Corrective Action Plans

2023-006 Reasonable Rents Documentation Name of contact person – Laura Straw, Finance Director and/or Elizabeth Machart, Director of Contracts, Compliance, & Special Initiatives Corrective action – Management has reviewed the current practice and has implemented a new form and procedures for documenting the determination and approvals in the case files. Completion date – Management and the Board of Directors implemented the above as of 2/28/2024

Pell Award Errors Finding: As noted in the audit report, there were 5 instances out of 60 students with Pell award errors. Auditors' Recommendation: The University should have appropriate policies and procedure, as well as safeguards in place to ensure Pell eligibility and awarding is correctly determined. School Response: The school agrees with this finding and has initiated corrective action. Corrective Action Plan: For student #5, there was a Pell awarding error where the student was under awarded Pell by $172. The school made the correction to the award and disbursed the additional Pell. For student #16, student was over awarded Pell Grant for $1723 due to incorrect refunds made while adjusting for changes in the student's schedule. The school has refunded the $1723 over award back to the fund source. For student #24, the student was initially awarded correctly, but withdrew during their 2nd term. Due to incorrect Pell Recalculation on the R2T4, the school refunded too much Pell grant, and the student was under awarded by $458. The school has disbursed the additional Pell so the student is now paid correctly. For student #27, the student was over awarded Pell by $350 due to in error in Pell Recalculation based on the student's schedule. The school has refunded the over award to the fund source. For student #43, the student was under awarded by $22 due to an error in Pell Recalculation based on the student's schedule. The school has disbursed the additional Pell grant funds to correct the error. Starting with the Fall 2023 semester the school has implemented a new student information system (SIS), Colleague. The school has also partnered with a third-party servicer, Financial Aid Services (FAS), to assist with packaging. The new SIS automatically adjusts Pell grant whenever there is a change to a student's schedule during the term through the school's census date for each term and module. The system will schedule a refund for any over awards and increase the Pell award for any that may have been under awarded. Since this is no longer reviewed solely by the financial aid office, this is expected to reduce the number of errors in Pell awarding. In addition to the system adjustments, the school's third-party servicer, FAS, will review packaging for any students with changes to the number of registered credits during the term to ensure the system is making adjustments properly and the students are correctly packaged. Name(s) of the contact person{s) responsible for corrective action: Financial Aid Director, Holly Hardnett and third-party servicer, FAS, representative Planned completion date for corrective action plan: • New Colleague SIS implemented live beginning in the Fall semester 2023. • Training for Pell Recalculations in Colleague July 2023. • Registration/schedule changes for term reviewed by FAS at least weekly.

Finding No. 2023-002 Corrective Action Plan: The University concurs with the finding. The Financial Aid office is in the process of tightening its policies and procedures to identify all students subject to the required exit counseling, with the goal of delivering said counseling within the prescribed 30-day window. Responsible Official: John Sircy, Interim CFO Anticipated Completion Date: June 2024

Oversight Agency for Audit, North Dade Senior Citizens Housing Development Corporation, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: July 1, 2022 through June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2023-001: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should implement procedures to ensure initial tenant income through EIV system and third-party documentation are verified in a timely manner, annual unit inspections are performed, and all required tenant documentation is complete and accurate. Action Taken: Monthly reminders are being sent to all managers to run their EIV reports for the month. In addition, random files are being reviewed by compliance to ensure EIV reports are pulled, unit inspections performed, and required documentation is complete and accurate.

During the Fiscal 2023 financial statement audit, Schneider Downs communicated the following finding from their Uniform Guidance procedures: The Food Bank did not obtain and or retain agency monitoring forms for 15 out of our sample of 25. Our response to the finding was: COVID-19 risk mitigation strategies employed by our Food bank and our partner agencies restricted our ability to directly monitor partner sites. The team responsible for monitoring and compliance also experienced staffing inconsistencies that have since been rectified; the team is now able to monitor at full capacity. Moving forward, new tools and processes for scheduling and tracking agency monitoring will provide better real-time insight into our progress and compliance. Finally, agencies are expected to renew their agreement with our Food Bank at 2024 calendar year-end, which will reassert our monitoring requirements to all partner agencies in our network. Update as of February 23, 2024 The Food Bank has taken the following actions: • The annual contract renewal process has been initiated, including reassertion of our monitoring requirements. • Additional compliance staff have started the regular monitoring process. • A system has been put in place to provide compliance progress updates to the Controller.

Housing Choice Vouchers - CFDA No. 14.871 - Eligibility Recommendation: The Authority should implement processes to ensure that all documentation is received and that the correct inputs are being accurately reported on the HUD-50058. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The errors found where: Income was miscalculated. GHA'S staff will continue to have refresher trainings to ensure that all documentation is correct and properly reported on the HUD-50058 Name(s) of the contact person(s) responsible for corrective action: Maria Godwin Planned completion date for corrective action plan: Ongoing

CORONAVIRUS STATE AND LOCAL RECOVERY FUNDS, ASSISTANCE LISTING 21.027 : INELIGIBLE COSTS / UNIFORM GUIDANCE 2 CFR PART 200 UNIFORM ADMINISTRATIVE REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL AWARDS, SUBPART E: COST PRINCIPLES SECTION 200.403(F) STATE "EXCEPT WHERE OTHERWISE AUTHORIZED BY STATUTE, COSTS MUST MEET THE FOLLOWING CRITERIA IN ORDER TO BE ALLOWABLE UNDER FEDERAL AWARDS: (F) NOT BE INCLUDED AS A COST OR USED TO MEET COST SHARING OR MATCHING REQUIREMENTS OF ANY OTHER FEDERALLY-FINANCED PROGRAM IN EITHER THE CURRENT OR PRIOR PERIOD. / THE CITY OF EAST PRAIRIE RECEIVED ARPA FUNDS THROUGH MISSISSIPPI COUNTY, MISSOURI FOR THE REMOVAL OF ASBESTOS AND DEMOLITION OF A HAZARDOUS SCHOOL STRUCTURE IN ORDER TO FACILITATE THE CONSTRUCTION OF A PUBLIC HEALTH FACILITY IN AUGUST AND SEPTEMBER, 2022. IN DECEMBER OF THE SAME YEAR, THE CITY RECEIVED WAS AWARDED AND ARPA GRANT AND FUNDS THROUGH THE MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION FOR THE SAME PROJECT. THIS WAS A DUPLICATION OF ARPA FUNDS DUE TO THE CITY NOT BEING FULLY AWARE OF THE COST STANDARDS OF UNIFORM GUIDANCE AND A MISCOMMUNICATION REGARDING ELIGIBILITY OF COSTS. / THE CITY OF EAST PRAIRIE HAS CONTACTED MISSISSIPPI COUNTY AND WILL BE RECEIVING AUTHORIZATION FROM THE MISSISSIPPI COUNTY COMMISSION TO RE-ALLOCATE THOSE FUNDS FOR THE SAME PUBLIC HEALTH FACILITY PROJECT. WE ARE ALSO DEVELOPING A WRITTEN POLICY AND PROCEDURE MANUAL CONFORMING TO UNIFORM GUIDANCE.

Finding Number: 2023-007 Condition: The Seminary did not identify or provide the appropriate notification to a student that was not meeting the Seminary's policy on satisfactory academic progress (SAP). Planned Corrective Action: Satisfactory academic progress is now being monitored more carefully. The Satisfactory academic progress report is run out of the student financial aid system. The internally generated report is reviewed by the Registrar and Financial Aid Director to confirm that student satisfactory academic progress statuses are correct. Once the appropriate status is confirmed, the Financial Aid Director will document students who are not in compliance with the institution’s policy and provide notifications to each student through email. The emails are recorded in the students' Jenzabar financial aid account. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 06/01/2024

March 1, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (ALN# 14.157)  Section 8 Housing Assistance Payments Program (ALN# 14.195) Condition. Out of a sample of 8 tenant files, we noted three instances where an EIV was not run for a tenant within 90 days of move in. Additionally, out of a sample of 8 tenant files, we noted one instance where a refund check was not disbursed to the tenant within 60 days of move out. Effect. As a result of this condition, employees did not follow HUD guideline procedures. While there were no differences in the amount of subsidies allowed upon review of the subsequent EIV compared to subsidies received, the lack of effective internal controls could lead to future significant noncompliance. Additionally, a former tenant was not disbursed a refund in a timely manner under the HUD guidelines. Plan. Management agrees with finding 2023-001. All files are to be inspected in the current fiscal year to ensure compliance with HUD regulations. File maintenance will be competed following each move in, move out, and annual recertification. In addition to one-on-one training, the housing administrator has signed up for additional training including a WebEx on annual recertification and a basic EIV course. Additional training sessions are forthcoming. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: December 31, 2024

March 1, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (ALN# 14.157) Condition. Out of a sample of 6 tenant files, it was noted: 1. Two out of six instances where an EIV was not run for a tenant file within 90 days of move in; 2. One out of six instances where the incorrect tenant income was used to calculate the tenant assistance payment; 3. One out of six instances where a tenant moved out and the requested overages were not adjusted for the correct time period; In addition, procedures were not in place to document the applicants, admissions, and removals to and from the tenant waitlist. Effect. As a result of this condition, certain tenant files did not contain all required supporting documentation. In addition, employees did not follow HUD guideline procedures, and/or did not properly calculate the tenant subsidy in HUD Form 50059. While there were no significant differences in the amount of subsidies allowed compared to subsidies received, the lack of effective internal controls could lead to future significant noncompliance. Plan. Management agrees with finding 2023-001. All files are to be inspected in the current fiscal year to ensure compliance with HUD regulations. File maintenance will be competed following each move in and annual recertification. In addition to one-on-one training, the housing administrator has signed up for additional training including a WebEx on annual recertification and a basic EIV course. Additional training sessions are forthcoming. A tenant waitlist will be created and maintained. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: December 31, 2024

The City agrees with the finding. The Treasury Portal automatically fills in the amounts for revenue loss for 2022 with amounts reported in 2020. The Treasury portal has many flaws that would cause errors in reporting. In addition, the portal has changed every quarter, which makes it challenging to report accurately. The City will implement controls to ensure that a second review is completed prior to certification of the report. Additionally, the Grant Administrator will work with department staff responsible for reporting and ensure that each report's supporting documentation is complete and ties to underlying subrecipient reports, the general ledger and grantor reports. All supporting documentation, along with a copy of the submitted report, will be stored in a central location to ensure that they are available for subsequent reviews and audits. This will be completed by June 30, 2024.

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan In the 2023-24 school year, Nutrition Services has implemented an additional step when processing meal applications to improve accuracy. Meal applications are verified a total of three times. The Nutrition Specialist is the Determining Official, the Director is the Confirming Official, and either the Secretary or Clerk is the Verifying official. Each official reviews the application for accuracy. Name of responsible individual: Brenda Zarate Implementation Date: 7/1/2023

ALLOWABILITY AND ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.489, 93.575, 93.596, COVID-19 93.575 For the one payment out of 40 whereby the provider requested and was paid for 13 non-traditional days although records indicated that only 11 of the days were non-traditional, the West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA), agrees that the condition resulted in an overpayment of $12.00. The BFA Case Manager entered 13 non-traditional days in the Family and Children Tracking System (FACTS), but the record indicated that only 11 days were non-traditional days. Per WV Child Care Policy and Procedures: 8.3.1. Worker Error Improper payments due to worker error are defined as payments that should not have been made, or that were made in an incorrect amount due to worker error in determining and verifying eligibility, and/or calculation and input of information into the Family and Children’s Tracking System (FACTS). Incorrect amounts include overpayments, underpayments and inappropriate denials of payment. 8.3.1.1. Examples of worker error: A. The child care regulatory specialist enables the “accreditation” box, allowing the provider to receive an extra $4 per day, when the provider has not achieved accreditation, and is not entitled to the enhanced rate. B. The case manager enters an incorrect number of days when entering information from the payment form into FACTS. C. The case manager enters more time on the child care assessment than the client’s work or school schedule supports. D. The case manager fails to verify income, school enrollment, or special needs status. 8.3.1.2. Repayment of an improper payment due to CCR&R worker error is not mandatory regardless of the amount. The BFA Division of Early Care and Education employs Child Care Policy Specialists who visit contracted Resource and Referral Agencies to monitor and audit both electronic and hard records. Training and coaching also takes place during these visits. These visits continued throughout the reporting period. The BFA will evaluate the effectiveness of the current training programs for the use of the FACTS system (and subsequently for the West Virginia People's Access to Help (PATH) system) for CCDF payments. Furthermore, the BFA will follow established policies and procedures to ensure client information is appropriately obtained and maintained and that all data is input accurately. For the payment whereby the $3.00 daily supplement was not included in the calculation or paid, although the documentation in the eligibility system indicated that the child was covered under a CPS Safety Plan, this was not in fact a CPS Safety Plan case. The CPS Safety Plan was being used as a temporary means to address an executive order regarding COVID-19 and grant eligibility to essential workers who would otherwise not have qualified for the child care subsidy assistance due to their monthly income being above the Federal Poverty Level but below 85% of the State Median Income. The payment in question was in March 2023. Via a case assessment on November 1, 2023, this case [and other similar cases] were approved in the eligibility system as formalized Policy Exceptions rather than being selected as part of a CPS Safety Plan.

ALLOWABILITY AND ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.659 The issues identified in the finding were due to a broad number of child welfare workers having access to select “Non-Recurring Adoption Expense” (NRAE) when issuing a demand payment through the eligibility system, causing the incorrect funding to be used. Two of the payments identified were manually entered to replace lost payments. The initial payments covered multiple children, but the replacement payment only identified one child’s name. For the Adoption Program, the DHHR phased in a new information technology system for determining eligibility, making payments, maintaining documentation, etc. during the State Fiscal Year 2023. The name of the new system is PATH (People & Access to Help). The PATH system replaced the Family and Children & Tracking System (FACTS). The PATH system will have additional controls and levels of review as compared with the FACTS system. For example, as specific to this finding, the ability to select NRAE when issuing a demand through PATH has been localized to adoption subsidy unit staff within the central office of the DHHR Bureau for Social Services.

ALLOWABILITY AND ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.658 As indicated in the Condition section of the finding, although the documentation related to safety considerations at child care institutions was not initially maintained in the official licensing files for 10 of the 40 cases tested for eligibility, the documentation was eventually provided to the auditors for eight of those 10 cases. For one of the remaining two cases, the child care institution is an out-of-state institution that is no longer in business. For the other case, the child care institution provided documentation, but the documentation did not include the dates of the institution’s safety checks. In an effort to enhance internal controls over the safety considerations at child care institutions, the West Virginia Department of Health and Human Resources, Bureau for Social Services (BSS), is continuing to analyze the condition that led to this finding and is considering a number of steps, including but not limited to the following as an immediate plan of action: • Transmit a copy of 2 CFR 1356.30(f) to all licensing personnel, supervisors, and other applicable staff within the BSS and oblige them to acknowledge that they have read and understand the requirements referenced therein. • Implement a formalized policy and develop written procedures for ensuring the licensing files for child care institutions contain documentation which verifies that safety considerations with respect to the staff of the institutions have been addressed. • Develop overall standards for the maintenance of documentation within licensing files (e.g., a consistent naming convention for the documents, which would improve internal tracking and ensure that requests from independent auditors are addressed efficiently and fully; personnel who have read-only access to documents versus those who can add, replace, and delete documents; record retention requirements; etc.). • Establish a formalized process for monitoring. Such a process would include a strategy for conducting internal reviews of all licensing files on a recurring basis, reporting the results of those reviews to appropriate officials internal and external to the DHHR, following up with those officials as may be necessary, and documenting the overall results accordingly. For example, if the results of a monitoring review indicated noncompliance [or potential noncompliance] on the part of a child care institution, the BSS would inform the institution, request a copy of the institution’s written policies and procedures regarding safety considerations, discuss it with the institution, and provide technical assistance to the maximum extent practicable. Once the BSS drafts the aforementioned policies and procedures and related monitoring process, or otherwise enhances their internal controls over the safety considerations at child care institutions, the BSS will discuss the matter with their regular programmatic contacts at the U.S. Department of Health and Human Services, Administration for Children and Families, and will ask the ACF if the BSS’s planned controls are aligned with the ACF’s universal expectations surrounding 2 CFR 1356.30(f).

ELIGIBILITY West Virginia Department of Health and Human Resources (DHHR) Assistance Listing Number 93.568, COVID-19 93.568 The LIHEAP policy staff within the DHHR, Bureau for Family Assistance (BFA), have worked with the Recipient Automated Payment and Information Data System (RAPIDS) team to confirm that the benefit table has been accurately entered into the RAPIDS system for fiscal year 2024. The LIHEAP policy staff will continue to review the work of the RAPIDS team to ensure that the benefit table has been accurately entered prior to the opening of LIHEAP application intake annually.

SPECIAL TESTS AND PROVISIONS – PENALTY FOR FAILURE TO COMPLY WITH WORK VERFICATION PLAN Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558 For each data element quarter of the calendar year, the new component entry deadline and the participation hours entry deadline are established by the West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA). For the first data element quarter (January, February, March), the new component entry deadline is April 30, and the participation hours entry deadline is May 5. For the second data element quarter (April, May, June), the new component entry deadline is July 31, and the participation hours entry deadline is August 5. For the third data element quarter (July, August, September), the new component entry deadline is October 31, and the participation hours entry deadline is November 5. For the fourth data element quarter (October, November, December), the new component entry deadline is January 31, and the participation hours entry deadline is February 5. To resolve the condition that led to this finding, the BFA will work with the Recipient Automated Payment and Information Data System (RAPIDS) Data Team. The BFA will request joint meetings with the RAPIDS Data Team to review sample cases and the components and hours related thereto to ensure they have been entered into the data system correctly. The meetings will take place quarterly, within five days after the participation hours entry deadlines, and will be documented accordingly.

ELIGIBILITY Department of Health & Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The TANF policy staff within the West Virginia Department of Health and Human Resources, Bureau for Family Assistance, will submit monthly reminders to field staff, supervisors, and community service manager to refresh them on policies and procedures regarding the 60-month lifetime limit for benefits funded by TANF. The TANF policy staff will send the reminder in February 2024 and June 2024.

SPECIAL TESTS AND PROVISIONS – INCOME ELIGIBILITY AND VERIFICATION SYSTEM Department of Health & Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The Division of Family Support within the West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA), will send the current desk guides to all WV WORKS (TANF) staff, which includes the Data Exchange desk guide and the Viewing Data Exchanges by Exchange Type desk guide. The BFA Division of Family Support will also work with the BFA Division of Professional Development to create a blackboard course for supervisors and community service managers [who supervise WV WORKS (TANF) staff] to assist the supervisors and management in identifying deficiencies regarding the IEVS system.

SPECIAL TESTS AND PROVISIONS – SATISFACTORY ACADEMIC PROGRESS Blue Ridge Community and Technical College, Bluefield State University, Fairmont State University, Marshall University, New River Community and Technical College, West Liberty University, West Virginia Northern Community College, West Virginia School of Osteopathic Medicine, and West Virginia University at Parkersburg Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364 Blue Ridge Community and Technical College (BRCTC) response BRCTC agrees with the auditor’s comments that the internal control process regarding the Satisfactory Academic Progress (SAP) Policy can be improved by maintaining documentation of an annual formal review of the SAP policy and its publication on the website, internal policy manuals and the student catalog. Effective January 2024, BRCTC’s website has been updated to appropriately reflect the SAP policy. Bluefield State University (BSU) response Effective January 2024, internal controls are in place to perform the Review of the Standards of Satisfactory Academic Progress Policy to comply with federal regulations 2-CFR 200.303, 34 CFR 668.16 (e) and 34 CFR 668.34. The current SAP policy was reviewed in June of 2023, but a signature was not maintained. The SAP policy will be reviewed annually prior to the new academic year that begins each August. The review will consist of the Director of Financial Aid, Chief Financial Officer and Provost reviewing all aspects of the current policy at first and then maintaining any changes annually along with retaining signatures of the annual review. The policies and procedures will be given a new review date each year to reflect the process.   Fairmont State University (FSU) response Effective January 2024, the following has been placed into the Satisfactory Academic Progress policy and will go into effect in Spring 2024 - Institutional Documentation Retention. Prior to the Satisfactory Academic Progress policy being applied to students at FSU, the Director will be responsible for the following: 1. Download the most current Satisfactory Academic Progress regulations from studentaid.gov. This documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 2. Review, compare, and update the current Satisfactory Academic Progress policy at FSU with the most current federal regulations. The most current version of the policy will be signed off and dated by the Director of Financial Aid & Scholarship. This documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 3. The Director of Financial Aid & Scholarships will provide any updates to the policy to the Information Systems Specialist by email in order for the Banner system to be updated with the updates. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 4. The Information Systems Specialist will update the Banner system in TEST. 5. The updates will be ran in TEST by running the ROPSAPR process for the future fall and future summer terms. 6. The TEST data will be reviewed and evaluated to ensure all policy updates have been captured and the students have been appropriately evaluated according to federal regulations. 7. The Information Systems Specialist will notify the Director of Financial Aid & Scholarships by email the status of the TEST system to determine if additional updates need to be made. 8. If the Director approves the data from the TEST system, they will notify the Information Systems Specialist by email that the updates are ready for production. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 9. Updates will be applied to the production system by the Information Systems Specialist and the ROPSAPR process will be run on all current students for evaluation. 10. The Information Systems Specialist will notify the Director of Financial Aid & Scholarships by email once the process is complete for one final review of the data to ensure all federal regulations are being met and the students have been evaluated accordingly. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 11. The Director of Financial Aid & Scholarships will sign off on the completed process by email to the Information Systems Specialist. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. Marshall University (MU) response MU updated the website in February-March which included a review of SAP Policies and Procedures. MU did not update the Revision Date as there were no updates to Satisfactory Academic Progress federal regulations for the 2023-24 aid year. The policy did not change but was reviewed when updates were made to the website. This policy was updated and also added to the website. Effective February 2024, MU will document and retain all reviews and approvals for compliance with federal regulations. New River Community and Technical College (NRCTC) response NRCTC will continue to review policies and procedures at least once, and sometimes twice a year when the catalog is reviewed. NRCTC will continue doing this review and maintain documentation to ensure compliance with federal regulations. West Liberty University (WLU) response Effective January 2024, to comply with internal control over federal awards, WLU will ensure that SAP policies are compliant with the US DOE standards and retain evidence of the review before the SAP procedures are completed annually. If there are no changes, the policy will be approved to move forward. A signed sheet of the SAP policy approval will be retained in the office and an email of no updates will be sent to others in the Financial Aid Office. If changes are necessary, a financial aid committee would meet to make the appropriate updates. Once the policies and procedures are updated, a signed copy of the update will be retained in the FA Office and an email of the updates will be sent to the Financial Aid Office and communicated to all faculty, staff and students. West Virginia Northern Community College (WVNCC) response Effective December 2023, a new internal control process has been added to validate WVNCC’s processes (including SAP) with any changes to the Dept of Ed regulations, as available for the upcoming school year. WVNCC begins creating the new policy and procedure manual as the new year financial aid setup begins. The Director of Financial Aid will be creating a task force which meets two times per year to review the procedures. As WVNCC’s policy and procedure manual is a live working document, updates will be made as needed with a revision date denoted where applicable. WVNCC had an initial conversation with NASFAA on their policy and procedure information available and has created a sign off form to verify the review of the policy each academic year. This process is being implemented during the 2023-2024, prior to this year, as with the 2022-2023 documents, changes in regulations or college policy changes were made in the policy and procedure manual but may not have had a revision date as it done during the manual creation. This process will be fully implemented for the new 2024-2025 policy and procedure manual as it is being created. The new control will formalize this process, a review of applicable review is in process. West Virginia School of Osteopathic Medicine (WVSOM) response WVSOM did not have adequate internal controls in place surrounding the satisfactory academic policy (SAP) policy. A new SAP policy will be written and published to the public website to include reasonable standards for measuring whether eligible students are maintaining SAP in the educational program in our published SAP policy. The new policy will provide notification to the students of the results of an evaluation that impacts the students’ eligibility for title IV program funds. WVSOM will retain sufficient documentation that the procedures are performed and reviewed by the Financial Aid Director and a second review performed by the Associate Director of Financial Aid. The review will provide two signature sign-offs. West Virginia University at Parkersburg (WVU-P) response Financial Aid employees review all financial aid policies and procedures at minimum once per academic year. The Satisfactory Academic Progress (SAP) policy was reviewed and updated by financial aid staff throughout the spring and was approved by the Executive Vice President in June 2023, the updated SAP policy was forwarded to the President’s office to be filed and posted in the appropriate places, including online. WVU-P agrees that the updated and most recent SAP policy was not posted to the website prior to June 30, 2023. There was a college-wide policy review this spring, and the volume of that caused a delay in the policy’s posting. The resolution for this issue is to complete our policy review process earlier, and ensure if updates are necessary then the Marketing and Communications staff are aware of a deadline prior to June 30 to post the updated policy. WVU-P believes that there is sufficient documentation to show that the review of the SAP policy occurred within the academic year. The policies themselves have footnotes to document that Heather Skidmore reviewed the policies, and then the secondary review completed by Alice Harris before submission to the President. WVU-P will retain all communication that occurs related to future review processes to avoid a repeat finding on this issue.

ALLOWABILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 The West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA), analyzed the condition that led to this finding and hereby offers more details into the condition and cause of the finding. The $463.00 cost in question was a supplemental Emergency Assistance payment from July 2022. The SNAP Assistance Group was due for recertification review for the month of July 2022. A review document was mailed to the client in June 2022. The client failed to return the review in a timely manner, which resulted in a late review interview. The SNAP household eventually submitted the review document on July 11, 2022, whereby the interview was conducted the same day. As the household was then required to submit updated income verification, the case was still pending on July 11, 2022. On July 28, 2022, the case comments document that the client submitted paystubs, but the paystubs were outside the period of consideration (POC); the SNAP benefit failed on this date. On August 2, 2022, the household submitted additional documentation and the BFA reopened the SNAP benefit retroactively for July. The Emergency Assistance (EA) supplements were not to be initiated until the second month of SNAP issuance (i.e., the month following active SNAP approval). Therefore, the $463.00 payment in question was ineligible because the SNAP Assistance Group was not receiving SNAP at the time of the July 2022 EA supplemental issuance. The condition is due to the household reporting new income prior to the start of the recertification, which caused the BFA to need or request additional payments immediately following. Client confusion added to this issue. On December 29, 2022, the U.S. President signed into law the Consolidated Appropriations Act, 2023. Division HH, Title IV, Section 503(b), of the Act ended the SNAP EA that was provided by Section 2302(a)(1) of the Families First Coronavirus Response Act (FFCRA). The law terminated EA after the issuance of February 2023 benefits. Therefore, the last benefit month that may include EA was February 2023. If future EA or related programs become available for SNAP, the BFA will work with its contractor to develop stopgap measures within the eligibility system that will require an additional review to process supplemental EA payments when a household is due for recertification.

SPECIAL TESTS AND PROVISIONS – ADP SYSTEM FOR SNAP Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 Management within the DHHR, Bureau for Family Assistance (BFA), appreciates and shares the auditors’ concern with SNAP program integrity as it relates to the Recipient Automated Payment and Information Data System (RAPIDS) ADP system. The BFA notes that 7 CFR § 272.10 begins with, “(1) Purpose. All state agencies are required to sufficiently automate their SNAP operations and computerize their systems for obtaining, maintaining, utilizing, and transmitting information concerning SNAP. Sufficient automation levels are those which result in effective programs or in cost effective reductions in errors and improvements in management efficiency, such as decreases in program administrative costs...” Within the RAPIDS ecosystem for SNAP administration, this automation includes data matching measures undertaken, in compliance with related federal rules as specified in 7 CFR § 272.8, 7 CFR § 272.16, etc., to automate the validation of client-provided, worker-input information while mitigating the additional administrative burden of secondary review for all worker interactions with a client’s case. Policy regarding state and federal data matching is laid out in Chapter 6 of the State’s Income Maintenance Manual (IMM) at https://dhhr.wv.gov/bfa/policyplans/Documents/ Binder4.pdf. The primary data exchange system detailed in IMM Chapter 6 that is applicable to SNAP is the Income and Eligibility Verification System (IEVS) required by 7 CFR § 272.8. Systems mandated federally for inclusion in the IEVS include those operated by WorkForce WV, the Internal Revenue Service (IRS), and the U.S. Social Security Administration (SSA). A variety of other sources may also be queried for the purpose of validating client-provided information entered into RAPIDS by a worker, including Veterans Affairs (VA), Beneficiary and Earnings Data Exchange (BENDEX), Beneficiary Earnings and Exchange Record System (BEERS), National Directory of New Hires, and Prisoner Matching with the Department of Corrections as well as the Federal Data Services Hub (FDSH). IMM Chapter 6, page 2 describes the purpose of data matching through the IEVS thusly: Information obtained through IEVS is used for the following purposes: • To verify the eligibility of the assistance group (AG). • To verify the proper amount of benefits. • To determine if the AG received benefits to which it was not entitled. • To obtain information for use in criminal or civil prosecution based on receipt of benefits to which the AG was not entitled. IMM Chapter 6, pages 2-3 further detail the points at which a match with the IEVS must take place: A data exchange in the eligibility system occurs: • When a new case is created; • When a new person is added to a benefit; • When a person’s demographic information is changed; and, • On a periodic basis for all individuals in the eligibility system, depending on the type of benefit being received. Requirements for independent verification of information when automated data matches fail or report a discrepancy with client-provided, worker-input information are spelled out in IMM 6.4.4. The BFA believes that these automations, while perhaps not foolproof, are in keeping with both the word and intent of 7 CFR § 272.10, 7 CFR § 272.8, 7 CFR § 272.16, etc., which aim to automate processes in order to reduce administrative burden and associated costs, such as those that would be associated with a secondary review of all worker interactions with a client’s case. Furthermore, page 4-10.551-9 of the Compliance Supplement 2023, which lays out the suggested audit procedures for this topic, recommends the use of the USDA-FNS SNAP System Integrity Review Tool (SIRT) to ensure that the State’s ADP system is in alignment with USDA-FNS requirements and ensure that automated processes within RAPIDS continue to comport with federal requirements for ADP systems. To our knowledge, the auditors neither utilized that tool to guide their work nor requested verification from the State that the SIRT had been completed and previously employed. To support this response, management advocates a review of the SIRT submitted to FNS on October 26, 2023 in preparation for the go-live stage of the West Virginia People’s Access to Help (WV PATH) Family Assistance pilot program; as there is no significant difference in system functionality between the Family Assistance module of WV PATH and the existing eRAPIDS system, the responses/comments/replies from both FNS and the State that are included in this version of the SIRT generally apply both to eRAPIDS and to PATH. Throughout 2023, the BFA Division of Performance and Quality Improvement continued its ongoing SNAP case reviews, as well as its efforts to report compliance with monthly requirements for expanded supervisor case reviews conducted and tracked through the Rushmore case review system, as mandated in a December 7, 2022 memorandum to supervisors and made available to the auditors last year. Furthermore, the BFA developed additional worker training, including the reinstatement of face-to-face Statewide Payment Accuracy Conferences (held throughout the summer of 2023), with the aim to ensure that client information is accurately captured in RAPIDS so the APD can perform its automated functions with integrity.

DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, COVID-19 93.777, 93.778 The DHHR is currently phasing in a new information technology system for determining eligibility, making payments, maintaining documentation, etc. The name of the new system is WVPATH (West Virginia People's Access to Help). The WVPATH system will replace the Family and Children's Tracking System (FACTS) and the Recipient Automated Payment Information Data System (RAPIDS), which are currently referenced in the finding. The WVPATH system will have additional controls and levels of review as compared with the FACTS and RAPIDS systems. Due to the timing of the phase-in process, the DHHR anticipates the finding will be resolved for the year ended June 30, 2024.

We propose to implement the following actions to ensure this doesn’t happen again. a. Audit existing patient records and patient registrations to identify missing documentation. We will start with the oldest patient files that likely started off with paper charts prior to being on the centralized electronic health record system. We will audit for: proof of IHS benefits, official identification card or other proof of identification, as well as reviewing 3rd party payor sources. For any missing items, we will be sure to request those from the patients and/or parents, if a minor child. b. Monthly - double check new registrations and have our central registration perform audits on those for completion. c. Perform immediate training with the registration and front desk team; stressing the importance of documentation. Send registration lead and primary care administrator to the Alaska Native Tribal Health Consortium ‘s Alaska Statewide Tribal Business Office Conference for Billing and Coding and Outreach and Enrollment April 2-5, 2024. Adopt any missing best practices. d. Adopt signage for patients necessary to understand that if they don’t submit the required documentation, they will be expected to pay for services provided. e. Adopt monthly registration and scheduling meetings with the front desk team to ensure the above tasks are coming along and address any known issues with acquiring documentation. f. Transfer supervision of front desk employees from the Medical Director to the newly hired, Primary Care Services Administrator. Thank you for giving us the opportunity to address and correct this important issue and improve our processes. It’s always our intent to comply with our federal programs.

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this finding. Caseworkers will be reminded of appropriate signatures needed within the application process. Training and refresher training on voice and telephonic signatures will be provided to Energy staff. Supervisors and/or Quality Assurance staff will continue to perform monthly second party reviews. Emphasis will be placed on forms requiring applicant signatures to ensure all signatures are secured and documented accordingly. Proposed Completion Date: The above procedures are currently in place and will be monitored on an ongoing basis.