Corrective Action Plans

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

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

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

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

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

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

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

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

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

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

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

2023-001: Section 811, Assistance Listing No. 14.181 Three tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD regulations, could not be located as follows: • Two of the files were missing Form HUD-50059, Owner’s Certification of Compliance. Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are completed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Dr. Seanelle Hawkins at (585) 325-6530.

2023-001: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing and the required documentation to determine eligibility, as required by HUD regulations, could not be located as follows: • The file was missing Form HUD-50059, Owner’s Certification of Compliance. Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are completed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the condition and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.

2023-001: Section 811, Assistance Listing No. 14.181 One tenant file was selected for testing. However, this tenant file could not be located. As a result, the following documentation could not be located to determine eligibility, as required by HUD regulations: • Form HUD-50059, Owner’s Certification of Compliance • A completed and signed application • The signed lease agreement • The move-in and move-out inspection forms Recommendation: We recommend the Corporation establish procedures for maintaining tenant files to comply with HUD requirements for verification of tenant information, as required. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all tenant files are properly maintained to comply with HUD regulations. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.

2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compliance Recommendation: We recommend the Corporation establish procedures to ensure that the annual recertifications are performed on a timely basis in accordance with HUD requirements. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.

2023-001: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and the required documentation to determine eligibility, as required by the HUD Regulatory Agreement, could not be located as follows: • One file was missing Form HUD-50059, Owner’s Certification of Compliance Recommendation: We recommend the Corporation establish procedures for maintaining tenant files to comply with HUD requirements for verification of tenant information, as required. Action Taken: Management agrees with the recommendation and the Corporation’s Board of Directors has made the decision to change property managing agents effective January 1, 2024. It is anticipated that the change to a new property managing agent will allow the Corporation to establish procedures to ensure all recertifications are performed and maintained in accordance with the regulatory agreement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Seanelle Hawkins at 585-325-6530.

Corrective Action Plan (CAP) The Ozark Housing Authority (Housing Authority) To the Department of Housing and Urban Development, During the Fiscal Year 2023 audit, the Housing Authority could not locate two tenant files along with one HUD 50058 Reexamination form, two HUD 9886 Authorization forms and three third party verification documents. The Housing Authority’s Executive Director, Dannie Walker, is responsible for implementing the corrective action plan. CAP developed to resolve audit finding: Finding 2023-001 – Tenant Eligibility and Reexaminations We were aware of the tenant file deficiencies before audit fieldwork began and had begun implementing the recommendation of strengthening internal controls over eligibility requirements in addition to having made personnel changes to the eligibility department. The deficiency that led to this finding will be corrected by March 31, 2024.

#2023-004 Material Weakness related internal controls and compliance with Special Tests and Provisions – Verifications: The District did not perform verification of free/reduced meal applications until March 2023. Recommendation: Auditor recommends the District maintain close communication with the Department of Education, particularly during any period when there is a change in manner in which the food service program operates. Action Taken: The Bandon School District will maintain close communication with the Department of Education, particularly during any period when there is a change in the manner in which the food service program operates. The Director of Food Services will also reach out to the verification team to make sure verifications are done promptly. They will also check regularly for incoming applications that also must be verified promptly. Effective May 2023.

#2023-002 Material Weakness related to eligibility for free and reduced price meals: During a transitional year where all meals were being provided free to all students under various funding sources, the District did not actively solicit applications from households and did not process those applications that were received until nearly six months later. Recommendation: Auditor recommends the District maintain close communication with the Department of Education, particularly during any period when there is a change in manner in which the food service program operates. Action Taken: The Bandon School District will maintain in close communication with the Department of Education, particularly during any period when there is a change in the manner in which the food service program operates. Director of Food Services will also regularly reach out to ODE’s assigned Nutrition Specialist to verify the certification of students’ classification on free, reduced and paid students is correct. Effective May of 2023.

Corrective Action Plan: While the student was not initially identified, the record was corrected within the appropriate term and the student received the full proceeds of their aid eligibility. The Office of Financial Aid will be notified of grade changes on a weekly basis, if applicable, by the Office of the Registrar who is responsible for documenting and recording corrections to grading. The Office of Financial Aid will recalculate, if appropriate, the student Satisfactory Academic Progress status and make any necessary awarding and disbursement updates to the student’s record. Implementation: The responsible parties include the Office of Financial Aid and the Office of the Registrar with initial submissions within the month of November 2023 and continuing forward until such further efficiencies have been identified.

After discussion with the auditor, senior management understands the importance of having a properly functioning monitoring system in place to ensure that controls that are properly designed are in fact placed in operation and functioning as intended. The compliance manager responsible for implementing the controls over compliance has been terminated, and senior management will institute monitoring procedures to ensure that controls over compliance are both properly designed and functioning as intended.

Management agrees with the recommendation of the auditor, and will ensure that evidence of certification review and approval is documented with a approval stamp or some other documentary evidence.

Lisa Chaney, Nicole Victory and Debbie McGuire Management will provide refresher training to staff on what process to follow in regards to making Child Support IV-D referrals. Management will review and revise current procedures in place to ensure that all required referrals are completed, accurate, sent timely and reflected in the case file within the NC Fast Case Management System Training will be completed by November 17th, 2023

Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented sources of income/resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 17th, 2023

Lisa Chaney, Mandy Edwards, Nicole Victory and Debbie McGuire Management will review cases internally to ensure proper documentation is in place for eligibility. Staff will be provided with refresher training on what information should be included in case files and the importance of this being complete and accurate. Management will review and revise current procedures in place to ensure that all eligibility determination criteria is completed such as online verifications, documented resources and amounts are accurately reflected and retained in the case file within the NC FAST Case Management System. Training will be completed by November 17th, 2023