Corrective Action Plans

Finding No. 2022 007: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 ? 10.561 ? Supplemental Nutrition and Assistance (?SNAP?) Cluster Award Number and Award Year: 7HI4004HI, 7HI400HI4, 7HI430HI4, 7HI400HI5, 7HI430HI5, 7HI460HI6, 227HIHI7F1003 Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $50,000 in monthly payments, out of a population of approximately 195,000 participant files which approximated $986 million in total annual benefit payments, for testing and noted exceptions in three case files as follows: ? One case file where manually entered unearned income and medical expense deduction amounts did not agree with the documentation retained in the participant?s case file. ? Two case files where manually entered income information did not agree with the documentation retained in the respective participant?s case files. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: Remind eligibility staff to ensure that verification submitted by the household and filed in household?s electronic case folder (ECF) along with documentation on cases through DHS 1006 and/or case notes are consistent with what is processed and recorded in the eligibility system - HAWI, and that processing is completed according to Supplemental Nutrition and Assistance Program (SNAP) policy to ensure that households are receiving the maximum amount of benefits they are eligible to receive. The SNAP office would also coordinate with the Staff Development Office to put an extra emphasis on this area when conducting SNAP basic training for new eligibility workers. Expected Completion Date: September 30, 2023 Responding Official: Manuel Banasihan, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator

Finding No. 2022 002: Special Tests and Provisions (Material Weakness) Federal Agency: Department of Health and Human Services AL Number and Title: 93.777, 93.778, and COVID 19 ? 93.778 ? Medicaid Cluster Award Number and Award Year: 2105HIMAP, 2205HIMAP, 2105HIADM, 2205HIADMN Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $21 million of payments out of a total payment population of $223 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned The conversion to the HOKU online provider enrollment system in 2020, the staffing and workload impacts of the COVID 19 public health emergency and the inability to fill key provider enrollment section positions have combined to tax the ability of the Department to come into compliance with the stated criteria. These factors have created backlogs in the processing turnaround time for new provider enrollment applications that have been submitted by providers and are waiting to be processed by the Department. These factors have also hampered the Department?s efforts to timely outreach with providers who are at/over the five-year revalidation threshold. The Department was able to fill the section administrator over the provider enrollment section in June 2022, and also fill a key contract specialist position in August 2022. The Department entered into a new provider enrollment staff augmentation contract with Maximus effective January 1, 2023, and initial vendor performance has been promising. New provider enrollment processing time has been reduced to no more than ten days for certain provider types, and Maximus is on track to eliminate the existing provider enrollment application backlog by the third quarter of 2023. The Department is expecting these changes to result in full compliance with the stated criteria by the end of 2023. Expected Completion Date December 31, 2023 Responding Officials Jon Fujii, MED Quest Division Health Care Services Branch Administrator

#2022-001 Sliding Fee Discounts Documentation U.S. Department of Health and Human Services Health Center Program Cluster: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) AL #93.224 Grants for New and Expanded Services Under the Health Center Program AL #93.527 Recommendation: We recommend the Center provide training to employees to ensure that the sliding fee discounts are being properly applied, supported, and documented. In addition, we recommend the employees administering the sliding fee discounts be properly monitored and supervised to ensure compliance with program documentation. Action Taken: The Mountaineer Community Health Center, Inc.'s management will take the necessary steps to ensure that the sliding fee discounts are being properly applied and documented to support the determination of adjustments to patient charges. Ciro Grassi, Chief Executive Officer is responsible for implementing these procedures by December 31, 2022.

Finding No. 2022 011: Eligibility (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition We selected a non statistical sample of 60 participant files, representing approximately $39,000 of benefit payments, out of a population of approximately 8,700 cases, representing approximately $17.8 million of benefit payments, for testing and noted exceptions in 17 case files as follows: ? Nine case files where eligibility redeterminations were not completed in the timeframe required by the State Plan. ? Seven case files where there was no evidence of a TANF case worker?s signature on the eligibility redetermination form. ? One case file where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Administration for Children and Families (?ACF?) will be notified in writing, within the required timeframe, if additional amendments will be or are made to the current Temporary Assistance for Needy Families State Plan. Expected Completion Date: On-going Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator

Finding No. 2022 010: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition We selected a non statistical sample of 60 case files for testing and noted 11 instances where the Department?s records did not support the use of the income information obtained through Income Eligibility and Verification System (?IEVS?) to evaluate or re-evaluate the benefit calculation. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: It was noted in the Corrective Action Plan, in response to the State fiscal year 2021 audit finding, the DHS 1006 form, ?Eligibility Documentation? (formerly titled ?Interview Documentation?), was revised to require the eligibility of staff to notate the date the Income Eligibility and Verification System (IEVS) query was completed, the findings, and what information was used for eligibility determinations. However, for most of the State fiscal year 2022, the interview requirement for new applicants and annual recertifications for recipients were waived; therefore, the DHS 1006 form was not utilized. Form DHS 1006 will be revised further to create IEVS query fields specifically under Section IX ? Temporary Assistance for Needy Families (TANF) Requirements, and a policy clarification will be issued to remind staff of the IEVS query requirement and instructions on how to complete the DHS 1006 form. Expected Completion Date: September 30, 2023 Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator

Finding No. 2022 004: Special Tests and Provisions (Material Weakness) Federal Agency: Department of Health and Human Services AL Number and Title: 93.767 ? State Children?s Health Insurance Program Award Number and Award Year: 2105HI5022 Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $240,000 of payments out of a total payment population of $7.2 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned The conversion to the HOKU online provider enrollment system in 2020, the staffing and workload impacts of the COVID 19 public health emergency and the inability to fill key provider enrollment section positions have combined to tax the ability of the Department to come into compliance with the stated criteria. These factors have created backlogs in the processing turnaround time for new provider enrollment applications that have been submitted by providers and are waiting to be processed by the Department. These factors have also hampered the Department?s efforts to timely outreach with providers who are at/over the five-year revalidation threshold. The Department was able to fill the section administrator over the provider enrollment section in June 2022, and also fill a key contract specialist position in August 2022. The Department entered into a new provider enrollment staff augmentation contract with Maximus effective January 1, 2023, and initial vendor performance has been promising. New provider enrollment processing time has been reduced to no more than ten days for certain provider types, and Maximus is on track to eliminate the existing provider enrollment application backlog by the third quarter of 2023. The Department is expecting these changes to result in full compliance with the stated criteria by the end of 2023. Expected Completion Date December 31, 2023 Responding Officials Jon Fujii, MED Quest Division Health Care Services Branch Administrator

Finding 2022-002: HOME Investment Partnerships Program ? Eligibility Requirements U.S. Department of Housing and Urban Development, Passed through the City of Pittsburgh ? Assistance Listing Number 14.239, Grant #MC-42-0501 Questioned Costs: Unknown Condition: During 2022, the URA did not have internal controls in place to ensure all Tenant Income Certification forms were reviewed for existing HOME projects. The URA?s current process is supposed to be that external property managers prepare the forms and the URA obtains the forms from the external property managers to review the forms to ensure the HOME projects are in compliance with the eligibility requirements. We reviewed a sample of Tenant Income Certification forms and noted that for one existing HOME project the Tenant Income Certification forms were not obtained by the URA during 2022 and for one HOME project the forms were obtained and in compliance but not signed. In conjunction with the audit, the URA obtained the forms from the one HOME project from the external property managers, and we noted that the forms reviewed were in compliance with the eligibility requirements. Action: The URA is updating its policies and procedures for its annual certification of tenant income and rent compliance for HOME-assisted projects. With the revamped policies and procedures and updated project information, we will be able to complete the annual compliance in a more timely and efficient manner. The URA will complete the remaining tenant income certifications before the end of the calendar year.

Finding Number: 2022-002 Condition: Participant files selected for testing did not include complete information to support participant eligibility Planned Corrective Action: Staff will be retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Supervisor. The Department Manager and Supervisor will continue to utilize all Yardi monitoring reports to ensure the Department is operating in accordance with industry standards. Reporting will be done and monitored monthly to meet set goals. We know and maintain we will work in accordance with HUD rules and regulations where Annual Recertification processes are concerned. Weekly, Department Manager will review the certification pipeline to ensure compliance and follow up with the Housing Specialist to ensure compliance and meeting set weekly and monthly goals and metrics. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2023

Finding Number: 2022-001 Condition: DHC did not complete fiscal year 2022 recertification. Planned Corrective Action: Staff will be retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Supervisor. The Department Manager and Supervisor will continue to utilize all Yardi monitoring reports to ensure the Department is operating in accordance with industry standards. Reporting will be done and monitored monthly to meet set goals. We know and maintain we will work in accordance with HUD rules and regulations where Annual Recertification processes are concerned. Weekly, Department Manager will review the certification pipeline to ensure compliance and follow up with the Housing Specialist to ensure compliance and meeting set weekly and monthly goals and metrics. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2023

Finding Number: 2022-004 Condition: Participant files selected for testing did not include complete information to support participant eligibility Planned Corrective Action: While the Detroit Housing Commission works towards implementing Rent Cafe, an electronic platform to allow applicants, residents, and Management the ability to streamline the continued occupancy and eligibility process, DHC will continue to utilize the manual application process with the following controls in place: 1. There will be ongoing training to support staff in Public Housing Rent Calculation. Within the designated training, Housing Specialists, Property Managers, Assistant Property Managers and Compliance Specialists will focus on correctly calculating subsidy for applicants and residents. Trainings will include but are not limited to properly identifying and verifying income, expenses, allowances, adjusted income, total tenant payment (TTP), utility standards, PHA payment and subsidy standards. 2. Regional Managers will conduct the first line of quality control file reviews. Upon Housing Specialist, Property Manager and Assistant Property Manager's completing Initial Eligibility, Annual and Interim recertifications, Regional Managers will review the proposed certification against the certification's checklist for approval. 3. The Compliance Department will conduct ongoing Quality Control File Reviews on a 10% sample selection of households to ensure timely completion and accuracy of ongoing participant rent determination. a. When deficiencies are identified during a Quality Control review, site staff will have 7 days to cure and upload the corrective file to SharePoint. b. The final quality control review will also include reconciliation for acceptance of the electronic file to PIC. 4 . To address the incorrect utility allowance amounts being utilized to calculate tenant rent, the following will occur: a. DHC's REM Department will work with DHC's IT Department of update the Utility Allowance tables in the housing's Yardi Software. Current utility allowances will be entered in the software's utility allowance table and will prepopulate based on the action type and effective date of the recertification. b. Site staff will include the printed utility allowance chart within the certification with the allowance amount provided clearly identified for review by the Regional Manager when conducting the first line of quality control file review. Contact person responsible for corrective action: Scharre Leslie, Operations Analyst & Compliance Manager Anticipated Completion Date: 6/30/2023

Item 2022-002: Compliance with Client Placement on the Sliding Fee Scale for the Health Center Cluster Program Implementation of Phreesia software will flag any placement discrepancies. Front Desk Staff has completed and signed off of an intensive two-week training. All front desk has been properly trained and will have ongoing and refresher training as needed. Front Desk Staff are required to check their work at the end of the day. We have a dedicated staff member who double checks each SFS registration. The corrected registration packet is returned to the corresponding Office Manager who reviews the corrections with the Front Desk staff member. The Front Desk staff member will make the noted corrections themselves. Front Desk will experience disciplinary action for continued incorrect placements such as write ups, or termination. We conduct an Eligibility Audit on a monthly basis. A report consisting of errors by facility as well as the employee responsible for the errors will be given to office managers and key administrative staff. The information collected is reported during our monthly CPI Committee meetings. Estimated Completion Date: Ongoing Responsible Party Contact Information: Jolene Busby Jbusby@hcmtx.org 936-591-8380 Ext 109

Finding Number: 2022-003 Condition: The University could not provide records to substantiate that the relevant criteria was complied with by the University in all cases. Planned Corrective Action: Train faculty to preserve and provide documentation related to reported last dates of attendance. This will be stored in the university?s enterprise document management system. Contact person responsible for corrective action: Dina DuBuis, Ann Elinski Anticipated Completion Date: February 15, 2023

Response to 2022-002 We agree there were errors in the calculation of lost revenue. The PRF guidance on reporting changed/updated several times over the course of 2 years and some requirements were missed right before the reporting was due. However, the organization?s eligibility did not change and the funded amount was fully supported by the actual loss of revenue calculation required by DHHS. Management will closely monitor future grant reporting. Contact person responsible for corrective action: Eden Ballatan, CFO Anticipated Completion Date: 3/31/2023

Finding 2022-002 Name of contact person: Vivian Tookes, DSS Division Director for Economic Services and DSS Director when appointed. Corrective Action: All cases will utilize guidance provided by Treasury to determine eligibility and will clearly document and store all copies of evidence to support the elig1ibility determination to issue payments. This will also be clearly documented as to the evidence gathered in the case file for each determination. Proposed Completion Date: February 28, 2023.

Finding 2022-001 Name of Contact Person: Vivian Tookes, DSS Division Director for Economic Services and DSS Director when appointed. Corrective Action: After approval of the disbursement, a 2nd party QA check will be completed and documented in the file by a lead or supervisor. This review will satisfy the requirement in the control documents that every case will have a 2nd party review prior to monies being distributed. Proposed Completion Date: February 28, 2023

Corrective Action Plan The University will update written procedures to include an additional manual process, which identifies and updates withdrawals within the National Student Clearinghouse with a higher frequency. These procedures are targeted for the summer term, in which the current year lapse was identified. This will ensure that no one is reported outside of the 60 day window.

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: In late June 2022, known settings and data required by the baseline report were in place, and a small sample of test records passed a basic test. In July 2022, full-term data generated by the PowerCAMPUS baseline tool was submitted to NSCH as a more extensive test for Summer 2022. Due to the discovery of a significant number of SIS data errors for at least two major categories and a quickly approaching deadline, the previous tool was used for that end-of-term enrollment data. In addition, the previous tool was used for earlier registration reporting within the Fall 2022 term. The PowerCAMPUS baseline tool is being updated and tested again during the Fall 2022 term with anticipation that the baseline tool will be used for reporting the final end-of-term enrollment data reported in January 2023. Person Responsible for Corrective Action Plan: Cagan Cummings, CIO and Christy Miller, Executive Director of Financial Aid Anticipated Date of Completion: January 2023

2022-002 Eligibility and Certification Approval Report (ECAR) Award Period: July 1, 2021 to June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matters Recommendation: We recommend the College review its reporting procedures surrounding updating the ECAR to ensure reporting is accurate and completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Tabor College will ensure that ECAR is updated in a timely manner when there is a change in a position of an official for the institution. Name(s) of the contact person(s) responsible for corrective action: Scott Franz, Interim Financial Aid Director Planned completion date for corrective action plan: April 2, 2023

Fiscal Year Ending (?FYE?) 2022 Audit Response Corrective Action Plan Finding 2022-001 ?Housing Choice Voucher Program Tenant Files ?Eligibility-Internal Control over Tenant Files-Noncompliance and Significant Deficiency? RHA Response The Raleigh Housing Authority and Leased Housing Department acknowledge and accept that there were a significant number (27 files of 120 reviewed) of past due annual recertifications during the FYE 2022 review period. The abundance of outstanding annual re-exams started mid-2020. During the height of the Coronavirus pandemic, we changed our process for in-person appointments for completing the Annual Re-exam paperwork to mailing the packets to the families. This caused us problems with obtaining the necessary documentation for processing the recertifications. Also, other agencies that provided the required income/household verifications were closed and families were unable to obtain the required information. The Leased Housing Department modified its procedures and accepted what was minimally allowable based on HUD?s guidance. The staff worked diligently with the families that had outstanding documents to avoid terminating the families which would have likely resulted in homelessness during a national pandemic. There was a moratorium in place that prevented evictions of tenants during that time also. The Leased Housing Department also had a number of vacant positions during this review period. The Client Manager worked a large portion of the previous review period FYE 2021 with two full-time staff person and 2 temporary employees during part of that time. In a department that normally worked with 4 full-time trained employees, this staff reduction and having to train temporary employees slowed the process down. The Leased Housing staff has put the following plan in place to catch up on our annual recertifications and to complete timely moving forward: ? Additional Staffing positions to hire and train o one (1) client specialist ? this team gathers all the required documents and confirms completed properly o two (2) account specialist ? this team calculates the annual recertification income and generates the 50058s transmitted to HUD ? Current staffing positions reassigned to assist including: o 2 Temporary employees o Compliance Officer o Contract Specialist o 2 File Review Specialist ? from Finance Compliance team o Client Manager ? Contract with an outside service provider to help with the volume - We have received quotes from both Nan McKay and Quadel and will look to procure within the next few weeks to help us move through the volume of past due files ? A new tracking system for Annual recertification has been implemented to ensure the number of Annual Re-exams that need to be processed weekly are meet to meet our monthly goals. ? The Client Manager and the Assistant Director of Leased Housing will meet weekly to discuss the progress and work together to meet the monthly lease-up goal. ? Voucher families will be scheduled to come-into the office to pick-up the annual recertification packet and speak to their assigned specialist if needed. ? Voucher families are notified 90-days prior to their annual recertification date and given a time and date to submit the requested documents. If requested documents are not received, the voucher family will receive a pre-term letter with a scheduled appointment to come into the office and meet with the assigned Client Specialist. They will only be given 7-business days to return requested documents after this meeting. If not received the family will be issued a letter of termination. Anticipated Completion: 12/31/22 Person Responsible: Liz Edgerton Respectfully, Liz Edgerton Interim Director

Finding Number: 2022-002 Title and Program Name: HUD Title 24 Part 982 - Section 8 Housing Choice Vouchers Program -CFDA No. 14.871 Category and Award No.: Internal Controls-Eligibility Form HUD-92006, Supplement to Application for Federally Assisted Housing. Section 8 - Award # RQ006 Management Response and/or Corrective Action: The Municipality of San Juan concurs with the finding. As part of the corrective action plan, the Housing Department incorporated the Form HUD-92006 into the system so that it could be included as part of the recertification documents kit. The forms can be filed on the participants case on paper and in a digital form.. Assigned Responsibility: Isamar Pina Rivera (787)480-5500 Director of Housing Department Status: June 30, 2023

Finding Number: 2022-003 Title and Program Name: Section 8 Project Based Cluster-CFDA No. 14.856 Category and Award No.: Internal Controls-Eligibility - Notice of Re-certification sent within 90 to 120 days Awards No. RQ006MR0001, RQ006MR0003 & RQ006MR0004 Management Response and/or Corrective Action: The Municipality of San Juan concurs with the finding. As part of the corrective action plan, the Housing Department reemphasized its technicians and staff in writing on the importance of filing copies of recertification letters once submitted and documenting in the case file any type of communication with the participant. Also, as part of the internal controls the Department will require quality control inspection on a weekly basis once the technicians perform their scheduled recertifications. Assigned Responsibility: Isamar Pina Rivera (787)480-5500 Director of Housing Department Status: June 30, 2023

2022-029 Oregon Housing and Community Services Ensure accessible documentation to evidence compliance with program requirements Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 21.023 Emergency Rental Assistance Program (COVID-19) Federal Award Numbers and Years: ERA 1, 2021 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles; Eligibility Type of Finding: Material Weakness Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.302(a); 2 CFR 200.332(a)(5) Department management is responsible for communicating to subrecipients that they are required to permit the department and auditors access to their records as necessary to ensure the department is compliant with program requirements. To ensure compliance with program requirements, subrecipient records must also be sufficiently detailed. The department passed through $140 million phase one program funds to community action agencies (subrecipients) to provide program delivery. The department performed limited fiscal monitoring during the audit period which included procedures to address compliance with activities allowed and allowable cost requirements for administrative costs. The department did not perform any program monitoring during the audit period which primarily addresses compliance with eligibility requirements. To determine whether the department complied with program requirements for the fiscal year, auditors attempted to reconcile detailed subrecipient ledgers with the intent of selecting and testing sample items at each individual subrecipient organization. We noted issues with two individual subrecipients, resulting in an inability to perform testing procedures over a total of $21,438,521 in program expenditures. For the first subrecipient we were able to reconcile their detailed ledgers to the department?s financial records, however their detailed ledger included pass-through payments to a third organization for program delivery. As a result of the combination of direct and pass-through payments, we were unable to obtain sufficiently detailed data that also reconciled to the department?s financial records to select individual transactions for testing. This subrecipient represents $19,877,962 of the unaudited expenditures. For the second subrecipient we were able to reconcile their detailed ledgers to the department?s financial records and select administrative and program transactions for testing. However, the subrecipient was unresponsive to documentation requests to substantiate expenditures. This subrecipient accounted for $1,560,559 of the unaudited expenditures. We recommend department management obtain and reconcile sufficiently detailed subrecipient ledgers and support to substantiate expenditures to allow for fiscal and program monitoring to ensure subrecipients are administering program funds in accordance with program requirements. MANAGEMENT RESPONSE: We agree with this recommendation. To effectively deliver much needed funds to maintain the housing stability of tens of thousands of Oregonians on the brink of experiencing homelessness during the pandemic, agency staff raced to stand up a first-of-its-kind ?single entry point? program for Oregonians to apply for assistance regardless of zip code. In our efforts to focus on speed we acknowledge that there was insufficient planning and capacity to stand up a large-scale emergency program including sufficient assurances our subrecipients could generate evidence of compliance with program requirements including transaction level details to assist with reconciliation. Oregon?s experience is in line with national findings. According to the January 2021 research brief conducted by the National Low Income Housing Coalition around key program challenges with administering emergency rental assistance programs. Survey respondents listed the two most common limitations to be staff capacity and the completeness of applications. Many agencies leaned on whatever local capacity was available to develop programs, review, and process applications, make payments and conduct outreach. Corrective action plan: OHCS had significant compliance monitoring staff turnover in FY22 leading to incomplete subrecipient monitoring reviews. OHCS completing these reviews would?ve ensured subrecipients had adequate time to produce necessary documentation to evaluate compliance, or if not, subrecipients would?ve been required to take corrective actions. For fiscal compliance, OHCS hired a contractor to perform fiscal monitoring of federal funded Grantees. OHCS also hired fiscal staff to pre-FY22 levels, fully trained them, conducted coordinated working sessions, and reached out to the CAA network for discussions on improving processes. OHCS continues to work with the contractor for much needed assistance in monitoring of back log while internal staff move forward to allow for all monitoring to be back on schedule and coordinating both fiscal and program compliance during future fiscal years. Program compliance employees have been hired and compliance efforts are underway. All providers will have internal compliance visits at regular intervals to ensure they have necessary documents and eligibility is being determined in compliance with program requirements. Additionally regular and ongoing check ins and trainings are being offered by program staff. Finally, program compliance teams are working with the Finance compliance team as well as a contracted expert to develop systems and processes in alignment with the Finance compliance team. As a result of program compliance efforts, a risk evaluation is being developed and incorporated into future contracting decisions. Efforts in hiring and systemic investments in infrastructure, processes, and procedures in addition to partner communications have taken place to ensure agency readiness in the event another emergency occurs. As part of our commitment to continual learning, our OHCS research team is collaborating closely with university and national partners to analyze our ERA program data and findings to see what themes emerge for improvement both nationally and in Oregon. Anticipated Completion Date: December 31, 2023 Contact: Jill Smith, Director of Housing Stabilization Division and Dean Criscola, Controller

2022-027 Oregon Housing and Community Services Ensure Monthly and Quarterly reports are accurate and adequately supported Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 21.023 Emergency Rental Assistance Program (COVID-19) Federal Award Numbers and Years: ERA 1, 2021; ERA 2, 2021 (COVID-19) Compliance Requirement: Reporting Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.302(a) and (b)(3); 2 CFR 200.303(a), (c)-(d) Department management is responsible for establishing and maintaining effective internal control that provides reasonable assurance the department is managing, evaluating, and monitoring the federal award in compliance with the terms and conditions of the award and taking prompt action when instances of noncompliance are identified. Additionally, the department is responsible for maintaining records to allow for submission of reports that are accurate and adequately supported. We tested four randomly selected monthly reports and found one report did not accurately report the number of unique households assisted and the amount of the assistance based on the supporting documentation. The department stated the differences were likely due to a transition in subsystem reporting formats and delays in report processing. We tested four quarterly reports, two of which were randomly selected and two of which were judgmentally selected. We found one report where the cumulative obligation amount did not agree to supporting documentation and were not accurate, and one report where the cumulative obligation and cumulative expenditures amounts did not agree to supporting documentation and were not accurate. The department stated these errors were due to erroneously entered information in the federal awarding agency?s reporting portal. Information included in these reports is used by the federal awarding agency to determine whether the department qualifies for receiving reallocation payments, as well as how much of a reallocation would be awarded to the department. Errors in these reports could result in errors in the federal awarding agency?s determination of eligibility for funding, and/or the reallocation formula. We recommend department management update and correct erroneous reports and establish controls to ensure reported amounts are accurate and adequately supported. MANAGEMENT RESPONSE: We agree with this recommendation. Numerous Community Action Agencies (CAAs), after months of exponential growth in program resources without time to strategize and scale operations, reported major capacity issues a chronic backup of applications at the local level. OHCS took the unprecedented step to augment CAA staff to contract with a third-party vendor to clear the backlog. This approach rapidly increased production and moved the federal program closer in line with the state?s then 60-day safe harbor period but came with additional monitoring and reporting challenges. OHCS did meet the reporting timelines and requirements of US Treasury. OHCS relied on information within the applicant tracking system that does have some discrepancies when compared to our accounting records. These discrepancies are due to various factors such as dates within the system causing application activity to be pulled into the reporting detail more than once, or the application tracking system not being updated with the most current payment record information by some grantees disbursing payments. These variances were overcome by relying on our accounting system and records as a control source of actual disbursements. During the audit, it was brought to our attention that the compilation of the application tracking system data at a point in time was not stored to demonstrate the reconciliation with the accounting information. SOS was then not able to verify the application tracking system data figures in one monthly reporting instance that were used to support the numbers reported to US Treasury as the file had likely been overridden. Similarly in one instance, the quarterly cumulative report was also impacted, however future cumulative figures were reported correctly. Corrective action plan: While OHCS submitted monthly and quarterly reports since program inception that include program and fiscal information, we acknowledge that there were some discrepancies between systems when one file was overridden with new information and one other file contained an error. We have taken steps to ensure data integrity and records retention moving forward and future compilations of the application tracking system data will be stored to support the point in time reconciliations and figures reported to US Treasury. One quarterly report will also be refiled if allowable by US Treasury to ensure quarterly figures reported are accurate. Data integrity is of the utmost importance to the agency, and we appreciate the thorough review by the auditing team. Anticipated Completion Date: June 30, 2023 Contact: Beth Brown, Accounting Manager

1. Correcting Plan CHEDA staff are aware of income eligibility documentation and will implement an internal control process. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding.3. Official Responsible for Ensuring CAP Karie Kirschbaum ? Executive Director 4. Planned Completion Date for CAP Immediately. 5. Plan to Monitor Completion of CAP The Executive Director will monitor completion of the CAP.

The finding was due to a human error. The Registrar?s Office failed to notify the Finance Division and Financial Aid Division of the student enrollment cancellation. These kinds of human errors will be prevented with the following procedure established by the university: Beginning with academic year 2022-2023 (August-2022), the university is taking the following measures: 1. A MSSharePoint was created in collaboration among the Registrar?s, Financial Aid and Finance Offices staff to serve as an easy access documentation repository and to enhance communication. Information of changes in the enrollment status of any student is documented internally for discussion among the offices (Monthly Withdrawal Conciliation Report). 2. Monthly meetings with the Registrar?s, Financial Aid and Finance Offices staff takes place. Personnel from the Institutional Effectiveness Office, and the Offices of the Dean and the Assistant Dean of Academic Affairs also attend to facilitate the discussion. During these meetings the three offices reconcile data on student enrollment status (as documented in the MSSharePoint). This best practice assures that: a. Student enrollment status is recorded accurately and on time. b. Withdrawal cases in which transactions are required with the USDoE are documented early so that funds are returned within the allowable prescribed period. c. As an extra bonus, communication is improved among the Registrar?s, Financial Aid and Finance Offices staff. 3. The dean of student affairs and the dean of academic affairs have provided faculty development seminars on the expectations of a faculty member to comply with federal regulations. Among the topics discussed is the importance of attendance recording and documentation. As well, faculty were required to refer to the Registrar?s and to the Dean of Admissions and Student Affairs Offices any student absent to two consecutive significant academic events. The purpose is: a. Early detection of a student that might be at risk of academic difficulties. b. Early awareness of a student that might be changing enrollment status. 4. To date four (4) attendance surveys have taken place taken place (3/semester). The attendance surveys provide the opportunity to capture any students at risk of changes in enrollment status. As a consequence, student enrollment status may be recorded accurately and on time and as well funds are returned to the USDoE within the allowable period. 5. Periodic letters to the faculty from the Office of the Dean of Academic Affairs to highlight the importance pf promptly referring any changes in student attendance to activate retention efforts or in order to identify and record accurately and on time any changes in student enrollment status.