Corrective Action Plans

The Reemployment Services and Eligibility Assessments (RESEA) policy and controls presently in place at the Department of Labor and Workforce Development (DLWD) require eligibility interviews to be conducted and eligibility review forms to be completed and signed by the participant and UI program representative. DLWD implemented a new process that allows staff to electronically obtain signatures through Simpligov, beginning June 2023. This process requires that staff obtain all necessary signatures before a RESEA claimant record is completed. Supervisors are assigned to monitor this process in order to mitigate the risk associated with missing information on any single RESEA customer registration. DLWD will monitor this process to ensure that all interviews are properly documented, and forms are signed and electronically uploaded to its electronic case management system of record for future reference. During the initial rollout of this process, there were records that didn’t migrate to the case management system of record. This issue has now been addressed through training. DLWD has also developed dashboards that will assist with monitoring data entry. Monthly reviews of RESEA data entry will be conducted to identify possible errors. These RESEA process changes that will be implemented by DLWD will ensure compliance with regulatory standards and assist with maintaining the integrity of its data management process. COMPLETION DATE/ CONTACT PERSON June 30, 2023 Baden Almonor (609) 777-1042 Baden.Almonor@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) has controls in place to only allow an FPUC payment to be made when an underlying Unemployment Insurance (UI) payment has also been processed. FPUC payments should not be issued to any claim without the underlying UI payment being made for the same week. The FPUC payments issued and noted as exceptions during eligibility testing will be reviewed independently by DLWD to determine if the payments issued were to eligible recipients or not. For the PUA exceptions noted during Eligibility testing, overall the DLWD issued PUA payments to over 680,000 claimants during the COVID-19 pandemic. DLWD had controls in place to require a COVID related reason to make the claim PUA eligible and the weekly PUA certification required claimants to choose a COVID related reason for why they were out of work before they could get paid. The PUA payments in question will be reviewed independently by the DLWD to determine if the payments issued under PUA were appropriate or if they should have been paid instead under the regular UI program. DLWD corrective actions related to FPUC and PUA payments were fully implemented as of September 2023. COMPLETION DATE/ CONTACT PERSON September 2023 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

Recommendation: The design of the current controls should be reviewed to ensure tenant files are accurate, complete, and orderly and include a checklist of required documentation and retention guidelines. Procedures should also be established to ensure that the Form 50059 is completed timely and properly executed. The documentation in the files should support the data used in preparing the Form 50059 and calculating the tenant’s share of the rent. Action Taken: Management has started the process of reviewing, revising, streamlining and educating all staff on the HUD guidelines related to tenant file documentation requirements and proper completion of the Form 50059, including the documentation required to support the rent calculations.

Recommendation: The design of the current controls should be reviewed to ensure tenant files are accurate, complete, and orderly and include a checklist of required documentation and retention guidelines. Procedures should also be established to ensure that the Form 50059 is completed timely and properly executed. The documentation in the files should support the data used in preparing the Form 50059 and calculating the tenant’s share of the rent. Action Taken: Management has started the process of reviewing, revising, streamlining and educating all staff on the HUD guidelines related to tenant file documentation requirements and proper completion of the Form 50059, including the documentation required to support the rent calculations.

Recommendation: The design of the current controls should be reviewed to ensure tenant files are accurate, complete, and orderly and include a checklist of required documentation and retention guidelines. Procedures should also be established to ensure that the Form 50059 is completed timely and properly executed. The documentation in the files should support the data used in preparing the Form 50059 and calculating the tenant’s share of the rent. Action Taken: Management has started the process of reviewing, revising, streamlining and educating all staff on the HUD guidelines related to tenant file documentation requirements and proper completion of the Form 50059, including the documentation required to support the rent calculations.

Finding 2023-002 - U.S. Department of Education (USD), Title IV Student Financial Aid Programs (material weakness): We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: (a) The College did not reconcile the following programs between the Office of Financial Aid and the Business Office. Per 34 CFR 685.300(b)(5). i. Federal Pell Grant Program ii. Federal Direct Student Loans iii. Federal SEOG (b) The Office of Financial Aid submitted unreconciled expenditures within the Fiscal Operations Report and Application to Participate (FISAP) for the programs below: i. Federal Pell Grant Program ii. Federal Work Study (FWS) Program (c) One (1) out of 6 students tested for withdrawals and the return of Title IV funds did not have their Title IV program funds returned within the 45-day requirement. HEA, Section 484B & 34 CFR 668.22. (d) One (1) out of 60 students had a credit balance on their account created by Title IV program funds longer than 14 days. 34 CFR 668.164(h)(1). (e) One (1) out of 60 students tested did not make satisfactory academic progress (SAP) for the academic year. The College did not provide supporting documentation for successful appeals and allowed the students to receive Title IV funding. 34 CFR 668.34. Questioned cost for this finding is: $6,198. (f) Five (5) out of 60 students tested did not have high school/GED to prove eligibility for the program they were enrolled within the College. HEA Section 484(d) and 34 CFR 668.32. Questioned cost for this finding is $41,443. (g) Four (4) out of 60 students tested were accepted as transfer students but did not have official (transfer) transcripts to prove eligibility for the program they were enrolled within the College. HEA Section 484(d) and 34 CFR 668.32. Questioned cost for this finding is $40,383. The College should implement corrective actions to ensure that the above findings are resolved and do not recur in future periods. Moreover, internal controls over compliance with federal program regulations should be revisited to ensure adequate supervisory controls, quality assurance reviews of processes, and policies and procedures are being updated and adhered to for compliance purposes. Corrective Actions – Philander Smith College concurs with this finding, and the following action has been taken. Philander Smith College improved the efficiency of reconciling between the Financial Aid Office and COD by standardizing procedures. Staff-wide calendar events have been set to standardize routine processing of reconciliation data. Direct Loan SAS files are imported into the COD "DL SAS Disb On Demand Reader" tool and converted to Microsoft Excel files. Pell SAS/ Reconciliation files are imported into the COD "Pell Recon Reader" tool and converted to Microsoft Excel files. The SAS files and financial aid management system (FAMS) files are imported into Microsoft Access tables and Microsoft Access queries are run to determine discrepancies between SAS file data and FAMS data. This standardization provides an efficient procedure for staff members to follow. Staff have been cross trained to reduce processing delays. This system, incorporating efficient technology, calendar reminders, and cross training has improved the efficiency of reconciliation activities. Financial Aid staff coordinate with Business Office staff for notification after the Financial Aid to COD reconciliation is complete. Financial Aid staff are updating the policies for SAP supporting documentation submission that require students to submit documents via the student financial aid portal where documents will be securely stored and backed up within the College servers. Financial Aid staff are updating processes among Financial Aid, the Registrar's Office, and Academic Affairs to strengthen timely identification of both official and unofficial withdrawals for timely Return to Title IV Funds processing. Finally, during the pandemic, the College experienced some difficulties obtaining official high school transcripts due to school closings. The College is continuing to work to review files to ensure this is fully addressed.

HCSO agrees with the audit finding regarding our lack of documentation on criminal convictions for inmates claimed as qualifying for our 2020 SCAAP submission. This audit has helped us recognize that criminal justice databases housing conviction information are dynamic and ever changing, which makes current verification of historical data very difficult. For this reason it’s very important to maintain detailed documentation of the information used to identify qualifying convictions. For future SCAAP submissions our plan is to take screenshots from the criminal justice databases used to verify convictions and maintain that documentation in files that are routinely backed up. In addition, we will ensure this documentation is reviewed by management to ensure adequacy based on SCAAP requirements.

Management’s Response: The Purchase Referred Care (PRC) Team of the PRC Supervisor and PRC staff are responsible for implementing proper processes and procedures for ensuring proper eligibility verification and documentation prior to payment of PRC claims. PRC staff attended a PRC training regarding eligibility verification on August 2-3, 2023, conducted Indian Health Service. Since, staff have increased their knowledge of eligibility requirements. Estimated Completion Date: September 30, 2024 Responsible Position: Chief Financial Officer, Purchase Referred Care (PRC) Supervisor, and Prior Authorization and Claims Technician

Federal Award Findings and Questions Costs Corrective Action Plan Year Ended August 31, 2023 Finding No. 2023-001: Inaccurate Enrollment Reporting CFDA Numbers: Various Program: Student Financial Assistance Cluster Corrective Action: Students will be required to request special permission to re-enroll, thus ensuring that their graduation is reported before any additional enrollment or withdrawal. Additionally, a thorough assessment of the management review process will be performed to identify areas that will help ensure the accurate submission of data to the NSLDS. We anticipate revised processes in the Spring of 2024. Contact Person: Jaci Casazza Expected Implementation: April 30, 2024

When SAP is run in the spring, students will be notified of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.

The North Providence Housing Authority will be creating a check list which will include Income Verification as part of the participants file to be used for examinations, and reexaminations of income. This check list will be completed by the Housing Authority staff member, signed, and dated, showing that all required documents have been obtained and used for a successful processing of the tenants rent. Additionally, due to being a small housing authority, with only one HCV staff member, we have hired an HCV Assistant to help the HCV Coordinator in obtaining all information needed to comply with HUD’s regulations. Planned Implementation Date of Corrective Action: January 1, 2024 Planned Implementation Date of Corrective Action: Eileen Reyes/Michael McMahon/ Cheryl Lonardo

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all files are accurate and follow all local, state and federal compliance guidelines. An Independent entity has also been hired to review all current files and all corrections have been made. Planned Completion Date for CAP April 30, 2024

Management was made aware of instances where timely recertifications were not being performed. To ensure these situations do not continue to occur, Management made the following improvements to their internal processes: 1. Recertification reminder letters are being consistently sent to residents at 120, 90, 60, and 30 days prior to recertification date. 2. Incentives were put in place to encourage site associates to complete recertification tasks timely including staff lunches. After working hour sessions are also being held. 3. Third party consultants are being utilized when necessary. 4. Site associates are going door to door and enlisting help from Resident Services teams to engage residents. Management is aware of the required use of the EIV system reports. Management believes the instance in which noncompliance occurred was due to lack of training and experience of certain individuals and has further addressed this condition by implementing additional training for all associates.

Finding 2023-003: Material Weakness in Internal Control over Compliance – Eligibility. Name of Contact Person: Phyllis Wimberley, Deputy Director. Corrective Action: The Heritage program will create and implement a checklist of required documentation to ensure all participants are eligible to participate in the program. Proposed Completion Date: June 2024

Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages and there was no documentation in their records. Management has reinforced the policy requiring documentation of beneficiary status and the Patient Access Manager has developed a registration performance improvement plan. Anticipated Completion Date: June 30, 2024.

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFRF funds. Proposed Completion Date: Immediately.

Finding: 2023-001 – Compliance and Controls over Compliance – Eligibility Supportive Housing for Persons with Disabilities (Section 811), CFDA No. 14.181 Material Weakness & Noncompliance In 2023, Home Share did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual making the initial determination or annual recertification. Actions Taken or Planned: Management agrees with this finding. Beginning in September 2023, management has changed the contractor they work with for the eligibility determination process. Management is working with the contractor to include a second individual in this process so that there will be a review performed by someone other than the individual making the initial determination or annual recertification. Contact Persons: Robert Pickering, Chief Financial Officer

2023-007 - Special Tests – Internal Control and Compliance over Housing Quality Standards Inspections (Material Weakness) Condition: We found five (5) instances out of 9 in which the City did not conduct the HQS failed inspection follow up in a timely manner. We also noted three (3) instances out of 40 samples for eligibility testing has HQS inspections that are over a year apart, which shows that the City did not conduct the HQS biennial inspection in a timely manner. Management concurs. Corrective Actions: Management has directed staff to abide by the PHA policy and HUD regulations for the HQS inspection process. Management will continue to enforce HUD regulations and the use of the PHA’s administrative plan to ensure staff will conduct the HQS biennial inspection in a timely manner. Name of Responsible Person: Ron Garcia, Director of Community Development Imelda Delgado, Housing Manager Projected Implementation Date: Immediately implemented.

Corrective Action Taken or Planned: Child Nutrition, Inc. is in contact with the Virginia Department of Health (VDH) awaiting official written notification of the requirement that the three visits per year take place within the fiscal year. Immediately, for the current fiscal year (FY2024), the Executive Director analyzed the Review History Report for all active providers to ensure compliance within the current fiscal year. The Executive Director drafted and finalized Reports Required to ensure Monitor Compliance within Fiscal Year (October – September) on March 11, 2024 and trained all Organization staff on March 14, 2024. Reports Required to ensure Monitor Compliance within Fiscal Year (October – September) • Review History Report: Executive Director and Field Specialist Manager are to review quarterly and communicate with Field Specialist if there are any discrepancies or required action. Field Specialists are required to run report for their case load and review quarterly. • Provider Due Reviews: Executive Director and Field Specialist Manager are to review monthly and communicate with Field Specialist if there are any discrepancies or required action. Field Specialists are required to run report for their case load and review monthly • Providers Not Trained: Executive Director and Field Specialist Manager are to review monthly and communicate with Field Specialist if there are any discrepancies or required action. Field Specialists are required to run report for their case load and review monthly • Sponsor Review Worksheet – Past Review History Executive Director and Program Manager will review the past review history on the Sponsor Review Worksheet as reports are received and entered into Minute Menu. The Program Manager will update Review# in Minute Menu. The Executive Director will edit next review due date as necessary. Name of Contact Person: Elizabeth Wittusen, Executive Director Phone Number of Contact Person: (540) 347-3767 Projected Completion Date: March 2024

Recommendation: We recommend the Authority review their process and internal controls for new tenants to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Under the leadership of the newly appointed Executive Director, HAPGC will develop and implement to internal control policies to ensure waiting list selection notices are properly documented in client files, and voucher forms and HAP contracts are appropriately executed. Additional efforts will be placed on increasing the number internal quality control reviews performed of re-examination transactions to ensure adherence to the above listed compliance items. Name(s) of the contact person(s) responsible for corrective action: Jessica Anderson-Preston Planned completion date for corrective action plan: November 30, 2024.

Recommendation: We recommend the Authority review their process and internal controls over eligibility to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Under the leadership of the newly appointed Executive Director, HAPGC will assess the overall operations of the Housing Choice Voucher Program. The assessment will include the following: a review of the overall effectiveness of the current voucher department management, a review and comprehensive update of the Administrative Plan; comprehensive staff training on the proper implementation and correct calculation and documentation of HUD program eligibility requirements including but not limited to income, assets, and expenses related to deductions from annual income and other factors that affect the determination of adjusted income. HAPGC will also implement policies to ensure the timely completion of annual re-examinations, and the proper retainage of supporting documentation for re-examination actions. Additional efforts will be placed on increasing the number internal quality control reviews performed of re-examination transactions to ensure adherence to the above listed compliance items. Efforts will also be place on increasing staffing levels and decreasing the amount of time required to fill vacant positions. Name(s) of the contact person(s) responsible for corrective action: Jessica Anderson-Preston Planned completion date for corrective action plan: November 30, 2024.

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023

Individuals Responsible for Corrective Action Plan: Daniel Hall (Interim Vice President for Finance and Administration) Libby Shull, CPA (Controller) April Baur (Director of Student Financial Aid) Kevin Crider (Chief Information Officer) Vicky Wilson (Registrar) Finding 2023-002 For 2 of 2 mid-year transfer students tested, the school did not actively add these students to the NSLDS transfer monitoring list. Corrective Action Plan: While the college experienced significant turnover in its staffing in fiscal years 2021 and 2022, the college has historically reviewed the NSLDS history of transfer students to ensure they were not enrolled or receiving a disbursement for the current term at another institution. Any student that showed a pending disbursement on COD would be notified to inform their previous college and request the pending disbursement be removed. Starting in the fall 2023, the transfer monitoring tool was utilized along with reviewing NSLDS history.

We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: a. Two (2) out of 21 students did not complete exit counseling requirements upon graduating or dropping below half-time status. 34 CFR 685.304(b)(1) b. One (1) out of 21 students was awarded Federal Direct Loans at less than half-time status. 34 CFR 685.200 (a)(1)(i). Attributable questioned cost: $3,000 c. Documentation to support the Center’s reconciliation of the Federal Direct Loan program between Common Origination and Disbursement (COD) and the Office of Financial aid was not available. 34 CFR 685.300(b)(5) d. Documentation to support the Center’s reconciliation of the Federal Work-Study program was not available. 34 CFR Part 668 Subpart L e. One (1) out of 21 students did not have timely or accurate enrollment reporting to the National Student Loan Data System (NSLDS). 34 CFR685.309(b) f. Documentation to conduct Federal Work-Study compliance testing was not provided. 34 CFR Part 675 g. Documentation to support testing for withdrawals and the return of Title IV funds compliance was not provided. HEA Section 484B & 34 CFR 668.22 h. Documentation to support credit balance (student refund) testing was not provided. 34 CFR 668.164(h)(1) i. Two (2) out of 21 students were paid Federal Direct Loans and did not make satisfactory academic progress (SAP) for the academic year. Additionally, the school did not provide updated documents supporting successful appeals. 34 CFR 668.34. Attributable questioned cost: $30,730 j. One (1) out of 21 students did not have an undergraduate transcript to prove eligibility for the program they were enrolled within the institution. HEA Section 484(d) and 34 CFR 668.32. Attributable questioned cost: $20,500. Auditor's Recommendation – The Center should implement corrective actions to ensure that the above findings are resolved and do not recur in future periods. Moreover, internal controls over compliance with federal program regulations should be revisited to ensure adequate supervisory controls, quality assurance reviews of compliance steps, technical training of staff, and adequate procedures are being followed for compliance purposes. View of Responsible Officials – Management agrees.

March 27, 2024 2023-002: Material Weakness in Internal Control/Material Noncompliance- Eligibility Condition: The Consortium did not provide documentation of eligibility for each participant selected for testing. Corrective Action: We agree with the finding. The consortium recognizes the importance of having support documentation for all eligibility determinations. During COVID-19 staff were allowed to work from home, as a result two staff were not following document saving protocol and saved vital documentation on their local drive (desktop). Upon the transition back into the office, those individuals did not follow protocol and ensure all files were backed up/saved to the networked database. Once of the individuals no longer worked for MWSE and the other employee as well as their manager both were made aware of the issue. After further conversations with the manager, management was assured this will not happen again. A process for spot checking and compliance sign-off by managers has been implemented to work to ensure this issue does not arise again. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: Completed January 2024 Respectfully, Shamar Herron