Corrective Action Plans

U.S. Department of Education 2022-003 Education Stabilization Fund- Reporting Assistance Listing No. 84.425E Recommendation: We recommend the College obtain an understanding of the reporting requirements established by the grant to ensure reports do not report on a cumulative basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All quarterly reports have been updated and will be published as revisions on our COVID webpage. We will also send the revisions to the UD Department of Education?s HEERF reporting email, as required. Name(s) of the contact person(s) responsible for corrective action: Joseph Holt Planned completion date for corrective action plan: May 1, 2023

2022-001 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 1,436 tenants, 43 tenant files were tested and the following deficiencies were noted: ? 13 files had incorrect utility allowance calculations, ? 12 files had an incorrect income calculation, ? 2 files utilized incorrect payment standard, and ? 1 file was missing the 214 declaration for all tenants in household. 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 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: This audit provides an opportunity for the Lakeland Housing Authority staff in correcting problems identified during the audit, we are implementing new procedures and increasing staff proficiency. The plan is as follows: ? The department under the supervision of Carlos Pizarro has hired an additional Quality Control and Compliance Specialist Courtney Mitchell, from now until done she will be leading with the assistance of the program's Assistant Manager Alondra Baez a full 100% file audit, ? The current staff will be re-trained on income calculation, file management, fair housing, occupancy, inspections, SEMAP, etc? ? The staff will continue to use a quality control sheet while processing all recertifications or changes, ? The HCV program issued a task order to one of the consultants to help us monitor the progress of our internal file audit.

2022-002 Eligibility Public and Indian Housing Program ? AL No. 14.850 Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 257 tenants, 30 tenant files were tested and the following deficiencies were noted: ? 5 files had incorrect income calculations, and ? 1 file was completed but not entered into the system. 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 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: This audit provides an opportunity for the Lakeland Housing Authority staff to correct problems identified during the audit, we are implementing new procedures and increasing staff proficiency. The plan is as follows: ? The department under the supervision of Carlos Pizarro has entered into a contract with a company named Preferred Compliance, we will be asking them to do a 100% review on all the public housing files, they are already reviewing all the files including admissions for the Low-Income Housing Tax Credits, ? The current staff will be re-trained on income calculation, file management, fair housing, occupancy, inspections, etc? ? The staff will continue to use a quality control sheet while processing all recertifications or changes,

We agree with the finding of the auditor. During 2022, the organization experienced a significant increase in grant activity and certain personnel changes. We believe that all required documentation was obtained, we were unable to locate these documents. We have implemented a final file review process to ensure that all documents are filed in the appropriate participant files.

December 20, 2022 The City of Lynchburg, Virginia respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 3906 Electric Road Roanoke, VA 24014 Audit period: June 30, 2022 The findings from the June 30, 2022 Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the-Schedule. FINDINGS AND QUESTIONED COSTS - MAJOR FEDERAL AWARD PROGRAM AUDIT 2022-001: Controls over Benefit Approval - Supplemental Nutrition Assistance Program - Assistance Listing #10.651 Condition: During our review of eligibility, we noted that one individual's income was not reviewed resulting in additional benefits until the error was identified. Criteria: All support for individual's income should be reviewed to ensure benefits are accurate. Cause: The case worker entered the number incorrectly and it was not reviewed. Effect: Individual was paid SNAP benefits for four months that they were not eligible for. Questioned Costs: An overpayment of $1,743. Perspective Information: One out of twenty-five tested. Repeat Finding: No. Recommendation: We recommend that all inputs are reviewed by supervisors to ensure calculations are correct. Corrective Action: Management agrees with the finding and has taken immediate action to ensure all inputs are reviewed by supervisors to ensure all calculations are correct. If the Federal Audit Clearinghouse has questions regarding this plan, please call Rhonda Allbeck, Assistant Director of Financial Services at 434-455-4218. Sincerely yours, Rhonda Allbeck. Assistant Director of Financial Services

2022-001 Sliding Fee Discount Determination Name of Contact Person: James Chen, CFO Corrective Action: Asian Health Services will: - Immediately retrain the staff involved in Sliding Fee Discount Program on proper documentation requirements and implementation of sliding fee determination and billing including scanning of documentation to Epic EHR. - Perform periodic audits of sliding fee documentation and transactions. Proposed Completion Date: June 30, 2023

Higher Education Emergency Relief Funding (HEERF) ? Assistance Listing No. 84.425 Recommendation: We recommend the colleges reevaluate their procedures surrounding allowable costs and costs being charged to the grant to ensure all are allowable costs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Clarkson College has reevaluated their procedures surrounding allowable costs and costs being charged to the grant to ensure all are allowable costs. The employee responsible for this finding is no longer associated with the college.

CORRECTIVE ACTION PLAN Project Legal Name: Evangeline Booth Garden Apartments Ocala, FL (A Project of Evangeline Booth Residence, Inc., a Florida Corporation) HUD Project No.: 063-EE011-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2021-9/30/2022 Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding Access to the Enterprise Income Verification (EIV) system [the system used to access Social Security information and Health and Human Services information] was not available due to the incorrect tax ID being identified to The Salvation Army personnel who had transitioned from another The Salvation Army HUD Project location. It took considerable efforts to get this corrected with HUD. The appropriate access to the system has now been given to the new personnel of this Ocala HUD Project. This lack of access may have impacted the early part of FY 2023. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations 1. Finding 2021-001 In Process. See finding 2022-001 2. Finding 2021-002 Cleared. 3. Finding 2021-003 Cleared.

CORRECTIVE ACTION PLAN Project Legal Name: Evangeline Booth Garden Apartments Pasadena, TX (? Project of Evangeline Booth Residence, Inc., A Texas Corporation) HUD Project No.: 114-EE095-NP-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2021-11/11/2021 (day before sale) Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. b. Action(s) Taken or Planned on the Finding The property was sold subsequent to September 30, 2021 reporting period with HUD approval and all reserves were transferred to buyer, therefore we consider this matter closed. 2. Finding 2022-002 c. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation management should either review the Project budget to determine if nonessential costs can be cut to ensure that the replacement reserve is funded in accordance with the terms of the regulatory agreement or management should obtain HUD approval to waive the remaining underfunded deposits due to the balance of the reserve exceeding $1,000 per unit. d. Action(s) Taken or Planned on the Finding The property was sold November 12, 2021 with HUD approval and all tenant files were transferred to buyer, therefore we consider this matter closed. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations 1. Finding 2021-001 Unresolved. See Finding 2022-002. 2. Finding 2021-002 Unresolved. See Finding 2022-001 3. Finding 2021-003 Cleared. 4. Finding 2020-001 Unresolved. See findings 2022-002 and 2021-001. 5. Finding 2020-002 Unresolved. See findings 2022-001 and 2021-002. 6. Finding 2019-002 Unresolved. See findings 2022-001, 2021-002, and 2020-002

CORRECTIVE ACTION PLAN Project Legal Name: Catherine Booth Garden Apartments Waco, TX (? Project of Catherine Booth Residence, Inc., A Texas Corporation) HUD Project No.: 113-EE005-NP-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2021-1/12/2022 (day before sale) Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation that management should establish procedures and monitor compliance with those procedures to ensure that tenant eligibility is correctly determined and that tenant lease files are properly maintained. b. Action(s) Taken or Planned on the Finding N/A. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations Finding 2021-001 Cleared. Finding 2021-002 Unresolved. See finding 2022-001

CORRECTIVE ACTION PLAN Project Legal Name: Catherine Booth Garden Apartments San Antonio, TX (? Project of Booth Residence San Antonio, Inc., a Texas Corporation) HUD Project No.: 115-EE072 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2021-1/11/2022 (day before sale) Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 2. Finding 2022-002 c. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation that management should establish procedures and monitor compliance with those procedures to ensure that tenant eligibility is correctly determined and that tenant lease files are properly maintained. d. Action(s) Taken or Planned on the Finding Management agrees with the finding The property was sold subsequent to year end and the current management agent did not provide the requested documents. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations 1. Finding 2021-001 Unresolved. See finding 2022-002 2. 2021-002 Cleared. 3. 2021-003 Cleared.

CORRECTIVE ACTION PLAN Project Legal Name: Catherine Booth Gardens of Tyler (A Project of Catherine Booth Gardens of Tyler, Texas, Inc., A Texas Corporation) HUD Project No.: 113-EE064 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2021-11/3/2021 (day before sale) Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 2. Finding 2022-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding and auditor?s recommendation to implement procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD, even during transition of management and/or ownership. b. Action(s) Taken or Planned on the Finding The property was sold November 4, 2021, therefore management plans to contact HUD to determine the appropriate handling of this situation. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations 1. Finding 2021-001 Unresolved ? see finding 2022-002.

CORRECTIVE ACTION PLAN Project Legal Name: Catherine Booth Gardens of Tyler (A Project of Catherine Booth Gardens of Tyler, Texas, Inc., A Texas Corporation) HUD Project No.: 113-EE064 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2021-11/3/2021 (day before sale) Corrective Action Plan prepared by: Name: Sriparna Mitra Position: HUD Specialist, THQ (Legal) Telephone Number: 404-728-6700 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation management should establish procedures to create and maintain a wait list for applicants in accordance with HUD guidelines even during transition of management and/or ownership. b. Action(s) Taken or Planned on the Finding The property was sold November 4, 2021, therefore management plans to contact HUD to determine the appropriate handling of this situation. 2. Finding 2022-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding and auditor?s recommendation to implement procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD, even during transition of management and/or ownership. b. Action(s) Taken or Planned on the Finding The property was sold November 4, 2021, therefore management plans to contact HUD to determine the appropriate handling of this situation. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations 1. Finding 2021-001 Unresolved ? see finding 2022-002. 2. Finding 2021-001 Cleared.

View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. After contracting a third-party entity to review 10% of our files in Oct 2022, findings of said review led to the recommendation to retrain staff. 2. All Managers and assistant Managers received HCV & PH Rent Calculation Training In June 2023. 3. We are also currently working with our TA from HUD, Ms. Valerie Jackson. Ms. Jackson has identified, and is about to roll out training for our staff, to uniform and streamline our tenant files.

Corrective Action Plan and Views of Responsible Officials LVUSD is challenged each year to reach our MOE given our unique programming as a school district. Staff will review progress toward MOE biannually to ensure compliance and tight oversight over these funds.

Finding 2022-001 ? Eligibility Audit Finding: Documentation of review and approval of the participant information should be completed prior to awarding eligibility to participate in the program. Audit Recommendation: We recommend Denver Indian Center, Inc. and Subsidiary use the checklists in the participant files to ensure all information is retained and/or reviewed as the internal control over eligibility. Management?s Response and Corrective Action Plan: Per the recommendation of the auditor, all staff have been trained and checklists will be used to verify eligibility. We are also currently reviewing previous cohorts to correct the oversight. Contact and Completion Date: Steve ReVello (steve@denverindiancenter.org), Co-Executive Director, and David Wright (david@denverindian.org), HFP Manager, are the contacts responsible for the correction action. The expected completion date of the remedy is March 31, 2023.

Finding Number: 2022-002 Condition: WakeMed charged costs associated with ineligible individuals to the grant. During testing of 60 patients, we identified one patient who should not have been submitted to HRSA for reimbursement, as they were covered by insurance and, therefore, ineligible. Planned Corrective Action: WakeMed identified all HRSA patients with other documented insurance within the system. Each claim was reviewed to identify patients with active insurance coverage. Patients identified with active insurance coverage were considered ineligible for grant purposes, and the HRSA payments are in the process of being refunded. These costs were removed from the SEFA. In addition, WakeMed has written off all outstanding HRSA claims. Contact person responsible for corrective action: Terry Flynn, Director, Reimbursement Anticipated Completion Date: 06/14/2023

Management?s Response: Lamar Housing Authority will begin making a copy of what is put in MINC and will check income from the worksheet we get at the beginning of each month before we submit it we will make changes to what was submitted into MINC, this will be a double check of income to make sure it was entered into MINC correctly.

ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.767 For the one instance ?where the social security number, age, date of birth, and immigration status was not verified in the Data Exchange System,? the DHHR Bureau for Family Assistance has requested the creation of an administrative report to identify cases without a social security number entered in applicable case records. This report will be available by February 28, 2023 and will eventually be generated on a quarterly basis. For the nine instances ?where income was not verified,? the DHHR Bureau for Family Assistance will develop additional training that is targeted at both the verification of income and non-financial factors such as date of birth, age, and social security numbers. The training materials will be available to field staff by March 31, 2023 and will include a mandatory completion date of April 30, 2023.

SPECIAL TESTS AND PROVISIONS ? PROVIDER ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.767 For the population related to provider eligibility, the auditors were provided a population/report of active providers, which the auditors used to select their sample. To determine if a provider is enrolled or terminated, the provider record must be accessed, and the enrollment effective date and termination effective date must be viewed. The termination dates on the provider record are accurate in HPAS (claims processing/payments system), as the claims processing system refers to the dates on the provider record. However, radio buttons in HPAS, system do not accurately reflect active enrollment. Claims submitted by terminated providers (providers with no active enrollment) are denied. The processing system looks for a termination date on the provider record and denies claims for providers with termination dates. No payments were made to providers with terminated enrollment and no claims payment errors were identified. Two other errors identified resulted from human error. One provider was erroneously indicated as enrolled with CHIP but had no CHIP contract attached in the system, and one provider did not receive an approval letter. Continuing training will be conducted with provider enrollment staff to ensure plan relationships are removed if not applicable and that letters are manually generated when the application is also manually reviewed.

SPECIAL TESTS AND PROVISIONS ? INCOME ELIGIBILITY AND VERIFICATION SYSTEM Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The Income and Eligibility Verification System (IEVS) provides the DHHR Bureau for Family Assistance (the Bureau) with sources of information for use in determining eligibility and the amount of the benefit for applicants and recipients. Procedures established to assist in the prevention of fraud and abuse in the form of computer matches are utilized. The social security number of the applicant or recipient is matched against the files from the West Virginia Bureau of Employment Programs, the Internal Revenue Service, and the Social Security Administration (SSA). The State Online Query (SOLQ) provides direct access to SSA?s databases. Information received includes SSN verification; Supplemental Security Income (SSI); and Retirement, Survivors, and Disability Insurance (RSDI) details. Requests can be made only for individuals known to the eligibility system within the previous five years. The Bureau?s Policy Unit will collaborate with the Bureau?s Division of Professional Development to create a more detailed and precise training for the IEVS System. The blackboard platform will allow supervisors to track workers that have completed the training. The anticipated date for completion is June 30, 2023. Furthermore, the Policy Unit will send out various IEVS Policy Reminders and will work to revise the IEVS User Guide.

Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 The DHHR Bureau for Family Assistance (the Bureau) analyzed the condition that led to this finding. The emergency supplement in question was paid on the initial month of SNAP issuance. However, these supplements were not to be based on the initial or prorated months of SNAP benefits. Per the U.S. Department of Agriculture, Food and Nutrition Service (FNS), emergency supplements were not to be initiated until the second month of SNAP issuance (i.e., the month following active SNAP approval). The emergency supplement allotments will end February 28, 2023. If the FNS instructs the Bureau to issue emergency supplement allotments for the SNAP Program beyond February 28, 2023, the Bureau will develop a blackboard course with video to ensure that all workers are trained on the procedures and policy. The blackboard platform has the capability to track who has completed the training which will ensure supervisors can determine who has or has not completed the required training.

SPECIAL TESTS AND PROVISIONS ? ADP SYSTEM FOR SNAP Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561 Management within the DHHR appreciates and shares the auditors? concern with SNAP program integrity as it relates to the Recipient Automated Payment Information Data (RAPIDS) ADP system. DHHR would note that 7 CFR ? 272.10 begins with, ?(1) Purpose. All State agencies are required to sufficiently automate their SNAP operations and computerize systems for obtaining, maintaining, utilizing, and transmitting information concerning SNAP. Sufficient automation levels are those which result in effective programs or in cost effective reductions in errors and improvements in management efficiency, such as decreases in program administrative costs?? Within the RAPIDS ecosystem for SNAP administration, this automation includes data matching measures undertaken, in compliance with related federal rules as specified in 7 CFR ? 272.8, 7 CFR ? 272.16, etc., to automate the validation of client-provided, worker-input information while mitigating the additional administrative burden of secondary review for all worker interactions with a client?s case. Policy regarding state and federal data matching is laid out in Chapter 6 of the State?s Income Maintenance Manual (IMM), which is available at https://dhhr.wv.gov/bfa/policyplans/Documents/Binder4.pdf. The primary data exchange system detailed in IMM Chapter 6 that is applicable to SNAP is the Income and Eligibility Verification System (IEVS) required by 7 CFR ? 272.8. Systems mandated federally for inclusion in the IEVS include those operated by WorkForce WV, the Internal Revenue Service (IRS), and the U.S. Social Security Administration (SSA). A variety of other sources may also be queried for the purpose of validating client-provided information entered into RAPIDS by a worker, including Veterans Affairs (VA), Beneficiary and Earnings Data Exchange (BENDEX), Beneficiary Earnings and Exchange Record System (BEERS), National Directory of New Hires, and Prisoner Matching with the Department of Corrections as well as the Federal Data Services Hub (FSDH). IMM Chapter 6, page 2 describes the purpose of data matching through the IEVS as follows: Information obtained through IEVS is used for the following purposes: ? To verify the eligibility of the assistance group (AG) ? To verify the proper amount of benefits ? To determine if the AG received benefits that were not entitled ? To obtain information for use in criminal or civil prosecution based on receipt of benefits to which the AG was not entitled. IMM Chapter 6, pages 2-3 further detail the points at which a match with the IEVS must take place: A data exchange in the eligibility system occurs: ? When a new case is created; ? When a new person is added to a benefit; ? When a person?s demographic information is changed; and, ? On a periodic basis for all individuals in the eligibility system, depending on the type of benefit being received. Requirements for independent verification of information when automated data matches fail or report a discrepancy with client-provided, worker-input information are spelled out in IMM 6.4.4. The State believes that these automations, while perhaps not foolproof, are in keeping with both the wording and intent of 7 CFR ? 272.10, 7 CFR ? 272.8, 7 CFR ? 272.16, etc., which aim to automate processes in order to reduce administrative burden and associated costs, such as those that would be associated with a secondary review of all worker interactions with a client?s case. With that in mind, the State commits to working to bolster SNAP program integrity as it relates to the auditors? expressed concerns through completion of the USDA-FNS SNAP System Integrity Review Tool (SIRT) in alignment with USDA-FNS requirements and timelines to ensure that automated processes within RAPIDS continue to comport with federal requirements for ADP systems. The DHHR Bureau for Family Assistance, Division of Performance and Quality Improvement (DPQI), will continue its ongoing SNAP case reviews, as well as continue its efforts to report compliance with monthly requirements for expanded supervisor case reviews conducted and tracked through the Rushmore case review system, as mandated in a December 7, 2022 memorandum to supervisors. Furthermore, the Bureau for Family Assistance will develop additional worker training, to include the reinstatement of face-to-face Statewide Payment Accuracy Conferences, with an aim to ensure that client information is accurately captured in RAPIDS so the APD can perform its automated functions with integrity.

DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 10.542, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, COVID-19 93.777, 93.778, COVID-19 93.778, ARRA 93.778 Enhancing the Quality Control process (by adding other programs to the overall scope and expanding the populations for sampling to include payments that have case data that is initiated and approved by the same person as well as case data that is entered by one person without another level of approval) would prove costly for the DHHR due to the additional staff throughout the DHHR that would be required to accomplish such a task. Although enhancing the Quality Control process is still a possibility, upon further discussions within the DHHR, it was determined that prior to considering such an enhancement, the Bureau for Social Services, Bureau for Family Assistance, and other DHHR units should work together to perform the following: outline the existing internal controls over payments by payment type or program, determine the number of payments per month whereby one employee initiates and approves a payment (in relation to the population of all payments) and conclude on the risk of those payments being improper. Management can then identify areas of focus to conclude on the adequacy of the internal controls and make revisions to policies and procedures, if necessary. In short, although there are existing controls in place, the controls have not been documented and communicated to the State?s independent auditors in an effective manner.

COVID-19 CCDF Cluster - Assistance Listing 93.575, 93.596 passed through Pennsylvania Department of Human Services - Pass-through Grantor's Number - SAP DC21079943; Temporary Assistance for Needy Families-Assistance Listing 93.558 passed through Pennsylvania Department of Human Services - Pass-through Grantor's Number - SAP DC21079943; Grant period Fiscal Year Ended June 30, 2022. Significant Deficiency Recommendation: STEP should ensure their file compliance review procedures include review of files at the end of periods of presumptive eligibility. Management Response: File compliance review procedures should include review of files at the end of periods of presumptive eligibility. Action Taken: STEP will ensure their file compliance review procedures will include end of periods of presumptive eligibility. Persons Responsible: Melissa Kerschner; Director ELRC Region 7; Tobi Allen, Eligibility Manager Completion Date: February 17, 2023.