Corrective Action Plans

Corrective Action: A review of related GEAR UP grant processes and eligibility requirements for students currently involved in the programs will be conducted by June 30, 2023. Additionally, records and reviews of student participation in GEAR UP activities will be performed on a monthly basis. Timeline of Corrective Action: The review of student participation will begin by November 30, 2022. Responsible Party(ies): GEAR UP Program Director; Roswell Campus

Corrective Action: (SSS): SSS will verify student?s low-income levels for those with a FAFSA on file by having the University?s Financial Aid Department confirm that the student?s income is low-level per the Student Aid Report and FAFSA University?s Financial Aid Department confirm that the student?s income is low-level per the Student Aid Report and FAFSA. The EFC that is listed at $0 is information that is derived from the institution?s Financial Aid Department that is uploaded into Banner once the department verifies the information which comes from the FAFSA and parent/student taxes. (TS): Students in question were offered allowable activities (e.g., tutoring, career/college exploration) by TS program staff. However, these eight students elected to forgo involvement in permissible activities. During the audited period, the former TS program director retired and a new program director was hired. There was no overlap between the former and new program director. The TRIO Tracking Specialist reviewed, signed, and initialed documents in the absence of the TS Director. The applications audited show evidence of the initials of the TRIO Tracking Specialist which was intended to provide evidence of internal program control. Timeline of Corrective Action: 1. The above processes will be put in place by December 31, 2022. 2. A review of related TRIO grant processes and eligibility requirements for students currently involved in the programs will be conducted by June 30, 2023. 3. In addition to the above steps, the Roswell campus is in the process of reviewing the job description for a grants director to oversee federal grants. This position would include oversight of compliance with federal rules, regulations, guidelines, and campus policies. The ENMU-Roswell Campus HR office reviewed the grants director job description and started the process of posting this position on October 24, 2022. It is anticipated this position will be filled by January 31, 2023. 4. Additional compliance discussion sessions and grant requirement reviews for the involved TRIO grant program directors will take place in November 2022 with the campus senior leadership. Responsible Party(ies): Roswell Campus; Assistant Vice President of Student Affairs

Reference Number 2022-004: The Office of Property Operations has reviewed the audit finding report and recommendations. The department will implement steps to monitor compliance with Public Housing program policies to ensure staff perform timely annual re-certifications, following established guidelines and retaining acceptable documentation to support resident eligibility determinations and subsequent re-certifications. These items include: ? Ensuring all initial eligibility information is received at the time of unit leasing ? Updating protocols for documenting the re-certification process, including file checklists to ensure all documents are in the resident file ? Re-establishing a file audit protocol to be performed on a quarterly basis ? Closely monitoring delayed re-certifications, including written documentation regarding any delays ? Creating a standard operating procedure to document any delays in re-certifications that may impact the timeliness and accuracy of data reported to the HUD system ? Scheduling recertification training for all staff involved in the re-certification process before June 30, 2023 Contact Information: Michelle Hasan, Director of Leased Housing

2022-003 Student Eligibility View of Responsible Officials Management agrees with the finding and recommendation. Corrective Action Plan The Community Education Specialist will create written AEFLA participant eligibility procedures for AEFLA-funded adult schools based on USC ?3272 and ?3102. The procedures will inform the adult school staff of the following: ? The Workforce Innovation and Opportunity Act ? The Adult Education and Family Literacy Act ? The relevant US Code and Code of Federal Regulations ? A definition of AEFLA-eligible individuals ? Categories of funding and their purpose ? The role of the US DOE Office of Career Technical and Adult Education ? The role of Hawaii state director (Community Education Specialist) for adult education ? The role of the AEFLA-funded local service providers The procedures will be disseminated to all AEFLA-funded adult school staff, and training will be provided. Contact Person: Dan Miyamoto, TA Community Education Specialist Curriculum Innovation Branch Office of Curriculum and Instructional Design Anticipated Completion Date: August 31, 2023

Finding 2022-001 Activities Allowed or Unallowed and Eligibility Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (HRSA COVID-19 Uninsured Program) Mercy Community: Various Award Number: Various Award Period of Performance: 07/01/2021?March 2022 Condition: Mercy Health did not retain supporting documentation over the HRSA COVID-19 Uninsured Program report query logic (the Report) that was developed to identify patients that meet the allowability and eligibility requirements of the HRSA COVID-19 Uninsured Program. In addition, supporting documentation was not retained to validate who had access to modify and run the script, what changes were made to the script, and how any changes to the script were tested and implemented during the fiscal year based on changes to Health Resources and Services Administration (HRSA) guidance. Further, management did not maintain supporting documentation to demonstrate how it validated the completeness and accuracy of the data extracted by the script. In addition, Mercy Health did not retain supporting documentation over its approval of HRSA COVID-19 Program claims, determination of a patient's uninsured/self-pay status, and review of credit balances. While management had a process to identify and review claims for allowability under the HRSA COVID-19 Uninsured Program, determine a patient's uninsured/self-pay status through third-party insurance discovery, and review of credit balances, sufficient supporting documentation was not retained to support internal controls over the process. Cause: Development of the Report occurred outside of the Information Technology (IT) department that would require a formal process for the development of IT reports, access and program changes; the report resided in the Revenue Cycle department. The Revenue Cycle department did not develop internal control over report writing, program changes and user access. In addition, while management represented that the Report?s logic and subsequent changes to the Report?s logic were reviewed, no audit evidence was retained to support internal controls over that process. Management represented it performed a review of claims charged to the HRSA COVID-19 Uninsured Program for allowability; however, supporting documentation to evidence that the internal controls were sufficiently designed and operating effectively was not maintained. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances used in the federal program were not suitability designed to address the unique aspects of the HRSA COVID-19 Uninsured Program. Views of Responsible Officials and Planned Corrective Actions: In March 2022, HRSA announced that the HRSA COVID-19 Uninsured Program was ending. Therefore, remediation of internal controls is no longer applicable. If this program is reinstated, Mercy will take the necessary steps to ensure proper documentation is retained to provide evidence of our internal control processes. Responsible Parties: Mercy?s Revenue Management Department Date of Completion: Not applicable since program has ended.

Finding 2022-006 Untimely Review of SSI Termination Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Training was conducted on the Untimely Review of SSI Termination topic with staff specifically concerning finding areas of SSI exparte reviews being tracked, documented (including updating of evidence and task status), completed timely and monitored to follow up within appropriate policy timeframes. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Proposed completion date: 11/17/2022

Finding 2022-005 IV-D Cooperation with Child Support Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Training was conducted on the IV-D Cooperation with Child Support topic concerning IV-D referral completion, documentation and appropriate follow up procedures with staff. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to this policy. Proposed completion date: 11/16/2022

Finding 2022-004 Inadequate Request for Information Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Training was conducted on the Inadequate Request for Information topic with staff specifically concerning finding areas of The Work Number and OVS being run as required by policy, property checks being completed at application and review, and documentation being completed concerning the responsibility for shelter costs as it pertains to In-Kind and 1/3 Reduction policies. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Proposed completion date: 11/16/2022

Finding 2022-003 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Training was conducted on the Inaccurate Resource topic with staff specifically concerning finding areas of correct determination and entry of vehicles including updating of vehicle values, ensuring all vehicles are addressed and documented appropriately at application and redetermination and rebuttals are documented and entered appropriately. Training was also conducted concerning appropriate documentation and verification of assets such as bank accounts are completed and entered appropriately. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Proposed completion date: 11/16/2022 and 11/17/2022

Finding 2022-002 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Training was conducted on the Inaccurate information topic with staff specifically concerning finding areas of correct determination, documentation and entry of income and appropriate determination, documentation and entry of household composition are completed. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Proposed completion date: 11/16/2022

Finding 2022-001: It was noted that BOCES allowed an adult student to take classes who was not eligible to take the class. Recommendation: To prevent future occurrences of this deficiency, we recommend that management begin to follow all aspects of their eligibility checklist to ensure all proper documentation is gathered and retained and determination is made and if student is ineligible they are not enrolled. Corrective Action Plan: Effective immediately (3/23/23), BOCES will review policies and procedures to ensure only eligible students are enrolled in the program. Adult Ed Coordinator will communicate to the staff the importance of only having eligible students in the program and adjust the existing checklist accordingly to ensure accuracy of use. Clerical staff will follow the approved checklist system to ensure that students meet all eligibility requirements prior to acceptance into the program

2022-002 Student Financial Aid Cluster ? (a) Federal Supplemental Educational Opportunity Grant (b) Federal Work Study Program (c) Federal Perkins Loan Program (d) Federal Pell Grant Program (e) Federal Direct Student Loans (f) Teacher Education Assistance for College and Higher Education Grants, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 (f) 84.379 ? Year Ended June 30, 2022. Condition: In one of the 40 student files tested (2.5%), Subsidized and Unsubsidized Direct loans we not properly awarded. The College under awarded the student $5,500 in Subsidized loans and over awarded the student by $5,500 in Unsubsidized loans. Corrective Action Plan: Jayne Schreck has reviewed the student?s file and the circumstances surrounding the instance of non-compliance. The college does have systematic policies and procedures in place to properly evaluate a student?s file and determine the proper levels of Subsidized and Unsubsidized Loan. The systems used did calculate the loan split properly as documented in the student?s paper file. The error was a human error caused when keying the amounts and codes into the computer system. Jayne has asked her staff to split duties whenever possible. For example, one person may calculate the package but a different person should key the information into the computer system. Human error is human error, it can happen, but having two sets of eyes on each file might help to minimize the risk of error. Responsible Person for Corrective Action Plan: Jayne Schreck, Associate VP for Student Financial Planning Implementation Date for Corrective Action Plan: September 2022

View of Responsible Officials and Corrective Action Plan ? Although the Organization has a secondary review process and a checklist in place to assure that clients are eligible and all required documentation is in place prior to authorizing payment assistance, the review processes will be corrected and improved in the following way: 1. Supervisor(s) will verify on the checklist that they have opened, viewed, and scrutinized all uploaded verifications to assure that the documentation meets funding source criteria and complies with eligibility standards set by the funding source, not simply note the presence of an uploaded document or concur that the client is eligible. 2. Another review of each file will be completed prior to any financial assistance payments being processed by the Associate Director for Housing. The purpose of this tertiary review is to monitor compliance with the updated checklist and approval process. Any errors will be noted and discussed with both the case manager and the supervisor. A log of the approvals and denials will be maintained and used to plan future training to ensure compliance. 3. When proof of eligibility is uploaded in a third-party system (such as the MSHDA CERA portal), OLHSA will retain the documentation in its local databases as well and a supervisor be required to indicate on the checklist that this step has been completed.

Planned Corrective Action: Once Project Safeguard realized that the organization didn?t have a copy of the file from the Board of Directors from the Executive Director having been hired in 2013, Project Safeguard has rectified the situation by replacing the missing i-9 with an updated i-9 with attestation in accordance to guidance from UCIS . All I-9s are completed and maintained in a separate file as soon as employment begins and E-verify is completed within three days of employment as stated in the Project Safeguard policies. Name of Contact Person: BethAnne O?keefe, Finance Director Anticipated completion date: This was completed and the updated I-9 with attestation as soon as the I-9 documents were requested on 03/08/2023.

Recommendation: The Organization should implement internal controls to monitor the activities and third-party providers to ensure the services being provided are in compliance with Federal Statues. Action: The Organization has scheduled regular meetings (twice per month) with the property management company to monitor the activities of the provider to ensure we are in compliance with Federal Statues.

Recommendation: The Organization should perform annual recertifications timely. Action: Effective February 1, 2023, the Organization has engaged with a different property management company with expertise in the HOME program. We are currently working a corrective action plan with 30-, 60- and 90-day deliverables.

2022-002 Department of Housing and Urban Development, Assistance Listing Number 14.239, Home Investment Partnership Program and 14.267 Continuum of Care Program: Control Deficiency Criteria: To meet the various aspects of program compliance, tenant files should have documentation that includes income verification, eligibility determination and current rental agreements. Condition: Tests of tenant files identified instances .where not all documentation was able to be located. Cause: Housing Initiatives, Inc. does not have a consistent process and recordkeeping system that ensures all tenant files are complete or that all applicable records are available timely. Effect: Without the necessary documentation to verify that tenants meet the various compliance requirements, there may be instances of noncompliance. Recommendation: We recommend that Housing Initiative develop processes and procedures to ensure that all tenant files are complete and include all necessary documentation to verify compliance. Response: Housing Initiative, Inc. is aware of the compliance requirements and the importance of complete tenant files. We have been working towards updating records and utilizing electronic records systems which may have resulted in not being able to find the documentation during testing. We feel tenant files and records should be complete in the future. Housing Initiatives, Inc.'s Corrective Action Plan: Regarding financial reporting finding, Housing Initiatives staff will continue to work with the same auditing firm to ensure that reporting for the current year is in line with GAAP requirements. In part, this will involve strengthening the agency's relationship with a third-party accounting firm. A recent merger involving the firm that Housing Initiatives used for the past several years provides an opportunity to involve a different firm. As regards the second finding, Housing Initiatives recognizes the importance and requirement of maintaining all required documentation for clients served. A review of all files will be implemented to reveal any incomplete documentation, and then steps taken to address any omissions.

Name of Contact Person: Dr. Kim Scott, Director of Public Housing Corrective Action/Management?s Response: The issues regarding applicant files was one of the first control issues identified when I came to the City. A written action plan has been developed with the approval of our local Housing and Urban Development field office. Each applicant is being reviewed at their anniversary date to obtain complete records of documentation to support eligibility. Proposed Completion Date: Immediately and ongoing.

Condition: The College did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 23 of the 40 students in the sample (57.5%). We consider this condition to be a material weakness in internal control over compliance relating to the Eligibility compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2021-003. Statistical sampling was not used in making sample selections. Corrective Action Plan: It is important to note that the entire 2021/2022 award year was processed by 3rd party servicer, Fully Disbursed. The current Financial Aid staff at Blackburn College started in October of 2021 but the processing was conducted by Fully Disbursed as they were under contract with Blackburn College for all 2021-2022 processing and packaging until August 2022 at the completion of the summer semester. The Financial Aid Office must emphasize the importance of accurate record-keeping in financial transactions. As a department we will continue to work closely with the Business office to ensure that every drawdown is properly documented and matches the corresponding dates and amounts. Additionally, we will continue to perform monthly reconciliations to ensure that any discrepancies are identified and addressed promptly. This process helps to minimize errors and maintain transparency in our overall financial aid operations. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: Fall 2022

Condition: Two of the 40 student files (5%) we examined, we noted the students were not properly awarded Direct loans. Further, we noted two of the 40 students (5%) were not properly awarded Pell. Corrective Action Plan: It is important to note that the entire 2021/2022 award year was processed by 3rd party servicer, Fully Disbursed. The current Financial Aid staff at Blackburn College started in October of 2021 but the processing was conducted by Fully Disbursed as they were under contract with Blackburn College for all 2021-2022 processing and packaging until August 2022 at the completion of the summer semester. The Financial Aid Office at Blackburn has evaluated and revised policies and procedures to ensure students receive the proper amount of Title IV Aid. Reconciling each month is necessary to ensure we catch any and all discrepancies that may occur. We will continue to utilize all available software to assist with packaging and that will allow all financial aid, including Title IV funds, to be reviewed frequently by both the Director of Financial Aid and the Assistant Director of Financial Aid. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: April 2023

Finding 2022-009: Eligibility-Significant Deficiency and Noncompliance Condition: For three of the twenty-five students selected for testing, the Pell Award calculation was not correctly performed, and the students did not receive an adequate amount of Pell Award for the period under audit. Responsible for the Plan: Janet Davidson, Director of Financial Aid Planned completion date: June 30, 2023 Corrective Action Plan: To ensure compliance with eligibility requirements the college will adopt the following procedure: ? The Financial Aid Assistant/Loan Officer will review the daily registration changes report to determine the students enrollment status for each term and then set the appropriate class load in Powerfaids in the POE screen. ? Powerfaids uses that class load screen and the Pell payment schedules to determine the students pell grant award. ? The Director of Financial Aid will work with IT/IR to create a report that details the pell load in Powerfaids to match it against current credit load in Jenzabar to ensure that the student has the appropriate credit load in Powerfaids and the appropriate Pell awards are disbursed.

Management agrees that they submitted the same invoice twice. The amount of the invoice was $700. They also believe that there were many expenses incurred of which they could have submitted and therefore have not used the grant monies inappropriately. We agree that a more in-depth review could be done for future submissions.

Finding 2022-001 ? Federal Assistance Listing Number 14.157 Statement of Condition: In connection with our lease file review, we noted: 1. One instance of one tenant tested where management did not maintain move-out inspection forms in the lease file. 2. One out of one tenant tested income verification was not performed with the use of the HUD enterprise Income Verification ("EIV") or other verification methods. 3. One out of two tenants tested recertification was not performed timely. Corrective Action: Due to either tenant non-compliance or challenges with scheduling meetings with tenants or obtaining verifications, some recertifications were completed late. REACH has policies in place to complete recertifications timely, and will be providing ongoing training and guidance to staff to make sure the policies are being followed. Management has a policy for conducting move-out inspections and completing the move-out form, and will review this policy and procedure with staff to make sure it?s followed on all move-outs.

Finding No. 2022-003; Federal Assistance Listing Number 99.999 Statement of Condition: In connection with our lease file review we noted that one out of two tenants tested did not have income verification in connection with the preparation of the recertification. Corrective Action: Due to either tenant non-compliance or challenges with scheduling meetings with tenants or obtaining verifications, some recertifications were completed late. REACH has policies in place to complete recertifications timely, and will be providing ongoing training and guidance to staff to make sure the policies are being followed.

Name of Responsible Individual: Jenn Hall, Director of Financial Planning Corrective Action: The Financial Planning Office has reviewed its policies surrounding FSEOG awarding and added additional quality control measures for the 2022-2023 award cycle so that FSEOG funding is provided solely to PELL recipients. Anticipated Completion Date: December 31, 2022