Corrective Action Plans

Recommendation: The District should verify that all required components of meal applications are completed fully and accurately and that income eligibility is recalculated accurately prior to approval. Action to be taken: The District concurs with the facts of this finding and will verify that all income eligibility is recalculated accurately prior to approval.

SIGNIFICANT DEFICIENCY 2023-001 Eligibility and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Condition Four providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Comments on the Finding Recommendation The CACFP at The Russell Child Development Center, Inc. is aware of the oversight and will continue to strive to improve its review process. Action Taken: As of November 1, 2023, CACFP staff verify that the tally marks from the paper claims match the total provided. Those tally marks are then entered into My Food Program, and the total is again verified to match the paper claim. Manual claim adjustments will be saved and filed with supporting documentation, if applicable.

The College has returned the ineligible FSEOG to ED. In addition, the College has implemented a system rule in our Financial Aid Management system to prevent additional funds from disbursing after a Return to Title IV is calculated. The College continues to develop its staff and is comfortable with their abilities to prevent such findings in future years.

Recommendation: The Commission should implement processes to ensure that waiting list documentation is maintained for all tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A new procedure will be implemented immediately requiring staff to upload a printed copy of the electronic wait list application along with the move in file. The Edgewood compliance team to verify that the applicant was selected from the waitlist prior to move-in approval. Name(s) of the contact person(s) responsible for corrective action: Darcel Cox, Vice President/Compliance Planned completion date for corrective action plan: Effective Immediately, Ongoing.

Recommendation: The Commission should implement processes to ensure that fatal errors occurring during PIC/TRACS submissions are corrected in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Edgewood Management Regional Managers will review monthly TRACs reports to ensure TRACs errors are addressed immediately. The HOC Compliance Team will monitor the Secure Portal monthly and follow up with the Edgewood team for any fatal errors not addressed. Name(s) of the contact person(s) responsible for corrective action: Darcel Cox, Vice President/Compliance Planned completion date for corrective action plan: Effective Immediately, Ongoing.

Recommendation: The Commission should implement processes to ensure that all proper documentation is being maintained during the recertification process for every client. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HOCs third party management agent, Edgewood Management, Regional Managers will review move in files and annual recertifications during monthly inspections of the property. In addition, Edgewood will ensure that the Regional Compliance Managers are spot checking and reviewing files throughout the year. The HOC compliance team will continue to monitor as part of the site inspections. Name(s) of the contact person(s) responsible for corrective action: Darcel Cox, Vice President/Compliance Planned completion date for corrective action plan: Effective Immediately, Ongoing.

Oversight Agency for Audit, Morse Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended March 31, 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: April 1, 2022 through March 31, 2023 The finding from the March 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2023-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that initial eligibility procedures are performed in a timely manner and that the corresponding documentation is maintained. Action Taken: The former community manager did not run an EIV timely as per HUD guidelines. We have provided staff with additional HUD training and we have set up automatic alerts to remind managers to pull the 90 day EIV Income Report based on individual tenant move in dates. If the audit Oversight Agency has questions regarding these plans, please call Christine Harris at 954-835- 9200. Sincerely yours, Christine Harris Accounting Manager

FINDING No. 2023-002: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Rental Housing Projects, ALN 14.155 Recommendation: The Project should implement procedures to ensure that tenant eligibility is verified, tenant files are properly maintained, and tenant signatures are obtained in a timely manner. Action Taken: The Compliance Department is in the process of implementing a plan that both move in and recertification tenant files will be reviewed by Compliance for accuracy. This will ensure files will have the proper forms and income is verified. Additional training will be provided to the staff in reference to eligibility requirements to prevent these errors moving forward. If the Oversight Agency for Audit has questions regarding the plan, please call Christine Harris at 954-835- 9200. Sincerely yours, Christine Harris Accounting Manager

Student Financial Assistance Program Cluster – Department of Education Federal Financial Assistance Listing #84.063 Federal Pell Grant Program (PELL) P063P202209, P063P212209, P063P222209 Finding 2023-003 – Eligibility – Material Weakness Finding Summary: Two instances identified in which the student was eligible to receive Federal Pell assistance but was not awarded the assistance. Responsible Individuals: Lauren Svanda, Director of Financial Aid Corrective Action Plan: Partake in additional training in the awarding of summer PELL. Update procedures on how information is communicated between the Registrar’s Office and Financial Aid to improve awareness of summer reporting and grade change updates. Recondition the reporting process to improve accuracy of delivered information. Anticipated Completion Date: January 1st, 2024

Finding 2023-005– Student Financial Assistance Cluster Internal Control over Compliance Condition City Colleges did not have sufficient documentation that internal controls were in place and operating effectively relative to the following areas: • Allowable Activities: For each of the seven campuses, City Colleges did not have sufficient supporting evidence that review controls were performed over the transfer, carryforward, carryback, and administrative cost calculations in the Fiscal Operations Report and Application to Participate (FISAP) for award year July 1, 2021 through June 30, 2022 submitted during fiscal year 2023. • Reporting: For each of the seven campuses, City Colleges did not have sufficient supporting evidence that secondary review controls were performed over FISAP data for award year July 1, 2021 through June 30, 2022 submitted during fiscal year 2023. Cause City Colleges did not formally document the additional reviews and approvals over the department’s review of the FISAP. Corrective Action Taken or Planned Financial Aid will develop and document a review/approval process that will detail accurate reporting, secondary reviews, and review/approval of FISAP submissions and completions. Contact Person: Tiffany Morrison, Associate Vice Chancellor, Financial Aid Anticipated Completion Date: December 31, 2023

Management agrees with the auditors’ finding. Federal Pell Grant funds are entitlement funds and cannot be returned. The student in question also worked the hours in which Federal Work Study funds were awarded. Going forward, the School has made changes to the provisions of the institutional scholarship to avoid overawards. All state and federal aid and endowed scholarships are applied first and then the scholarship covers the remaining tuition cost. The corrective action was completed in September 2023. Contact Person Valorie Quesenberry, Financial Aid Coordinator 513-763-6659

2023-001 Incorrect Direct Loans Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2023 Condition Found During our student file testing we noted one student out of forty was disbursed the incorrect Direct Loan amount. Based on the student’s enrollment status and need this student was eligible for $1,750 in Subsidized Loans and $1,000 in Unsubsidized Loans; however, the College awarded the student $1,750 in Subsidized loans and $1,250 in Unsubsidized loans which resulted in an over award of $250 in Unsubsidized Loans. We consider this error in awarding to be an instance of noncompliance of the Eligibility Compliance Requirement. Corrective Action Plan During the audit for the year ending Jun 30, 2023, the financial aid office reviewed the finding and was able to refund the over-award of $250 in Unsub within the student’s loan period. Since the finding our Financial Aid Coordinator completed additional trainings related to the administration of Financial Aid. Within these trainings, successful completion of loan processing training was required. As of May 12, 2023, our Financial Aid Coordinator is a certified Financial Aid Administrator through the National Association of Financial Aid Administrators. Responsible Person for Corrective Action Plan Gregory Putra, Director of Financial Aid & Veterans Affairs Implementation Date of Corrective Action Plan 7/1/2023

Corrective Action Plan: The District will put procedures back in place to make sure we are using current eligibility procedures (applications) to determine student eligibility. Anticipated Corrective Action Plan Completion Date: August 15, 2023 Contact Information: For additional information regarding this finding please contact Bill Trewyn, Business Manager, at 262-741-9143.

2023-001 Sliding Fee Discount Determination Name of Contact Person: Chief Financial Officer: Gurjeet Sandhu Corrective Action: Golden Valley Health Centers will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions Proposed Completion Date: October 31, 2023

Federal Agency Name: U.S. Department of Treasury Program Name and FALN #: FALN # 21.023 COVID-19 Emergency Rental Assistance Program (ERA) Finding Summary: One homebuyer payment was allocated to ERA instead of the Homeownership Assistance Fund (HAF). Homebuyers are not eligible for assistance under ERA. Responsible Individuals: Chas Olson - Executive Director and Bridgette Loesch, SD Cares Housing Assistance Program Manager Corrective Action Plan: We have made the adjustment to the correct program once we were made aware of the issue by the auditors. We will carefully review the program sheets prior to submitting to accounting to ensure they are allocated to the correct program. Anticipated Completion Date: September 30, 2023

The operations team, under the guidance of Chief Operating and Quality Officer, will evaluate and develop a sustainable annual review process for all Chase Brexton patients qualifying for Ryan White services. This will ensure that all persons regardless of need will be evaluated annually or documented that they no longer quality for services under the Ryan White Part A program. Chase Brexton will begin the process of evaluating and developing these protocols immediately.

Finding 2023-003 Eligibility – Calculation of the Amount of Pell, Subsidized and Unsubsidized Direct Loan Assistance Awarded Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.033 – Federal Work Study Program CFDA # 84.268 – Federal Direct Student Loans CFDA # 84.007 – Federal Supplemental Educational Opportunity Grants (FSEOG) CFDA # 84.063 – Federal Pell Grant Program Finding Summary: During testing over the eligibility requirements, the following deficiencies were noted: • 2 of 60 students were not awarded the correct amount of Pell. One student was under awarded by $2,773 and one was over awarded by $862. • 7 of 60 students were not awarded the correct amount of subsidized loans. 4 students were under awarded subsidized loans based on being awarded as the wrong academic year in school; and 3 students were over awarded subsidized loans as the student did not have financial need. • 5 of 60 students were not awarded the correct amount of unsubsidized loans. All 5 of the students with errors were under awarded unsubsidized loans based on being awarded as the wrong academic year in school. Responsible Individuals: Jillaine Smith, Chief Operating Officer, Erin Drew, Facilitator of Advancement Services and Patty Pietz, Presentation Sisters Accountant. Corrective Action Plan: The College has reviewed all students impacted by the errors noted above and made corrections to the students as needed. Anticipated Completion Date: September 30, 2023

While this finding is isolated to the Wood Clinic which ended its AACO program in November 2022, we have communicated the requirement to maintain supporting award documentation to all Penn Medicine practices continuing with Ryan White programs.

The Financial Aid Director recalculated the “need” for each student in question. The Financial Aid Director agreed with the auditor’s calculations. The following corrections were made on August 8, 2023: For the first student, $2,000 of subsidized federal direct loans were reallocated to unsubsidized federal direct loans. For the second student, $382 of subsidized federal direct loans were reallocated to unsubsidized federal direct loans. For the third student, $1,649 of subsidized federal direct loans were reallocated to unsubsidized federal direct loans. For the fourth student, $1,145 of federal work study funds were returned to the Department of Education. The student had already worked for the University and earned the funds in question. He was treated as a regular employee of the University and paid with institutional funds instead of federal work study funds. Anticipated Completion Date: The corrective action was completed on August 8, 2023. Contact Person Shala LaTorraca, Director of Financial Aid 918-335-6260

The Lac Courte Oreilles Ojibwe University (LCOOU) has currently implemented an admissions procedure to guarantee that all self-identified United States (US) federally recognized American Indian/Alaska Native (AI/AN) students’ documentation of tribal enrollment is verified, collected, and secured. All students that apply to the institution who self-identify and are affiliated with a US federally recognized tribe, band or nation must provide verification of tribal enrollment to be fully admitted as an LCOOU student. If this documentation is not provided, students can still register; however, will not be included in the annual Indian student count submitted to the Bureau of Indian Education. All continuing students who have matriculated to the institution with a self-identified tribal affiliation will be reviewed to confirm that all tribal enrollment documentation is collected and securely stored. The LCOOU Registrar’s office will closely monitor student’s files throughout the academic year to make certain all files are completed.

Department of Education 2023-002 Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University review their internal control procedures over awarding, return of title IV calculations, and professional judgment and implement a formally documented review process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will make the following changes: Awarding: The following are internal controls that the University already has in place to review awards for accuracy. • Financial aid worksheet: As part of the awarding process every award year, a financial aid worksheet is created to verify that the awards input in Colleague are accurate. The worksheet is updated each time there is a change to a student’s financial aid eligibility or status. • COD report monitoring: On a weekly basis, reports are processed to determine if there are any discrepancies between what has been awarded in Colleague and what is being reported/accepted in COD. Any discrepancies found are reviewed and corrected. • Monthly loan/grant reconciliation: The monthly loan/grant reconciliation monitors for any discrepancies between what is shown as disbursed in Colleague and the disbursements that have been accepted by COD. Any discrepancies found are reviewed and corrected. • Over award report: Processed at the beginning of each term, this report details if any students are awarded beyond unmet need and/or cost of attendance. Any discrepancies found are reviewed and corrected. • Enrollment level report: Processed before the start of each term and at the end of the add/drop period, this report evaluates awarded enrollment level against actual enrolled credits. Any discrepancies found are reviewed and corrected. • Disbursement processing rules: There are rules built into the Colleague system to limit disbursement of awards when actual enrollment status does not match awarded status. Any discrepancies found are reviewed and corrected. Beyond the internal controls already in place, the University will implement the following: • Secondary review of awards: For new Financial Aid Counselors, all awards will be reviewed for the first two months to ensure accuracy and commitment to proper training. Additionally, based on current staffing levels, a random selection of 10% of all awarded students will be reviewed to evaluate for awarding accuracy. • Grade level review: After the 10th day of each term, a review will be performed to compare the current class standing of each student to the grade level that was used for awarding. Any discrepancies found will be reviewed and corrected. Return to Title IV (R2T4) Calculations: The Colleague system is used to process R2T4 calculations. This system has been developed to correctly calculate the return formula based on limited information entered by the R2T4 processor. To ensure the correct information is entered, the University will implement a secondary review of all R2T4 calculations. The primary R2T4 processor will enter all required information in the R2T4 calculation screen within Colleague, and then print the screen for review by a secondary member before the return is referred for processing. The primary processor and secondary reviewer will be required to sign off on the printed calculation sheet, verifying the accuracy of the information. The items that will be included as part of the secondary review will be the date of determination, enrollment status, last date of attendance, and institutional charges. Professional Judgment: The University will implement a Professional Judgment Committee. The committee will consist of at least one Financial Aid Counselor and the Director of Financial Aid. The committee will collectively review all the documentation for each case to make a final determination. Name of the contact person responsible for corrective action: Dustin Kummrow, Director of Financial Aid Planned completion date for corrective action plan: November 1, 2023

Aggregate Loan Limits Planned Corrective Action: ·The financial aid leadership team (Director and Associate Director) will review the current awarding loan processes to determine where the deficiencies are to ensure this issue does not reoccur next year. ·The financial aid leadership team will review the setup to configure automation and minimize manual processes to catch student approach loan limits ·The financial aid team will review NSLDS when students are flagged for approaching loan limits to verify remaining eligibility. Person Responsible for Corrective Action Plan: Kary Tejeda-Executive Director of Financial Aid and Veteran Services, Elisa Fisher-Associate Director of Financial Aid Operations and Dr. Anthony Turner-Vice President of Enrollment and Marketing Anticipated Date of Completion: March 15, 2024

Plan: A second staff member will review certifications and annual certifications to ensure accuracy based on the required back up documentation. Contact: Christina Morin, Program Director. Anticipated completion date: September 28, 2023.

Views of Responsible Officials and Planned Corrective Actions: The Association will undertake review of its procedures related to FFATA reporting and will implement additional controls to ensure timely submission of FFATA sub-award reports.

2023-003 - Income Eligibility Guidelines - Contact: Sam Lehman, Director of Business Services. Completion date: June 30, 2024. The District will improve its evaluation of income eligibility for Child Nutrition Cluster program by following the income eligibility guidelines.