Submittal function on the NSLDS website. The file will include graduated status information for each conferred student in our most recent conferral period. Timeline for Action Plan The corrective action plan will be implemented as follows: Starting in March 2024, the Office of Financial Aid will provide the NSLDS Graduated Student file template to the Registrar. At the close of each conferral period, the Registrar will populate the template spreadsheet with required data points for all graduating students. After the Office of Financial Aid securely receives the completed spreadsheet from the Registrar, it will be uploaded, within the required 60 days, to NSLDS for processing of the students’ graduation records. Responsible Individual: Jason Crowe Email: Jason.Crowe@nyu.edu

The following represents the Corrective Action Plan related to the audit finding listed in the Schedule of Findings and Questioned Costs included in the December 31, 2023 audited financial statements of McDonald Presbyterian Senior Housing, Inc. d/b/a HaveLoch Commons: Finding 2023-001: Incorrect Eligibility Assessment Condition and Criteria: The Corporation made a data entry error for the annual medical expenses of a resident. Accurate financial information is essential in order to calculate the correct subsidy each resident is eligible for. Management Response and Corrective Action Plan: Management agrees with the finding. The Corporation will perform re-education to its existing members on the importance of this data entry, and update its standard review process over these calculations in order to detect errors on a timely basis.