Corrective Action Plans

Corrective Action Plan: ? The program office will reach out to the county to advise of the error and ensure it has been corrected. ? The county will be reminded of the proper income entry and explain their plan to ensure it doesn?t happen again. ? The county will need to confirm they have started the overpayment process for any benefit overissued. Anticipated Completion Date for Corrective Action: February 2023 Contact Person Responsible for Corrective Action: Betsy Suver, Bureau Chief, Ohio Department of Job and Family Services 30 East Broad Street, Columbus OH 43215 Phone Number: 614-387-8302, E-Mail Address: Betsy.Suver@jfs.ohio.gov

Corrective Action Plan: Alerts - The Ohio Department of Administrative Services (DAS) in coordination with the Ohio Department of Medicaid (ODM), the Ohio Department Job and Family Services (ODJFS), and our vendor partners will continue to work to address system design weaknesses by identifying and prioritizing system changes and updates that impact eligibility determinations and benefit amounts as well as alert volume and processing improvements. Weekly problem review meetings will continue to be held to identify reported system issues and track any needed updates through the normal prioritization and slotting process. These changes will be delivered according to the agreed upon release cadence based on business priority and impact. Upon delivery of such system changes, the Ohio Benefits Program Team will monitor production to determine if the desired outcome was achieved. The Ohio Benefits Program Team continued to analyze system alerts during FY2021 and FY2022 and presented recommendations to the vendor partners for overall system alert improvements; these recommendations were prioritized, and strategic modifications were implemented in our normal release cadence through calendar year 2022, with the most recent release occurring in February 2022. Comprehensive alert reduction efforts thus far have reduced by approximately 29 million the overall number of backlog alerts and have resulted in approximately 22 million fewer new alert generations. The next alert-centered release, R4.6.1, is scheduled for April 2023. This release, specific to IRS IEVS enhancements will streamline the work for County Caseworkers to process IRS IEVS matches from the IRS Unearned Income interface. There will be both E-Verify enhancements and a change in the match logic which will result in a reduction in the volume of IRS records that are flagged as IRS IEVS matches. County Caseworker time spent processing IRS IEVS matches is expected to reduce; remaining time spent on IRS IEVS matches is expected to have more value by allowing County Caseworkers to focus time on matches with an eligibility impact or potential for benefit recovery. Interagency Agreements - An Interagency Agreement is entered into by the Ohio Department of Job and Family Services (ODJFS) and the Ohio Department of Administrative Services (DAS). A second Interagency Agreement is entered into by the Ohio Department of Medicaid (ODM) and the Ohio Department of Administrative Services (DAS). Each of these Agreements are entered into for the purpose of setting forth the roles and responsibilities, budget methodology and payment terms, data sharing restrictions, security protocols, and compliance requirements for the Ohio Benefits Program. DAS, ODM, and ODJFS have completed extensive policy, program, and legal reviews and the final Agreement is in circulation to secure DAS, ODM, and ODJFS Director?s signatures. Data Governance - A well-designed, mature, data governance program typically includes a governance team, a steering committee that acts as the governing body, and a group of data stewards. They work together to create the standards and policies for governing data, as well as implementation and enforcement procedures that are primarily carried out by the data stewards. The Ohio Benefits Program Data Governance Team meets monthly since September 2022. The team, led by ODJFS as one of the primary data owners, is working to complete its initial objectives which include: ? Address and Remediate Concerns about Reporting Cleanliness. o Develop an improved process for report intake, development, and delivery. ? Enhance Automatic Reporting and Monitoring. o Develop oversight reports to examine key areas of the business that are used to monitor for compliance. ? Evaluate EDMS? Audit Accessibility. o Understand the audit process and make recommendations on how to organize and display data to assist with future audits. ? Address Additional Priorities as determined by the data governance committee (in conjunction with the steering committee and other stakeholders). o The team will continue to establish key objectives to monitor and improve. DAS follows DAS Policy 2100-04 for Data Classification. The Ohio Benefits Program systems store data in a consistent manner, with shared data understanding for making program eligibility determinations based on quality data. As a collector and processor of the data, DAS acts as a DATA STEWARD for the agency DATA OWNERS. Per state data classification policy (2100-04, point 5.4), "? a data owner is responsible for establishing data use guidelines. An information owner shall not be a data or system administrator, but rather the head of a business or program area?? DAS customers are responsible for classifying their data and for informing DAS as to its levels of confidentiality and criticality." Since the DAS Ohio Benefits Program team has not been given data ownership and data classification information, the DAS Ohio Benefits Program team treats all data as "Confidential Personal Information". Some data may be further classified as Federal Tax Information (FTI) or Health Insurance Portability and Accountability Act (HIPAA) information, with the corresponding data access restrictions, monitoring and reporting requirements. As a Data Steward, the DAS Ohio Benefits Program team is responsible for carrying out data usage and security policies and meeting state and federal regulations for data contained on the Ohio Benefits Program systems and storage. Anticipated Completion Date for Corrective Action: ? Alerts ? April 2023 ? Interagency Agreements ? Completed ? Data Governance - Completed Contact Person Responsible for Corrective Action: Kristina Hagberg, Deputy State Chief Information Officer, Ohio Department of Administrative Services 30 East Broad Street, Columbus, Ohio 43215 Phone: 614-644-9245, E-mail Address: Kristina.Hagberg@das.ohio.gov

FINDING 2022-003 Contact Person Responsible for Corrective Action: Janet McCreary, Director of Curriculum, Instruction, & Assessments Contact Phone Number: 812-274-8001 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Data Management Specialist will save all reports submitted to the DOE. This will ensure that supporting documentation is kept that will be used determine Eligibility for Title I. The Title I Compliance Specialist/Grants & Compliance Specialist will verify the information for accuracy and keep documentation of the review. Anticipated Completion Date: 2/13/2023

Community Housing Services ? Ashley Valley Shadows, Inc. Corrective Action Plan December 31, 2022 2022-001 Finding Phil Carroll, President of Community Housing Services, has implemented steps to correct the issue. The onsite manager has been replaced. The Organization will review tenant file procedures to ensure that required documentation is obtained and maintained in accordance with HUD regulations. The anticipated completion date is December 31, 2023.

Finding Ref. No. 2022-002 Finding: The Uniform Guidance, 2 CFR 200.303, requires non-Federal entities receiving Federal Awards (i.e., auditee management) to establish and maintain effective internal controls over the Federal Award that provide reasonable assurance that the non-Federal entity is managing the Federal Award in compliance with Federal statutes, regulations, and terms and conditions of the Federal Award. 20 CFR 604.3(a) requires a State to only pay an individual who is able to work and available for work for the week which Unemployment Compensation (UC) is claimed. Based on work performed on unemployment compensation payments at the Alabama Department of Labor, for the period of October 1, 2021, through September 30, 2022, we identified 243 payments, totaling $58,809.00, which were made to 22 deceased claimants. We also identified an additional 186 payments, totaling $42,276.00, which were made to 27 incarcerated claimants. The combined improper payments to deceased or incarcerated claimants total $101,085.00 for the Unemployment Insurance Program. The Alabama Department of Labor did not have internal controls in place which were adequately designed to identify deceased or incarcerated claimants in a timely manner, in order to help prevent and/or detect improper payments. The lack of a well-designed system of internal controls, to identify deceased or incarcerated claimants, could cause the Alabama Department of Labor to continue to pay benefits to claimants who are deceased or incarcerated. Recommendation: The Alabama Department of Labor should establish and maintain effective internal controls to help ensure payments are not made to deceased or incarcerated claimants. Response/Views: We agree with the finding. Corrective Action Planned: ADOL now utilizes IDV through the Integrity Data Hub (IDH) for death crossmatch, giving ADOL the capability to crossmatch all claimants through the IDV. However, the review process is manual at this time. ADOL continues to pursue a fully automated process with the system vendor. ADOL is also working with the Interstate Connection Network (ICON) through the National Association of State Workforce Agencies (NASWA) to implement a match of SSN?s with the Social Security Administration?s Prisoner Update Processing System (PUPS). This will allow records to be checked in a nationwide database not just the State of Alabama. Reason for the Recurrence: The cause of this was due to the workload of pandemic claims and the lack of requirements to provide proof of income and employment. Prior to the pandemic a person had to have wages in order to qualify for benefits, eliminating a deceased person of more than 2 years from being monetarily eligible for benefits. Any remaining claimants that had died would be reported by the employer or through returned mail or a surviving of family member. Any notice of deceased person would be reviewed. With no way to verify whether a person was deceased or not, some did pay benefits. Anticipated Completion Date: ADOL implemented checking claims through IDH June 2022. Netacent, the vendor who maintains ADOL?s unemployment system, anticipates the PUPs project to be fully functioning by December 31,2023. Contact Person(s): Brent Langley, Assistant Unemployment Administrator

2022-004 Title I Grants to Educational Agencies Recommendation: School Corporation management should implement procedures and controls to ensure the required Title I templates are used and properly reviewed and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation will review the homelessness provisions of Title I and ensure documentation is retained to support the allocation. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

Eligibility, Nonmaterial Noncompliance, Significant Deficiency Per Title 24 of the Code of Federal Regulations parts 880 through 883, only eligible individuals should participate and the program and there should be evidence of eligibility determinations. The Authority has established a move-in and re-examination checklist to be used during the eligibility determination process to ensure that all required documents are maintained in the tenant?s file. Of the forty (40) tenants selected for testing, we noted the following: Seventeen (17) tenants were missing the re-examination checklist. Three (3) tenants were missing documentation that they were selected from the waiting list. Two (2) tenants were missing documentation of inspections and tenant certifications. The Authority has had a significant amount of turnover in their staffing who complete eligibility determinations, and the staff who were completing the eligibility determinations did not properly include the completed checklists in the file to evidence their review that all required documents were included in the file. The Authority did not have documentation of compliance with the eligibility requirement for one (1) tenant for the year ended June 30, 2022. Response: Within the next thirty days the Housing Program Compliance Analyst will complete a random audit at each complex of new admissions to confirm all HUD required forms have been completed, and will review random files to confirm the re-examination checklists have been completed. A report will be provided to the Director of Housing once the analyst has completed the review. Target Date: April 2023 Responsible Party: Director of Housing

Eligibility, Nonmaterial Noncompliance, Significant Deficiency Per Title 24 of the Code of Federal Regulations parts 5, 902, 960, 966, and 990, only eligible individuals should participate and the program and there should be evidence of eligibility determinations. The Authority has established an application and re-examination checklist to be used during the eligibility determination process to ensure that all required documents are maintained in the tenant?s file. Of the forty (40) tenants selected for testing, we noted the following: One (1) tenant where the Authority was unable to locate the tenant file to document their eligibility to participate in the program. Twelve (12) tenants were missing the re-examination checklist. Five (5) tenants were missing documentation that their income was accurately calculated and verified. For the one tenant whose file was unable to be located moved out of the program during fiscal year 2022, the Authority believes the file was moved to storage but was unable to locate it. For the missing checklists and other documentation, the Authority has had a significant amount of turnover in their staffing who complete eligibility determinations, and the staff who were completing the eligibility determinations did not properly include the completed checklists and other supporting documentation of eligibility in the file to evidence their review that all required documents were included in the file. Response: The Authority will have the Housing Program Compliance Analyst audit a sample of tenant files based on the latest re-examinations to ensure that the calculated income agrees with the supporting documentation, the checklist is completed in its entirety and is maintained in the tenant files. Target Date: April 2023 Responsible Party: Director of Housing

The Program Coordinator will complete the Volunteer File Master Checklist for each new volunteer including the income verification and background checks as well as other required steps. The Program Coordinator will sign and date the form. The Program Supervisor will review the checklist for completeness and sign and date the form. The completed form will be filed in the volunteer?s file. This practice is being implemented currently.

Finding: 2022-003 Name of contact person: Amy Seay - Director of Social Services Corrective Action: The Department will continue to provide more in-depth training to ensure cases requiring IV-D Cooperation are meeting policy guidelines. Proposed Completion Date: As soon as possible

Identifying Number: 2022-005 - USDOE Student Financial Assistance Cluster - Special Tests and Provisions: Students' Satisfactory Academic Progress Ineligibility Finding: The College disbursed funds within 30 days of the first day of class for 12 first year students out of 40 students tested. Name of Contact Person: Karen Overton, Director of Financial AidCorrective Action Plan: The College will create, follow, maintain, and monitor an appropriate satisfactory academic progress (SAP) policy that meets USDOE requirements. The USDOE requires all institutions to sustain an SAP policy that requires students to maintain a 2.0 GPA and successfully complete 67% of their educational program in order to be eligible for financial aid. Anticipated Completion Date: Beginning August 2022

Corrective Action Plan Section III. Findings and Questioned Costs for Federal Awards Material Weakness in Internal Control Over Compliance ? Medicaid Cluster Finding 2022-001 and 2022-002 "See Corrective Action Plan for Chart/Table"

Finding 2022-001 ? Moving to Work Tenant Files ? Eligibility ? Annual Recertifications ? Noncompliance & Significant Deficiency ? CFDA #14.881 Corrective Action Plan: The Auburn Housing Authority (AHA) has implemented and/or will implement the following by FYE 2023: a. PBV case management is now administered in-house b. HCV has developed an action plan to ensure that all PBV files are HUD-compliant c. PBV calendar-year 2022 (January 2022-December 2022) re-exams are substantially complete. All files will be HUD-compliance by FYE2023. d. During FYE2023, the HCV Manager will perform quality controls by randomly selecting departmental files. e. Other internal control measures will be implemented to eliminate future audit findings. Person Responsible: Sharon Tolbert, CEO Anticipated Completion Date: June 30, 2023

U.S. DEPARTMENT OF TREASURY 2022-002 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: The Health Board should ensure that program managers are aware of the significant compliance requirements of an award and implement a system of internal control that supports compliance and documentation of compliance. Explanation of disagreement with audit finding: We respectfully disagree with the characterization of the finding as a material weakness in internal control. The sample size of 28 selections called for 3 specific source documents to be provided in association with each sample. Thus, 10 out of a total of 84 source documents requested were not immediately available. The eligibility forms in question are part of the process which initiates the determination of the validity of the request for assistance. Due to the sensitive nature of this program, these documents are not readily available electronically (in order to protect the privacy of the recipients). The Health Board?s Community Services Team, which includes Rapid Rehousing, Gender-Based Violence, and Emergency Housing, experienced significant turnover due to the pandemic. We have informed the auditor about the turnover challenges faced by this specific department and the difficulties in securing physical documentation. Action taken in response to finding: In September 2022, the Community Service Team began reporting to the Health Board?s Behavioral Health Officer. Under her direction, processes have been updated and documented along with the creation of a stronger review process. The health board remains committed to further strengthening our controls and processes where necessary. We will ensure that program managers are aware of the compliance requirements associated with the award and implement a robust system of internal control that supports compliance and proper documentation. Name(s) of the contact person(s) responsible for corrective action: Linda Zhang, CFO Planned completion date for corrective action plan: September 30, 2023 If the U.S. Department of Treasury has questions regarding this plan, please call Linda Zhang, CFO at (206) 324-9360.

Item 2022-002 ? Eligibility Contact person: Chellye Stump, Dean of Administrative Services Finding ? During a dual purpose tests of controls and compliance there were 3 participants who were identified that did not certify to the fact that they were a citizen, national, or permanent resident of the United States, a requirement for eligibility of the TRIO program. Management Response ? The College will implement additional controls to ensure there is evidence of review of certifying statement from participant prior to services being rendered. TRIO Services Director will be responsible for the corrective action and anticipates completion of corrective action will be taken before 9/30/23. Effective date of completion: within the fiscal ending September 30, 2023

The Organization agrees with the recommendation. An internal review is currently in process to review and update policies as needed to address the use of federal funds.

2022-057 Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2105OR5MAP, 2021; 2105OR5ADM, 2021; 2205OR5MAP, 2022; 2205OR5ADM, 2022 Compliance Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency Prior Year Finding: 2021-020 Questioned Costs: N/A Criteria: 42 CFR 455.436; 42 CFR 455.102 to 455.107; 42 CFR 455.414 Provider eligibility requirements for the Medicaid program differ depending upon the type of services provided; however, all providers are subject to specified database checks and are required to sign an adherence to federal regulations agreement (agreement). Typically, the agreement includes disclosures specifically required by federal regulations. Additionally, the federal regulations require that the Oregon Health Authority (authority) and Department of Human Services (department) determine eligibility for Medicaid providers and revalidate providers at least every five years by performing database checks to ensure providers are still eligible to participate in the Medicaid program. We selected a random sample of 62 providers in the Medicaid program with 32 providers enrolled by the authority and 30 enrolled by the department. For 4 providers we found the issues described below. I-9 form for 1 department provider could not be located. This provider is not currently a provider with the State and an updated I-9 will not be obtained. Based on our review of other available support we were able to determine this to be an eligible provider during the fiscal year. I-9 form for 1 department provider could not be located. The department has since obtained a completed I-9 form. I-9 forms for 2 department providers did not include a review of minimum acceptable documents to verify identity and employment authorization. The department is actively working to obtain missing documentation and based on our review of other available support we were able to determine these to be eligible providers during the fiscal year. The above issues occurred due to human error and inadequate record maintenance which could lead to ineligible providers receiving Medicaid funding. We recommend department management strengthen controls to ensure documentation supporting a provider?s eligibility determination and revalidation is complete. MANAGEMENT RESPONSE: We agree with this recommendation. ODDS Response: The department is committed to having completed I-9 forms on file for all Personal Support Workers through our Fiscal Intermediary. The Provider Enrollment Unit now has a quality assurance staff who will conduct spot checks of the FI work. This is in process now and reviews will continue. APD Response: The department is committed to having completed I-9 forms on file for all employees and homecare workers. This expectation, as it relates to homecare workers, was reinforced by the department at the Client Employment Program Annual Summit held on 3/28/23 and 3/29/23. This Summit was attended by approximately 160 local office staff. Local office staff were instructed on how to properly fill out the I-9 form and retention requirements. Staff were also reminded of resources available to answer questions, including central office points of contact. The department is also exploring short- and long-term solutions to mitigate this risk, including creating a peer review process on business procedures across the state intended to assist in not only accuracy, but knowledge transfer, developmental growth and mentoring opportunities. The department may also explore system changes that would automatically validate the completion of tasks related to provider enrollment and renewals, including the presence of required documentation. Anticipated Completion Date: June 1, 2023 Contact: Vanessa Richkind, ODDS Provider Administration Manager or Diana Nott, APD Provider Relations Unit Manager

2022-058 Department of Human Services Perform timely reconciliations of refinanced OR-Kids transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.667 Social Services Block Grant Federal Award Numbers and Years: 2101ORSOSR, 2021; 2201ORSOSR, 2022 Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: $1,308,457 (likely) Criteria: 42 USC 1397a(c); 45 CFR 75.386a(2); 45 CFR 96.30b(2) According to federal requirements, to be eligible for federal funding, expenditures must be expended in the fiscal year allotted or in the succeeding fiscal year (period of performance). Additionally, federal post-closeout requirements stipulate the return of any funds due because of later refunds, corrections, or other transactions. As part of the grant closeout process, block grants also require the grantees to report the total funds expended and the date of the last expenditure. Grant closeout is the process by which the federal awarding agency determines that all applicable administrative actions and all required work have been completed. Social Services Block Grant (SSBG) has expenditures originating from the child welfare system, OR-Kids. OR-Kids is used to manage placements, eligibility, payments, and other case information. When various corrections are initiated, OR-Kids can re-process transactions as far back as January 1, 2008. For some placement corrections, OR-Kids processed the recovery of the funds in a state grant (Miscellaneous Other Fund grant), instead of the federal grant. To date, the department has not completed permanent fixes to the OR-Kids system to prevent these re-processing errors from occurring. During fiscal year 2022, the department was reconciling the Miscellaneous Other Fund grant and identified refunds related to SSBG. The refinanced expenditures reduced the amount of SSBG expenditures originally reported in closed grant awards. Instead of submitting a refund, the department identified expenditures recorded in subsequent grants that could have been used to backfill the reduction of expenditures. Allowable expenditures, that met the period of performance, were subsequently moved. To illustrate, a total of $1.3 million of expenditures were moved in the accounting system from grant award 21 (federal fiscal year 2021) to grant award 20. The department then moved expenditures totaling $1.2 million from grant award 20 to grant award 19. This process continued for all grant awards going back to grant award 11 (federal fiscal year 2011). The table below illustrates the movement of expenditures between grant awards. ?See Corrective Action Plan for Table? Although the department only moved expenditures that qualified for each respective period of performance, we question whether the federal awarding agency would allow the department to backfill the $1.3 million of expenditures in question after grant closeout had been completed. We recommend department management conduct more timely reconciliations of OR-Kids refinancing adjustments to ensure adjustments are made during the related periods of performance. We further recommend management work with its federal awarding agency to determine if it is appropriate to backfill program expenditures between grants to account for the reduction in expenditures created by the reconciliation process. If not appropriate, the questioned costs should be repaid to the federal awarding agency. MANAGEMENT RESPONSE: The agency disagrees with this finding. SFMA grant phase is an internal tracking mechanism only and is not mandated by ACF. None of the expenditures observed were moved into or out of the period of performance for which they originally qualified for. SSBG awards have a two-year period of performance for claiming. As a result, there is an overlap between internal phases where expenditures qualify for two at any given time. Assignment of phase in SFMA is based on internal balancing needs to ensure claiming is not over or under the award for that period. Prior period adjustments occur periodically and are debited or credited to the phase they were originally recorded under. Should those adjustments cause a phase to become under or over reported, the assigned phase in SFMA is adjusted to maintain consistency between SFMA expenditures and the SF-425 report provided to ACF. If a prior period increasing expenditure is outside the period of performance, it is moved to non-reportable and state only funding. Anticipated Completion Date: N/A Contact: Fariborz Pakseresht, Oregon Department of Human Services Director

2022-040 Department of Human Services Improve controls to ensure eligibility criteria are met Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $9,569 (known); $931,750 (likely) Criteria: 45 CFR 264.1; Oregon TANF State Plan The State of Oregon Temporary Assistance for Needy Families (TANF) State Plan (Plan) defines financial neediness criteria with its adjusted income limit tables. Federal regulations establish 60 cumulative months as the length of time a client may receive federal TANF assistance. The department uses its case management system, Oregon Eligibility (ONE), to count federal-eligible benefit months, and when 60 months is reached, an indicator is sent to the financial subsystem to change federal funding to state funding. From a population of 105,267 TANF benefit payments recorded in ONE, we randomly selected a sample of 40 and two additional individually significant payments for testing. We found: One sample?s financial eligibility information included a disaster relief benefit without details showing the date of payment and the covered time period. As a result, auditors and the department are unable to determine if this case met financial eligibility criteria, resulting in questioned costs of $1,311. One individually significant case?s child support and spousal support were entered incorrectly into ONE. The countable income at time of certification did not meet the adjusted income limit, making the client ineligible for TANF benefits. Questioned costs for this case total $8,258. We recommend department management ensure federally-funded client benefits are paid on behalf of eligible individuals, and documentation is retained to support eligibility decisions. We also recommend department management correct the identified error cases and reimburse the federal agency for questioned costs. MANAGEMENT RESPONSE: We agree with this recommendation. The Department will communicate to eligibility staff the importance of reviewing information reported by the applicant compared to information received from a third-party and direct staff to case note in the ONE system how the discrepancy was reconciled. The Department will also communicate the requirement to maintain eligibility records in both case notes and electronic file when applicable. The Department will review the cases cited and make an appropriate referral to the Overpayment Recovery Unit. Overpayments recouped can then be adjusted by Office of Financial Services to credit the TANF federal grant rather than reimbursing, per instructions outlined in TANF-ACF-PI-2006-03. Anticipated Completion Date: October 31, 2023 Contact: Annette Palmer, TANF Program Manager

2022-039 Department of Human Services Improve documentation of required income and benefit verifications Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Special Tests and Provisions Type of Finding: Material Weakness Prior Year Finding: 2021-011 Questioned Costs: N/A Criteria: 45 CFR 205.55 Federal regulations require each state to participate in the Income Eligibility and Verification System (IEVS), which for Oregon, includes using income and benefit screens accessible through Oregon Employment Department, Internal Revenue Service, and Social Security Administration, when making Temporary Assistance for Needy Families (TANF) eligibility determinations. The department?s current procedure instructs caseworkers to narrate ?IEVS checked? in the case management system, Oregon Eligibility (ONE), after reviewing all appropriate IEVS screens at the time of eligibility determination. The department submitted change requests to the eligibility system?s service provider that would prohibit ONE from paying benefits until all IEVS screens are checked; however, the system change has not yet been completed. From a population of 105,267 TANF benefit payments recorded in ONE we randomly selected a sample of 40 and two additional individually significant payments for testing. We found in 16 cases, there was no narration of the IEVS check by caseworkers, in either ONE or the former narrative system. We verified these clients did meet the TANF eligibility criteria related to IEVS screens, however, by not providing assurance of verification of the use of IEVS screens, the department increases the risk of providing benefits to TANF ineligible applicants. We recommend department management ensure verification of income and benefits with IEVS screens is clearly documented in client case files when determining client eligibility. MANAGEMENT RESPONSE: We agree with this recommendation. The Department is implementing a new tool, Note Buddy, to assist workers with case notes when determining eligibility. Note Buddy will include a field that allows staff to select whether IEVS was checked. Staff will be encouraged, not mandated, to use Note Buddy. The Department will form a small workgroup to discuss options for revising and lowering the level of effort for the Change Request (CR) previously submitted. The Department will re-submit the CR for changes to ONE. Anticipated Completion Date: September 30, 2023 Contact: Annette Palmer, TANF Program Manager

2022-037 Department of Human Services Improve accuracy of cases reported as noncooperating with child support Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Special Tests and Provisions Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 45 CFR 264.30-31 Federal regulations require the department to refer all appropriate individuals in the family of a child to the child support enforcement agency. If the department determines referred individuals are not cooperating, without good cause, in establishing, modifying, or enforcing a support order with respect to the child, then the department must reduce or deny assistance in the Temporary Assistance for Needy Families (TANF) program. The department faces reduced State family assistance grant payments for failure to enforce penalties against noncompliant individuals. In March 2020, the department established good cause exemptions due to Covid for all individuals. Noncooperation sanctions were reinstated in April 2021, by which time the department had moved its case management system to Oregon Eligibility (ONE). When a caseworker enters a child support noncooperation code in ONE, the system should automatically reduce TANF benefits. The population of cases identified in ONE as not cooperating with child support is obtained from the quarterly performance data reports compiled by a service provider. As stated in a separate finding, titled `Ensure performance data reports are complete and accurate,? we determined the data reports are not complete or accurate, therefore, the population of cases not cooperating with child support is also incomplete. However, we tested some cases in the reports to verify ONE was appropriately reducing benefits. The quarterly performance data reports for periods October 1, 2021, through June 30, 2022, consisted of 133 unique cases identified as not cooperating with child support. We randomly selected 14 cases and could not find support in ONE for noncooperation. The department identified one case entered in ONE incorrectly by a caseworker and the remaining cases had various nuances causing the performance data reports to retrieve the information incorrectly. All 14 cases were either cooperating with or not applicable to child support. The department also identified at least eight defects in child support data retrieval it reported to the service provider. We are unable to determine if ONE is correctly reducing TANF benefits when a case is not cooperating with child support. We recommend department management ensure noncooperative child support cases from ONE are completely and accurately reported in its performance data reports. MANAGEMENT RESPONSE: We agree with this recommendation. The Department has logged defects to correct Federal reporting requirements. The ONE system approving eligibility without a cooperation record was addressed through a defect and system build which corrected the issue on May 10, 2023. The Department has logged a defect to correct historic records where referrals were not sent; currently awaiting input from Division of Child Support. The system defect fix for issues identified related to incorrect values of child support cooperation status in ACF reports is currently in the development and testing cycle. Once the fix is deployed, future submissions will have correct data for this element. The reports will be resubmitted to ACF at the end of the current fiscal year (for months October 2022 ? Sept 2023) to correct previous data. Anticipated Completion Date: December 31, 2023 Contact: Annette Palmer, TANF Program Manager

2022-036 Department of Human Services Ensure performance data reports are complete and accurate Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Reporting Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: 2021-009, 2020-013, 2019-008 Questioned Costs: N/A Criteria: 45 CFR 265.7(a) and (b) and (f) Federal regulations require the department to collect monthly and report quarterly certain financial and non-financial data elements for services paid with Temporary Assistance for Needy Families (TANF) federal funding in the ACF-199 TANF data report. Federal regulations also require the department to report data quarterly for TANF eligible clients whose benefits are paid with designated state funds called maintenance of effort (MOE) in the ACF-209 SSP-MOE data report. Both data reports should be supported by applicable performance records. During fiscal year 2021, the department transitioned key aspects of the TANF program to Oregon Eligibility (ONE) for case management, while TANF child welfare payments continued to be recorded in OR-Kids the child welfare system. The department contracts with a service provider to extract data from ONE and OR-Kids to populate the data reports. Program staff currently work with the service provider to obtain comprehensible data reports prior to submission to review them for errors and when found, each issue is logged as a defect for the service provider to correct. The department and the U.S. Administration for Children and Families identified data reports submitted for state fiscal year 2022 were incorrect. The federal quarterly report ended September 30, 2021, was revised and resubmitted but still had likely errors according to program staff. Quarterly reports ended December 31, 2021 (Q1), March 31, 2022 (Q2), and June 30, 2022 (Q3), were corrected and resubmitted in February 2023. Data reports are comprised of individual component reports identified by ?T? for ACF-199 TANF and ?M? for ACF-209 MOE. We reviewed the resubmitted Q1, Q2, and Q3 reports and found: The Q1 TANF T2 and MOE M2 reports corrected a prior known defect. The fields identifying work participation have populated associated fields with job type and hours. The Q3 T6 report showing number of applications, number and types of families, and amount of assistance, reported $4.5 million more than supported by accounting records. The April 2022 T1 report contained 4,035 case numbers not found in the underlying system records, and 1,081 from system records not reported in the T1 report. OR-Kids cases in the Q1, Q2, and Q3 T1 24 of 45 fields left blank. In 10 of 21,171 cases recorded as having surpassed the federal funding limit of 60 months in the Q1, Q2, and Q3 T2 reports, we found three where the T2 reports did not agree to support in ONE. As the performance data reports are known to be incomplete and inaccurate, we are unable to test them for compliance with federal reporting requirements. To date, the implementation of ONE has not resolved findings related to performance data reporting, which have been ongoing since fiscal year 2010. Though the department has yet to receive a Service Organization Control (SOC) report from the service organization administering ONE and compiling data reports the department is in the process of contracting for a SOC report. Without an annual SOC report, the department does not have assurance controls are functioning as intended at the service organization for the TANF program. We recommend department management continue to review ACF-199 and ACF-209 reports prior to submission and monitor known compilation defects to ensure performance data reports submitted are complete and accurate. We also recommend department management obtain an annual SOC report over the service organization?s internal controls for the ONE application. MANAGEMENT RESPONSE: We agree with this recommendation. The Department continues to review ACF-199 and ACF-209 reports prior to submission to identify and resolve defects. The Department continues to monitor defects, sync up reports design with federal instructions, and progress towards complete and accurate reporting. The ACF 199 report issue regarding OR-Kids cases with 24 of 45 fields left blank is currently under development; mapping has been identified to rectify the missing data and once fixed, the future submissions will be corrected. The reports will be resubmitted to ACF at the end of the current fiscal year (for months October 2022 ? Sept 2023) to correct previous data. The issue regarding discrepant case counts between ACF 199 report and OR Kids data extract is under analysis. Child Welfare, TANF, and our technical team will develop a plan for rectifying and reconciling case numbers. The Department?s, Oregon Eligibility Partnership, has contracted for a SOC Type 2 audit, through contract 178884. The first audit review will be utilized to make sure all the reporting requirements and functional areas are in place. This means, the first formal audit finding, based on recommendation from the vendors, will occur in FFY25. Additional internal and external audits are happening on the system. Anticipated Completion Date: December 31, 2023 Contact: Annette Palmer, TANF Program Manager

Finding Number: 2022-002 Planned Corrective Action: The Business office has endeavored to keep pace with the shifting and changing guidance that is promulgated by the Department of Education. This has been a challenge. The Chief Financial Officer continues to monitor any guidance updates and make the appropriate changes to the reports to ensure their accuracy. There was only one report posted that contained one typographical error, but it is the University?s responsibility to ensure the accuracy of the reports and these reports will be monitored more closely going forward. Anticipated Completion Date: Continuing Responsible Contact Person: Eugene L. Munin

Action Taken The Paterson Community Health Center, Inc. is committed to its mission to provide quality and respectful health care to the greater Paterson community and beyond, especially to the uninsured and underinsured. The center had a training session in May, 2023 and discussed the one error out of twenty-five audit samples with applicable staff and discussed how to assure they understand how to implement the annual updates of the sliding fee discount schedule and to review the sliding fee discount given to eligible patients as outlined in our Fiscal Policies and Procedures. The center will continue with periodic checks of patients records to see if the training is effective and will provide training to new staff as added and continue to provide ongoing support to existing staff and make sure the annual training takes place in the month with the annual update of the sliding fee discount schedule. Person Responsible: Debora Walcott, CFO

Name of Contact Person: Ginger Loscavo, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a top priority in the program?s operation. There are currently more than 1,475 applications processed through WOFB and 40 site locations for CSFP. During the auditing process, there were 6 participants who did not sign the signature sheet to receive their box. They had a proxy sign and received the box for them that was not listed on their application as being a proxy eligible to do this. It was discovered for four of the participants that the pantry site administrator, who distributes the boxes monthly, signed for the participant because of a misunderstanding they had assuming they were automatically considered a proxy for those receiving boxes from their location. The remaining two participant?s boxes were signed for by another program participant who received her monthly box along with boxes for 2 other participants who were unable to get their box on their own because of not having transportation. The site administrator made an error allowing this person to sign for the boxes as that person was not listed as a proxy. Additional testing discovered 2 participants out of 25 were not eligible at the time of the distribution based on an invalid or expired application on file. One of the applications had the client put his annual income in the income field of the application but marked he received this monthly instead of annually. The other participant had an application that was not dated properly but was processed allowing him to receive a box. Effective January 1, 2023, WOFB will conduct a refresher course for all program sites and site administrators reviewing eligibility and program requirements for CSFP. The Program Specialist will oversee these training sessions. Any new sites that may develop throughout the year will be trained on all rules, regulations, and eligibility for the program. All new site staff and/or volunteers will be trained annually. Every six months, the Program Specialist will audit signature sheets from all site locations and make any necessary adjustments. This will be an ongoing corrective action plan throughout the existence of CSFP at WOFB. The process will be overseen by the Chief Operations Officer. In addition, all applications will be reviewed thoroughly ensuring the correct income field is marked by the applicant that coordinates with their stated income and dates will be reviewed on each application ensuring the client is eligible and using the correct annual application. The Program Specialist will review at least 10% of the applications currently on file each month. These will also be reviewed by the Chief Operations Officer to check for accuracy. Proposed Completion Date: WOFB?s fiscal year begins July 1 each year. The Program Specialist will conduct training with all program sites by October 30th of the current year. As new sites, staff and/or volunteers distribute food boxes for CSFP, training will be conducted before their first distribution. This process will be ongoing. Beginning January 1, 2023, the Program Specialist will begin reviewing 10% of CSFP applications monthly with the Chief Operations Officer doing a 2nd check and periodically spot-checking applications for the program. This will be ongoing.