Corrective Action Plans

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this finding. Caseworkers will be reminded of appropriate documentation techniques and when IV-D referrals are necessary within the eligibility determination process. Supervisors and/or Quality Assurance staff will continue to perform monthly second party reviews. Emphasis will be placed on documentation and IV-D referrals to ensure compliance with NC Medicaid policy. Proposed Completion Date: The above procedures are currently in place and will be monitored on an ongoing basis.

Caseworkers are to review and verify income and deductions by policy standards. Food and Nutrition Lead workers and Supervisor will conduct second-party reviews on caseworkers. The Food and Nutrition Supervisor will go over errors found by second parties during their team's monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisor due to performance and 4 for applications workers and 3 for redeterminations workers per month. The supervisor and lead workers will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisor and/or Lead workers will conduct monthly meetings which include mini trainings on errors found in second parties. Refresher training will be held quarterly and annually for in-depth training regarding policy areas in which the Supervisor and lead workers identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest training needed to the Supervisor to ensure that policy/procedures are being implemented accordingly. The supervisor will schedule and hold a meeting each month to inform Program Administrator, Heather Hayes, of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisor and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator monthly and at quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training will be held on Food and Nutrition policy sections 340 Deductions, 310 Budgeting New/Change/Terminated Income, and 315 Special Budgeting Income on January 24, 2024.

Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. The supervisor will go over errors found by second parties during their team monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisor will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2352 on November 29, 2022. Plan was discussed on November 17, 2023 with Lead Workers Michelle Ogle and Delta Elliot on a new team procedure regarding SSI terminations. Meeting will be held on November 28, 2023 discussing new procedure and a Training will be held by December 29, 2023 regarding SSI Expartes.

Caseworkers are to review the determinations tab and policy manual to properly ensure that the case is showing correctly. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. Family and Children Medicaid Lead Workers and the Supervisors will conduct second-party reviews on caseworkers. Both Adult Medicaid and Family and Children Medicaid supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisors will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisors due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisors will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. Supervisors will schedule and hold a meeting each month to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2250 on November 29, 2022, DSS Terminial Message regarding Admin Letter 11-22 dated 12/12/2022 on COLA procedures was provided to Adult Medicaid team members on 12/12/2022. Meeting held regarding COLA income on 12/29/2022. Update meeting regarding the COLA increases will be held by December 31, 2023 when policy guidelines are provided by state. Family and Children Medicaid sections MA-3300 was held on November 30, 2022 regarding income. Meeting regarding Incorrect income will be held on by November 30, 2023.

Corrective Action: Proposed completion date: Finding 2023-005 Inaccurate Information Entry Name of contact person: Kim Grissom, Family and Children's Medicaid Supervisor, Shelia Morton, Family and Children's Medicaid Supervisor, and Vanness Taylor, Adult Medicaid Supervisor To ensure that the caseworkers do not repeat these errors, the following will happen: Adult Medicaid Documentation Templated was updated November 13, 2023. Training was held on July 6, 2023 for Recertifications for Adult Medicaid. Adult Meeting will be held on November 28, 2023. Family and Children held team meetings on November 30, 2022, January 26, 2023, and May 23, 2023. Family and Children meeting will be held by November 30th, 2023. State mandatory Training was held for all Medicaid Staff on July 25, 26, or 27, 2023 for Mastering Medicaid Policy , MAGI Recertifications and NCFAST 20020, and September 26, 27, or 28, 2023 Authorized Representatives and NCFAST 20020 Reminders. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. Family and Children Medicaid Lead Workers and the Supervisors will conduct second-party reviews on caseworkers. Both Adult Medicaid and Family and Children Medicaid supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisors will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings.

Corrective Action: Proposed completion date: Finding 2023-004 Inadequate Request for Information Name of contact person: Caseworkers are to review the determinations tab and policy manual to properly ensure that the case is showing correctly. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. The supervisor will go over errors found by second parties during their team monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly.The Supervisor will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator Staff Development Specialists and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2230 on Janaury 31, 2023, July 6, 2023 and September 28, 2023. Documentation Templates were recently updated as of November 13, 2023. Meeting regarding the cited errors will be held on November 28, 2023.

Finding 2023-002 IV-D Cooperation with Child Support Name of contact person: Corrective Action: Proposed completion date: Finding 2023-003 Inaccurate Resources Entry Name of contact person: For the Year Ended June 30, 2023 Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings July 1, 2023 Stephen McNally, Finance Director The Finance Department will attempt to make all necessary transfers of funds between Forfeiture accounts in the current period. However, this correction notification from US Treasury was not sent to the Finance department until after the reporting period in which the transaction took place. Kim Grissom, Family and Children's Medicaid Supervisor and Shelia Morton, Family and Children's Medicaid Supervisor Family and Children Medicaid Lead Workers and Supervisors will conduct second-party reviews on caseworkers. The supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisors will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisors due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisors will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisors will schedule and hold a meeting to inform the Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invites to Program Administrator, Staff Development, and Human Services Planner Evaluator, for monthly and at quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on November 30, 2022, for Family and Children Medicaid section MA- 3365. Documentation Template was last updated on November 3, 2023, which includes IVReferral reminder. Family and Children meeting will be held by November 30, 2023.

Over Award Review and Correction Action Taken – Kansas Health Science Center (KHSC) Identifying Number: 2023-001 Finding: Eligibility – Determining Federal Direct Student Loan Awards Applicable Regulation: Per 34 CFR 686.203(b)(iii), in the case of a graduate or professional student for a period of enrollment beginning on or after July 1, 2012, the total amount the student may borrow for any academic year of study under the Direct Unsubsidized Loan program may not exceed $8,500. Per 34 CFR 685.203(c)(2)(v), the additional amount that a student described in paragraph (c)(1)(i) of this section may borrow under the Direct Unsubsidized Loan Program for any academic year of study may not exceed the following: in the case of a graduate or professional student, $12,000. Finding: During testing of eligibility, 7 out of 7 students selected for testing were over awarded Unsubsidized Federal Direct Loans. KHSC improperly awarded 61 out of 61 students Unsubsidized Federal Direct Loan in excess of the maximum amount for one academic year, amounting to [$4,445] per student, for a cumulative over award of [$271,146]. Summary: Prior to the commencement of the independent audit conducted for the fiscal year ended May 31, 2023, the institution discovered that it had over awarded Unsubsidized Federal Direct Loan funds to its students. Specifically, the institution awarded additional Unsubsidized Federal Direct Loan funds based on 12-month academic calendar instead of prorating the award based on a 10-month academic calendar. This error resulted in an over award of [$4,445] per student. The institution conducted a file review and refunded all amounts owed to the Federal Student Aid programs because of the file review. The institution also informed the auditor of this error. Corrective Action Taken or Planned: Once the above noted error was discovered, the institution conducted an audit of all student aid packages for students enrolled in the 2022-2023 academic year. It was determined that 61 current students had been over awarded by a net amount of $4,445, for a total of $271,146. Findings were compiled and a plan was created to return over awarded funds and communicate the error to students. The institution also consulted with the Department of Education to confirm its revised calculation was appropriate. The institution returned the funds between July 5-July 20, 2023. Further, the institution made students whole by forgiving any student balances that would have been paid by the over award amount. Emails were sent to all impacted students on July 3, 2023 notifying them of the error. The institution also subsequently notified students that any account balance that remained based on the reversal of the over award would be forgiven. Students who received an estimate financial aid award with the incorrect figures, but who had not yet received aid, were notified of the error and provided updated award information. To ensure this does not happen again the institution has updated their internal student finance audit to include a review of all aid eligibility in conjunction with the next year’s academic calendar for each class of students. Upon any determination that future aid should be prorated, calculation(s) will be completed and reviewed with leadership before implementation. An internal review and approval process will then be enacted and documented. The institution informed RSM of this error and the corrective actions taken. Contact Person Lawrence McGhee, Associate Vice President of Financial Aid, lawrencemcghee@tcsedsystem.edu Completion Date July 20, 2023

Finding: 2023-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2024

Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name(s) of the contact person(s) responsible for corrective action: Nancy Siddens, Director of Financial Aid. Planned completion date for corrective action plan: November 1, 2023.

Pell Awards Planned Corrective Action: We have engaged an outside vendor to provide knowledgeable staff augmentation to help us improve our processes and the timeliness of verifying students’ enrollment status. Person Responsible for Corrective Action Plan: Cathy Morgan Anticipated Date of Completion: March 1, 2024

Item 2023-002 - Special Tests Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken 1. To train all staff involved with the calculation of sliding fees on the policies and procedures to ensure: ► The sliding fee guidelines document is known. ► Understanding of the methodology for calculating fees, including how family size and income are considered. ► Documentation required to support income and family size information provided by clients. This may include tax returns, pay stubs, or other relevant documents. ► To use the standardized form (checklist) to ensure all necessary information is collected and verified. 2. To perform a monthly audit review, utilizing a selected sample to identify any discrepancies and make necessary corrections in a timely manner. 3. To ensure the sliding fee scale is clearly communicated to clients. Responsible Party: Director of Patient Services/RCM Director Target Completion Date: 04/30/2024 If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Hewart Tillett, CFO at 1-314-882-1463, or email at htillett@phcenters.com.

The Office of Academic Achievement Programs will update their procedures to ensure that all appropriate documentation is maintained when making eligibility determinations for each student.

Incorrect Pell Calculations Planned Corrective Action: The University will provide oversight and review of Pell calculations on a weekly basis. Person Responsible for Corrective Action Plan: Donnie Purvis, Director of Financial Services Anticipated Date of Completion: Effective Immediately, February 15, 2024

The District will continue to enhance procedures and controls over the verification compliance requirement with adequate oversight and will identify and train additional individual(s) to ensure appropriate back-up is in place, that is also knowledgeable of its requirements. Responsible official: Cory Kaisler, Data Systems Coordinator – ckaisler@shawanoschools.org Anticipated Completion Date: June 30, 2024

The District will continue to enhance procedures and controls over the eligibility requirements with adequate oversight of both manual and electronic processes and will identify and train additional individual(s) to ensure appropriate back-up is in place, that is also knowledgeable of its requirements. Responsible official: Cory Kaisler, Data Systems Coordinator – ckaisler@shawanoschools.org Anticipated Completion Date: June 30, 2024

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: Material Weakness Condition and Context There was no evidence that the Direct Certifications were correctly and properly included in the software system, or that there was an oversight, review, or approval process over the Direct Certifications. Contact Person Responsible for Corrective Action: Lori Boyce Contact Phone Number and Email Address: 765-653-3148 lboyce@sputnam.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Food Service Director will have the Guidance Secretary check and initial that the Food Service Director has completed the Direct Certification correctly. Anticipated Completion Date: 2/2024

in 2024, the Vilalge will implement processes and conrols to ensure the completeness of underlying records and accuracy of HAP and utility allowance calculations. The Village will sample case files to help ensure compliance.

Finding 2023-003 – Child Nutrition Cluster – Special Tests and Provisions – Verification of Free and Reduced Price Applications Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: As an internal control, the Director of Business Affairs and Human Resources has reviewed the process for Verification of Free and Reduced Price Applications. We have now contracted with a Food Service Director through NIESC. They will perform the Verification of Free and Reduced Price Applications and the Director of Business Affairs & HR will review these documents for accuracy. Anticipated Completion Date: FY24 Verification of Free and Reduced Price Application Review Period

Bloomfield College and Affiliates respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 - June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-001 Student Financial Assistance Cluster – Federal Assistance Listing Numbers 84.268 & 84.063 Recommendation: The College should strengthen policies and procedures to ensure that student status transmission reports are submitted accurately to the NSLDS at least every 60 days, or more often, as determined to be appropriate. The College also should ensure that student Published Program Length Measurements are listed in years and that the Published Program Lengths are calculated in years as recommended by the NSLDS Enrollment Reporting Guide so that the Published Program Length calculation is accurate to the true length of the program for each student. Action taken in response to finding: The College has updated its policies and procedures in overseeing submissions to NSLDS by the third-party servicer “National Student Clearinghouse.” The Registrar’s office, Enterprise Information Services, and the Financial Aid office will work together to ensure that relevant information is reported accurately and timely by “NSC” in accordance with applicable regulations. Contact persons responsible for corrective action: Aylin Solu-Brandon, University Registrar, 973-655-7525 Planned completion date for corrective action plan: We implemented the corrective action in January 2024. Following a discussion with the staff about the finding, new processing procedures were promptly implemented. The College will ensure that student Published Program Length Measurements are listed in years and that the published Program Lengths are calculated in years.

Finding Number: 2023‐011 Federal Program, Assistance Listing Number and Name: ALN 14.905, United States Department of Housing and Urban Development, Lead Hazard Reduction Demonstration Grant Program Condition: Original Finding Description: Certain controls in place did not operate effectively specific to eligibility, earmarking, and reporting compliance requirements. Contact Person Responsible for Corrective Action: Julie Schneider (HRD) Anticipated Completion Date: June 2023 Planned Corrective Action: The City will review during the AFCAP process and implement additional controls and training to ensure the required review of eligibility approval is in place and all supporting documentation is stored and maintained.

Finding Number: 2023-007 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS (HOPWA) and COVID‐19 HOPWA Condition: Original Finding Description: In conjunction with eligibility testing, instances of noncompliance specific to the rental assistance calculation and distribution of benefits were identified. Contact Person Responsible for Corrective Action: Denise Fair Razo (DHD) and Angelique Tomsic (DHD) Anticipated Completion Date: June 2023 Planned Corrective Action: City of Detroit HOPWA program has a dedicated quality coordinator position. The coordinator will continue to work closely with the HOPWA program team and conduct regular file audits. The HOPWA program team has also implemented additional steps which includes the use of eligibility templates to help ensure accurate rental assistance calculations. In addition, the City will review during the AFCAP process to ensure the required process improvements and procedures are in place for accurate rental assistance calculations.

Finding Number: 2023‐003 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City did not have adequate controls in place to exercise its oversight responsibility of eligibility determinations that were performed by a contractor for the program. Contact Person Responsible for Corrective Action: Denise Fair Razo (DHD) Anticipated Completion Date: Complete May 2023 Planned Corrective Action: The City has implemented controls to ensure that the Health Department provides oversight over the contractors. In May 2023, the Health Department hired a WIC Program Director to monitor participant eligibility compliance and ensure policies and procedures are maintained and followed.

Finding Number: 2023-001 Anticipated Completion Date: May 2024 Responsible Contact Person: David Tatro, CEO Planned Corrective Action: The Organization provided 2,682 self-pay encounters to be audited for the year ended May 31, 2023. Out of the 2,682 self-pay encounters, 20 were identified for further review. Two self-pay accounts were identified with issues which resulted in this finding. The first issue was attributed to a patient inaccurately placed on a slide level, and the other patient account did not have an updated sliding fee scale application completed on file. This issue has been resolved as of November 2023 by reviewing all sliding fee scale applications for accuracy. The Organization will continue to monitor the sliding fee scale amounts applied to ensure ongoing compliance with the requirements. The Organization will review five sliding fee scale applications each week to ensure eligibility determination, billing and collection follows the Sliding Fee Discount Program. This will go through May 2024 with a reassessment at that point, based on the results of the internal review.

The University filed four quarterly HEERF reports for the year that accurately reflected the spending and accounting of federal funds. The report in question is the annual report, which, by its design (it cannot be saved prior to submission, and the only way to print it is to print a screen shot of each of the 48 pages) makes review before submission extremely difficult. There were literally hundreds of entries in this report, and there were three errors, each of which reflected information that was reported accurately in the quarterly reports posted on the University’s website. Despite the unfortunate design constraints, the University will endeavor to identify a practical way to conduct a review of the annual report before submission next spring. Anticipated Completion Date: Continuing Responsible Contact Person: Eugene L. Munin