Corrective Action Plans

Identifying Number: 2023-003: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: For one student out of 61 students tested, an incorrect amount of subsidized and unsubsidized loan was awarded. Corrective Action Taken or Planned: STC Financial Aid Office will request a list of Build Dakota students and estimated scholarship amounts at the beginning of the academic year. This information will be added into the student’s financial aid packaging formula to review for potential changes needed in federal aid awards. Once the Business Office has completed applying Build Dakota funds for the term, the information will be shared with the Financial Aid Office to make adjustments to the original estimates used. Contact person: Micah Hansen, Director of Financial Aid, Southeast Technical College Status of finding – The above corrective actions will be implemented beginning July 1, 2024.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 26, 2024 regarding a reportable audit finding related to inadequate internal controls over eligibility determinations. LDH appreciates the opportunity to provide this response to your office's findings. Finding: Inadequate Internal Controls over Eligibility Determinations. Recommendation: LDH should ensure its employees follow procedure relating to eligibility determinations and redeterminations in the Medicaid and CHIP programs to ensure the case records support the eligibility decisions. LDH Response: LDH partially concurs with LLA's finding of inadequate controls over eligibility determinations. For the one noted Medicaid error of failing to discontinue coverage for a recipient who moved of out of state, LDH concurs. The LDH staff member who received the reported out of state address noted in the case record that coverage was already terminated and no further action was necessary when in fact it was not terminated at the time. For the one noted Medicaid error of not performing all required eligibility determinations before enrolling the recipient, LDH concurs. The eligibility determination system approved coverage for the recipient based on self-attestation of resources prior to checking the electronic data sources for verification. For the one noted Medicaid error of not perform all required eligibility determinations before transitioning the recipient, LDH concurs. In transitioning the recipient from a program without a resource test to one with a resource test based on a change in circumstance, LDH used existing resource information in the case record without requesting or checking for any new information. For the fourteen noted Medicaid errors of renewals not performed, LDH does not concur. When possible, LDH attempted to perform an ex parte renewal per federal guidelines. If an ex parte renewal could not be completed to extend benefits, a "standard" renewal is required which involves mailing a renewal form to the recipients to complete and return. During the public health emergency (PHE), LDH was operating under a March 25, 2020 CMS approved waiver for certain flexibilities in meeting the timeliness of Medicaid renewals. LDH used the flexibility to suspend processing of standard renewals. Audit staff were informed the noted cases would have needed a standard renewal and therefore not processed per the waiver. For the one noted CHIP error of not discontinuing coverage on a recipient that was invalidly enrolled prior to the start of the PHE, LDH does not concur. The recipient was validly enrolled. LDH staff did not timely act on a task to terminate coverage for this beneficiary prior to the beginning of the PHE in March 2020. Under the continuous eligibility provision of the FFCRA of 2020, a state could not terminate individuals from Medicaid if such individuals were enrolled in the program as of the date of the beginning of the emergency period, unless the individual voluntarily terminates eligibility or is no longer a resident of the state. No exceptions were noted for delays in taking negative action, therefore, out of an abundance of caution to not jeopardize the entirety of enhanced federal funding for keeping recipients enrolled during the PHE, LDH reinstated the coverage. For the one noted CHIP error for not discontinuing coverage on a recipient who became ineligible for a separate CHIP program, LDH concurs. The recipient was covered under the CHIP conception to birth option and coverage should have been terminated when her pregnancy terminated. She was inadvertently reinstated for coverage by the eligibility system. For the thirteen noted CHIP errors of not following policies and procedures regarding documentation of renewals, LDH does not concur. When possible, LDH attempted to perform an ex parte renewal per federal guidelines. If an ex parte renewal could not be completed to extend benefits, a "standard” renewal is required which involves mailing a renewal form to the recipients to complete and return. During the PHE, LDH was operating under a March 25, 2020 CMS approved waiver for certain flexibilities in meeting the timeliness of Medicaid renewals. LDH used the flexibility to suspend processing of standard renewals. Audit staff were informed the noted cases would have needed a standard renewal and therefore not processed per the waiver. As for the performance audit report issued in August 2023, the LDH formal response dated August 10, 2023 addressed the concerns that were noted at that time. Corrective Actions: 1. For the out of state finding in this audit and the August 2023 performance audit report, the LDH formal response dated August 10, 2023 addressed this issue. 2. LDH will make changes to the Medicaid eligibility system to ensure resources are re-verified when recipients transition from programs without a resource test to those that require a resource test. LDH has already implemented changes effective June 2023 to automate checking of electronic data sources for verification of resources as part of the recipient's annual renewal. 3. By the end of the PHE Unwind process, LDH will have completed a renewal and/or closed any separate CHIP cases that inadvertently remained open during the PHE and are no longer eligible for coverage. 4. LDH did adhere to regulations, guidance, and/or approved waivers in processing or suspending renewals and transitioning recipients to other coverage during the PHE. LDH continues to firmly believe the "case record" contemplated in CFR 435.912(f) includes all aspects of data repositories or system actions in the case, along with text fields in the case notes and the documents in the LDH document management system. In accordance with 42 CFR 433.112(b) and 45 CFR 164.312(b), LaMEDS logs system activity and enables the State to examine and document system actions. You may contact Kimberly Sullivan, Interim Medicaid Executive Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Rhett Decoteau, Medicaid Section Chief at (225) 342-9044 or via email at Rhett.Decoteau@la.gov with any questions about this matter.

Dear Mr. Waguespack: The Division of Administration, Louisiana Office of Community Development (LOCD) is submitting the following in response to the audit finding titled "Restore Louisiana Homeowner Assistance Program Awards Identified for Grant Recovery." LOCD acknowledges the LLA finding of "Restore Homeowner awards identified for Grant Recovery." In response to the 2016 Floods, the LOCD created the Restore Louisiana Homeowner Assistance Program (HAP). Grant recapture procedures were established from the beginning of the program and have been implemented timely. It is impossible to administer a disaster recovery program that will not have certain files requiring grant recapture during the life of the program. The Restore Program requires a duplication of benefits check on all files prior to grant execution. For example, it is always possible an applicant may receive additional funding, e.g., insurance proceeds that are deemed duplicative by law. The Restore Program has controls in place to capture these amounts in the grants management system, subrogation agreements executed with each applicant, and recapture procedures to recover the funds. From the very beginning, the Restore Program was created to minimize the potential of applicants' ending up in recapture. As a result, the state has issued over $670 million to 17,262 homeowners of which 86, or 0.50% are in recapture. As the Restore Homeowner Program comes to a close, LOCD does not anticipate further files requiring recapture of funds. LOCD agrees with the observation of 10 files with a potential grant recapture as a necessary ongoing activity for the Program. LOCD will continue to follow the established recapture procedures for these grant awards to ensure ultimate compliance, however, this is not a corrective action, but rather the continued implementation of program protocols. The contact person responsible for these ongoing compliance activities is Ginger Moses, OCD Chief Operating Officer. The anticipated completion date for activities addressing this finding will coincide with the closing of the Restore Louisiana program. If you have questions or require additional information, please feel free to contact me.

Dear Mr. Waguespack : The Division of Administration, Louisiana Office of Community Development (OCD) submits the following in response to the audit finding titled "Inadequate Recovery of Small Rental Property Program Loans." The Small Rental Property Program (SRPP) has two tiers of compliance obligations. The federal compliance requirements are for the CDBG funds issued to a borrower to meet a National Objective and be expended on an Eligible Activity. On top of the federal requirements, the State has its own program requirements. Upon the initial placement of an eligible tenant in a habitable unit at a restricted rent amount, the U.S. Department of Housing and Urban Development (HUD) requirements have been satisfied. Most of the matters made the subject of your report deal with the borrower's non-compliance with the State's program rules, not the HUD requirements. OCD has allocated approximately $653 million to the SRPP program to fund approximately 4,500 applicants and we maintain an ongoing monitoring process to promote compliance and continued availability of affordable housing. Consistent with the program's mission of preserving and expanding much needed affordable housing, OCD's primary focus for the SRPP is to assist property owners in achieving and maintaining compliance, i.e., creating and continuing affordable housing opportunities, as opposed to foreclosure and/or recapture of funds, and are, therefore, not subject to recapture by HUD. In summary, as of June 30, 2023, the LLA reports that 814 applicant files have been identified as noncompliant. Of these, 166 files have been determined to be uncollectible, leaving 648 files that are actively being addressed. OCD's compliance and repayment efforts relating to the state imposed continuing requirements of the program are ongoing. The optimal outcome of these efforts is the continued availability of affordable housing through compliance. In June 2016, OCD, working with the Louisiana Housing Corporation (LHC) and HUD, identified 397 SRPP borrowers that did not meet a National Objective. Immediately thereafter, OCD's Legal Section and LHC program staff began communicating with non-compliant borrowers and evaluating proposed workouts. OCD sent default letters to and initiated recapture efforts on all borrowers. Each file is processed with a goal of either achieving compliance, securing repayment, or identifying another viable workout plan. As of June 30, 2023, of the 397 files identified, 83 borrowers have become compliant, 20 have either partially or fully repaid their loans, 18 borrowers have transferred their housing obligations to other compliant properties and 166 have been determined uncollectable for various reasons. As noted in the audit, OCD continues to seek technical assistance regarding the enforcement of mortgages through the judicial foreclosure/public auction process. In conclusion, OCD will continue the efforts to recover those loans determined to be ineligible in accordance with policies and procedures that are acceptable to HUD. Concurrently, OCD will also continue to assist rental property owners to become compliant and to resolve any program compliance issues, thus increasing available affordable rental housing and reducing or eliminating the need to recapture funds from rental property owners, where appropriate. The contact person responsible for the corrective action is Ginger Moses, OCD Chief Operating Officer. Once approved by HUD, the anticipated completion date for this corrective action plan will coincide with the closing of the SRPP program. If you have questions or require additional information, please feel free to contact me.

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Public Health Award No. and Year: 1946001347 A7, 2022/2023 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County agrees that eligibility determinations and redeterminations including obtaining documentation and verifications should be performed annually to determine if individuals are eligible in accordance with the compliance requirements of the programs. There are overdue redeterminations in our system for a myriad of reasons related to increasing number of IHSS cases due to Medi-Cal expansion and increasing community need for IHSS services, limited Social Worker staffing due to budget restrictions, uncovered IHSS caseloads related to Social Worker job transition or leave; and more complexity of clients requiring case management during the year and additional fair hearings. Of the 36 instances out of the 60 sampled, two of the cases sampled were Intercounty Transfer (ICT) cases where the referring county sent us these overdue reassessments. According to ICT policy and practice standards, we evaluated these clients timely. These cases should be removed from the findings. Currently, of the remaining 34 cases, 2 case were terminated due to death; 15 cases are current, meaning the reassessment has been completed within the last 12 months; 9 cases have been completed since the September 2023 audit, 7 cases have been assigned to Social Workers to be seen in the next 30 days. One client case is in process of authorization. In regards, to the two missing forms, these forms have been obtained to complete the clients’ file. To address the Social Worker staffing issue and rising caseloads, we do have pending County budget requests for additional Social Worker staff. We have two Extra Help Social Worker vacancies which have been difficult to fill over the last 18 months. For about 6 months, we filled an Extra Help Social Worker who transferred to a regular County position. We participate in State level discussions related to advocacy, budget requests for IHSS administrative funding and related issues. Responsible Individual(s): Gwendolyn Gill, Health Services Administrator Bela Matyas, Chief Deputy Director Anticipated Completion Date: July 1, 2024

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2022/2023 Compliance Requirement: Allowable Costs, Eligibility, and Special Tests and Provisions Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County has policies and procedures as well as systematic processes set up to ensure the required collection and documentation of the applicant’s intent to cooperate with child support. It is Solano County’s policy that the Child Support Questionnaire and Notice and Agreements be processed which require workers to: • Conduct an interview either via telephone, or in-person with the applicant, print the forms, and document the County Use Section which requires worker’s signature and date. • Mail the form to the applicant for a wet signature or collect the signature via electronic means. • Upon return, review the CW2.1 form(s) for completeness. • Initiate the required case action(s) based upon information provided on the forms. Solano County has a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent this error in the future: • The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the pertinent CalWORKs Eligibility Handbook sections with verbiage to emphasize the following: o The requirement to review and collect the information needed to complete the notice and agreement (form CW2.1) for child, spousal, and medical support from the applicant. o That the case be authorized according to program rules only after required forms are received by the county, reviewed to ensure that the case is updated with the correct information, documented in the case journal, and the form(s) scanned into the document imaging system. o Highlight these requirements when training this topic. • The CalWORKs Program Specialist will discuss the findings and requirement in the following ways: o Monthly Program Support Forum conducted with managers, supervisors, and lead workers. o Issue a reminder to all staff. o Written material will be published in the Monthly Program Support Newsletter to all staff. Responsible Individual(s): Daniel Horel, Employment and Eligibility Services Manager Thomas West, Employment and Eligibility Services Manager Diana Hernandez, Employment and Eligibility Services Manager Anticipated Completion Date: May 31, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. The PHA should establish and maintain policies for the selection of tenants from the waiting list. As documented in the CMR, the PHA did not properly maintain its waiting list. In addition, the PHA is required to obtain an executed General Depository Agreement for all bank accounts. Tenants were selected and traced to the waiting list. However, as documented in the CMR, the waiting list did not include applicants that had been ineligible when they originally applied. We also were not provided with an executed General Depository Agreement. Due to the change in management, some bank accounts have not been able to update the authorized signers on the accounts. Auditor’s Recommendation: The Authority should update its waiting list requirements and ensure that applicants are selected in the proper order. The PHA should obtain the required General Depository Agreement and make sure that current management and board members have access to all bank accounts. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent, safe, and affordable housing to low-income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family’s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following: f. As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility.g. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent.h. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. i. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies.j. Re-examine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary.We selected twenty public housing tenant files for testing, but the Authority was not able to locate one of the requested files. It appears that the utility allowances had not been reviewed during the fiscal year as required by HUD standards. Auditor’s Recommendation: All files should be maintained and available for review. Utility allowances should be studied to determine if a change should be made. Grantee Response: We will comply with the auditor’s recommendation. We are currently making changes related to our response to the CMR. We have completed our utility allowance study and implemented the new allowance amounts. Anticipated Completion Date: June 30, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent, safe, and affordable housing to low-income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family’s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following:a. As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. e. Re-examine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary.Testing of ten HCV family files, it appeared the housing assistance payments were being computed correctly based on documentation in the file. However, and based on results from the CMR, it appears that incorrect payment standards and outdated utility allowance forms were being used in the computations. Auditor’s Recommendation: A thorough review of tenant files should be performed for the purpose of eliminating the deficiencies. Utility allowances should be studied and determined if a change should be made. Payment standards should be approved and consistently applied. Grantee Response: We will comply with the auditor’s recommendation. We are currently making changes related to our response to the CMR. We have completed our utility allowance study and implemented the new allowance amounts. Anticipated Completion Date: June 30, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. As such, HUD requires the Authority to comply with special tests and provisions relating to its Housing Choice Voucher program. The Authority must inspect the unit leased to a family at least annually to determine if the unit meets Housing Quality Standards (HQS) and the Authority must conduct quality control re-inspections. The Authority must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). In addition, the PHA is required to obtain an executed General Depository Agreement for all bank accounts. During our testing of 10 HCV tenant files, we noted annual HQS inspections for all the tested units. However, the Authority did not perform the required quality control re-inspections. Tenants were selected and traced to the waiting list. However, as documented in the CMR, the waiting list did not include applicants that had been ineligible when they originally applied. We also were not provided with an executed General Depository Agreement. Due to the change in management, some bank accounts have not been able to update the authorized signers on the accounts. Auditor’s Recommendation: The Authority should perform housing quality control re-inspections according to HUD guidelines. The Authority should update its waiting list requirements and ensure that applicants are selected in the proper order. The PHA should obtain the required General Depository Agreement and make sure that current management and board members have access to all bank accounts. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2024

Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The 21st Century Cures Act requires all states to enroll both fee-for-service and managed care providers. Idaho Medicaid is currently out of compliance with this requirement for most of the providers within managed care contractor networks. The state is also working to come into compliance with a requirement in the Affordable Care Act to revalidate all enrolled providers at least every 5 years. The Division has begun the systems work necessary to come into compliance with both of these requirements and anticipates working through enrollment and revalidation activities into CY2025. Once completed, the Division will have an accurate and complete provider file that will be shared with contracted managed care plans to support their contracting efforts. Any providers who contract with the managed care plans will be required to be fully enrolled and credentialed with Idaho Medicaid before rendering services and billing. Pursuant to the Consolidated Appropriations Act of 2023, states are required by July 2025 to have a searchable and regularly updated provider directory for both managed care plans and fee-for-service programs. Idaho Medicaid is working to develop processes to validate directories and ensure that providers are providing updates to their information as necessary. Through this effort, Idaho Medicaid will further bolster internal processes and controls to ensure accurate provider network information is shared with Medicaid participants and maintained within our systems. Anticipated Corrective Action Date: July 2025 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-220: The Department failed to provide necessary supporting documentation for five Adoption Assistance Title IV-E eligibility determinations. Federal Programs: 93.659 – Adoption Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The department agrees with the finding related to the critical importance of obtaining and maintaining documentation for all necessary background checks. Although the department was ultimately able to verify background checks were completed, we agree that we were unable to readily pull the needed documentation on these in a timely manner. The department will assure supporting documentation for Adoption Assistance Title IV-E eligibility determinations are maintained within the electronic filing system by adding an additional verification to the current process. When a supervisor reviews a departmental adoption for finalization, they will verify that a copy of the Enhanced Criminal History Background clearance letter for all adults residing in the home is uploaded to the prospective adoptive parents’ profile in eCabinet (the electronic case management system), and the signed copy of the adoption assistance agreement is uploaded to the child’s profile. The application process for Adoption Assistance Title IV-E eligibility for private adoptions will be updated to include the addition of the Enhanced Criminal History Background clearance letters for all adults residing in the home to the child’s eCabinet file. When a supervisor approves an adoption assistance agreement for a private adoption, they will verify a copy of the signed adoption assistance agreement is uploaded to the adoptive child’s profile. This will be completed by August 2024. Anticipated Corrective Action Date: August 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-218: The Department failed to provide necessary documentation to support the eligibility determination for two foster care providers within the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The department agrees with the finding related to the critical importance of obtaining and maintaining documentation for all necessary background checks. Although the department was ultimately able to verify background checks were completed, we agree that we were unable to readily pull the needed documentation on these in a timely manner. To correct the issue, the department will add an additional point of verification that the Enhanced Criminal History Background Check clearance letter from the Background Check Unit’s system is uploaded to eCabinet, by having supervisors view the document within eCabinet prior to approving the initial foster care license. Supervisors will also confirm that all ICPC home studies address results of background checks for all adults in the home and any additional potential caregivers. This will be completed April 2024. Anticipated Corrective Action Date: April 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-217: The Department does not have documented internal controls for adjustments processed to the Foster Care -Title IV—E program. Federal Programs: 93.658 – Foster Care Title IV-E Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Action: The Department will continue to record adjustment activity through Help Desk tickets, SharePoint documentation, and ESPI. The Department will ensure improved visibility to the adjustment and approval process and documentation by ensuring all roles who need access (including auditors), have access to all relevant systems and storage locations such as access to SharePoint and Help Desk tickets. This step will be completed by April 30, 2024. Anticipated Corrective Action Date: April 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-214: The Department did not maintain sufficient documentation to support eligibility award decisions for the Community Partners Grants within the Child Care and Development Fund (CCDF) program. Federal Programs: 93.575 – Child Care and Development Block Grant; 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The division will: • All employees who administer grants will be required to complete training related to awarding grants, to include components on appropriate internal controls, identifying required grant elements, detailing the grant process, and outlining record retention requirements. All current employees have been trained as of March 2024. • The Division will work closely with the Division of Management Services to support the development and implementation of updated record retention policies and processes which will result in relevant documents being centrally retained. Estimated completion date December 31, 2024. Between now and when that central repository is available, individual rubrics and their supporting documents related to grant awards will be retained. • All employees will complete an annual employee conflict-of-interest disclosure and recertification process. Current completion of the new employee conflict of interest from will be completed by April 2024. Anticipated Corrective Action Date: December 2024 Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-211: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Federal Programs: 93.568 – Low-Income Home Energy Assistance Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: Testing of the updated benefits matrix will be completed by the Program annually, and the results will be documented using an established scenario testing script. Results of the testing will be documented and submitted to the Bureau Chief, as a second review of accuracy and compliance, prior to moving the updated matrix into the production environment. Documentation will be maintained to support the review and approval. Anticipated Corrective Action Date: The Program will write a process document to support this corrective action and will implement this process prior to the start of the new LIHEAP season beginning 10/1/2024. Program will have a process document in place by 9/30/24. Responsible for Corrective Action: Shane Leach, Division Administrator Shane.Leach@dhw.idaho.gov 208-859-1033 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Views of Responsible Officials and Planned Corrective Actions: Management agrees with the auditors and has initiated the necessary corrective action plan to mitigate the deficiency from occurring again. The plan is to implement new procedures to ensure the reporting to the NSLDS is done on a timely basis. Implementation date: Immediately. Persons Responsible: Vice President of Business & Finance, the Registrars Office and the Director of Student Financial Aid.

Finding No. 2023-001 Housing Choice Voucher: Tenant Eligibility – Significant Deficiency Contact Person: Ronald Jackson, Interim Executive Director/CEO CORRECTIVE ACTION: New Admission EIV compliance • SRHA has procured professional services for Quality Control and Consulting. The Nelrod Company was selected. The agency intends to work with this firm to setup a Quality Control program and establish stronger internal controls. • SRHA will add a Compliance/QC position to monitor all aspects of the agency’s operations to ensure compliance. • SRHA has engaged with the Nelrod Company to review and establish a quality control system for the Project Based Voucher program to include vouchers currently controlled by the separate entity Whitemarsh Pointe Eagle Landing. The Quality Control position in its Administration department will monitor and perform program compliance. TARGET DATE: April 15, 2024

Plan: The Data Manual is available in Appendix B. CES has trained staff in the Enrollment Requirements and will implement enrollment through the process contained in the manual.

Corrective Actions Taken or Planned: Going forward for payments, under the direction of the Executive Director, Rachel Erpelding, the Kim Wilson Housing Staff will sign-off on the access database check request sheets and have the Executive Director provide her physical signature as written evidence of the review and approval process for housing payments. For drawdowns, beginning July 2023, the Director of Fiscal Services, Linnea Cullumber, implemented a monthly reconcile process between the housing check payment requests and grant billing drawdown support provided by the Kim Wilson Housing Staff. The accounting staff now reconcile the payment and drawdown support, then retain the email correspondence supporting the drawdown process providing confirmation of review and approval. Rachel Erpelding, Executive Director of Kim Wilson Housing, and Linnea Cullumber, Director of Fiscal Services are responsible for this corrective action plan. The anticipated completion date is 3/31/24.

2023-001 Eligibility Public and Indian Housing Program - AL No. 14.850 Significant deficiency in internal control Other matter required to be reported in accordance with Uniform Guidance Condition: Out of an approximate population of 2,083 tenants, 44 tenant files were tested and the following deficiencies were noted: • 1 file was missing the support packet for the fiscal year 2023 recertification including but not limited to income support, third party verification, and flat rent sheet, • 3 files had late recertifications, • 2 files were missing support of inspection, • 1 file was missing tenant wage support, and • 1 file was missing a valid 9886 form. Auditor Recommendations: The Authority should consider reevaluating their established procedures and controls in place to ensure full compliance in regards to eligibility. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: • 1 file was missing the support packet for the fiscal year 2023 recertification LaTonia Young, Director of Asset Management, lyoung@memphisha.org, 901-544-1129, is working with the new Community Manager to make the corrections for the missing information no later than April 30, 2024. Going forward Tomecia Brown, Director of Compliance and Training, tbrown1@memhisha.org, 901-544-6402, will continue to conduct file reviews to ensure that the required documentation is in the file. •3 files had late recertifications. We will ensure that all recertifications are completed within 30 – 120 days of the effective date. Tomecia Brown, Director of Compliance and Training, will complete a recertification due review on a monthly basis effective April 1, 2024. • 2 file was missing support of inspection. LaTonia Young, Director of Asset Management, will ensure that all units are inspected on an annual basis. In our monthly site staff meeting, Asset Management will inform staff to ensure that all inspections are in the file. • 1 file was missing tenant wage support. We will have the new Community Manager verify wages and make corrections by April 5, 2024. MHA will be sending the owner a non-compliance letter no later than April 30, 2024. Tomecia Brown, Director of Compliance and Training, will continue to complete file reviews on a monthly basis and train staff on the Public Housing process. • 1 file was missing a valid 9886 form. Tomecia Brown, Director of Compliance and Training, will continue to conduct file reviews to ensure that the HUD 9886 form is in the file for all Public Housing sites effective April 23, 2024.

REFERENCE: 2023-001 – Eligibility Medicaid Cluster (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Dignity Health Medical Foundation Finding: The Dignity Health Medical Foundation did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided. Corrective Action Plan: For the Medical Assistance Program, eligibility is validated through a Medi-Cal system website. Dignity Health Medical Foundation personnel have implemented procedures to ensure documentation of eligibility checks are retained. The Clinic Operations manager has instructed staff and supervisors to save proof of eligibility for all months. The Clinic Operations manager checks for retention of eligibility documentation on a random basis and an internal audit will be performed to check for compliance with the documentation retention. Person Responsible: Nicole Hill, Clinic Operations Manager, Dignity Health Medical Foundation. Completion: September 1, 2022

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Management did not consistently retain evidence to support that internal controls were in place and operating effectively for approval of invoices with purchase orders and to ensure that bonuses paid to employees related to COVID-19 were eligible to receive the bonus. Corrective Action Plan: This program has ended. CHIC has no additional funding to apply expenses to.

REFERENCE: 2023-010 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science and CHI Health School of Radiologic Technology did not have internal controls over enrollment reporting. Corrective Action Plan: This finding has been corrected for Good Samaritan as of April 2023. Enrollment reporting to the National Student Clearinghouse is conducted 5 times per year and reconciled monthly with loan borrowers to ensure active enrollment. Additional Status Update: The Dean of Enrollment Management validates and reports to the oversight committee regarding the monthly reporting. Monthly reporting to the GSC Compliance committee has verified completion since May 2023 and has been timely thereafter. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science David Velasquez, Nuclear Medicine Technologist Coordinator, CHI Health School of Radiologic Technology Expected Completion: April 2023 (Good Samaritan) and June 2024 (CHI Health School of Radiologic Technology)

REFERENCE: 2023-009 – Activities Allowed or Unallowed/Eligibility SFA Cluster (Assistance Listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: CHI Health School of Radiologic Technology Finding: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Corrective Action Plan: The financial aid administrator will implement an eligibility checklist to document the review of student documents in line with US Department of Education criteria. The checklist will be completed and a review performed prior sending the financial aid package to the student. Person Responsible: David Velasquez, Nuclear Medicine Technologist Coordinator, CHI Health School of Radiologic Technology Expected Completion: June 2024