Corrective Action Plans

2022-003 - Eligibility ? Tenant Files Section 8 Housing Choice Vouchers ? CFDA Number 14.871 Material Weakness in Internal Control, Material Noncompliance Repeat of 9/30/21 Finding 2021-005 (Originally reported as finding 2020-005 at 09/30/20) Condition: Out of a total tenant population of approximately 884 leased vouchers, 25 files were selected for testing in a statistically valid sample. Exceptions were noted as follows: ? 1 error where the lease agreement was not signed by the owner ? 1 error where the file did not contain a signed lease agreement ? 1 error where the file did not contain a signed HAP contract. Also, during our New Admissions testing (11 tested out of 108 new admissions) we noted the following: ? 1 error where the HAP contract was signed but not dated by the Authority. ? 1 error where the lease agreement was not signed by the owner. ? 4 errors where the RFTA was signed but not dated by the landlord and/or by the tenant. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority has hired an outside CPA firm to conduct quarterly reviews of files and to assist in training staff on HUD compliance requirements. The noted deficiencies in the tested files are being corrected and staff will continue to receive adequate training involving the compliance of all the Department of Housing Urban Development (HUD) requirements.

2022-004 - Eligibility ? Tenant Files Public and Indian Housing Program ? CFDA Number 14.850 Significant Deficiency in Internal Control, Other Matters Required to be Reported Repeat of 9/30/21 Finding 2021-003 (originally reported at 9/30/19 as Finding 2019-009) Condition: Out of a total tenant population of approximately 141 tenants, 15 files were selected for testing in a statistically valid sample. Exceptions were noted as follows: ? 1 tenant file where the tenant?s flat rent was overstated by $4 due to a miscalculation. ? 1 tenant file where the tenant?s flat rent was overstated by $2 due to a miscalculation. ? 1 tenant file where the tenant?s income was miscalculated. Correcting this error caused the tenant?s rent to increase by $6. ? 1 tenant file where the tenant?s income was miscalculated. Correcting this error caused the tenant?s rent to decrease by $63 ? 1 tenant file where the tenant?s General Assistance was coded as wages on the 50058 form. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority has hired an outside CPA firm to conduct quarterly reviews of files and to assist in training staff on HUD compliance requirements. The noted deficiencies in the tested files are being corrected. Although this is a repeat finding, the Authority has made great strides in the current fiscal year reducing the error rate by 72% from the prior year. The Authority will continue to improve file reviews and training procedures to ensure the files meet the required guidelines. Effective Date: June 26, 2023 Contact Information Chanosha N.E. Lawton, CEO Housing Authority of the City of Aiken, South Carolina PO Box 889 Aiken, South Carolina 29802 (803) 617-7978

The Department agrees with the finding and recommendation. A memo will be issued to all Kin-GAP eligibility staff to remind them of their responsibility to ensure that all required Kin-GAP documents and forms are received and reviewed for accuracy prior to the continuance of Kin-GAP funding beyond age 18. The memo will also instruct the eligibility staff to ensure that all required documents are maintained in the Kin-GAP case file. Additionally, the Quality Assurance Eligibility Supervisors (QA/ES) will randomly sample and review additional Non-Minor Kin-GAP case files to ensure all required forms are received, and are appropriately filed in the case file.

Responsible Official Caronanne Procaccini, Director of Client Self-Sufficiency and Compliance Plan Detail CACCI will implement a new annual income calculation sheet that is completed by program personnel to support the income information entered into the CSG Engage database. Prior to any assistance payments being made, program staff will review income verification documentation to ensure it is consistent with the annual income calculated during intake. Anticipated Completion Date September 30, 2023

Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls to ensure compliance with federal Title I requirements for allocating funds to school buildings. Name, address, and telephone of District contact person: Gabriela Chacon, 411 E Saddle Mountain Dr. Mattawa, WA 99349 Tel: (509) 932-4565 Ext: 3031 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). The Wahluke School District concurs with this finding. The following corrective actions will be taken: ? The Title I Program Director will work closely with the Grants Manager and Director of Finance to ensure that the annual application is completed correctly, including the allocations to school buildings. ? An action plan was submitted to OSPI which includes initial planning with the District Office team prior to the beginning of the school year, as well as monthly meetings with the Title I Program Director to ensure ranking and allocations are maintained. ? The district now has a Grants Manager that is working closely with the Title I Program Director to ensure that the buildings are within ranking order. Anticipated date to complete the corrective action: 08/31/2023

Management?s view: Management is in agreement that the tenant eligibility age according to the regulatory agreement is 62. Through miscommunication, the property staff incorrectly believed that non-subsidized units were not subject to the minimum age of 62, but that the minimum age of 55 was allowable in keeping with current trends and fair housing standards. Proposed corrective action: Management has adopted the proper age restriction in accordance with HUD requirements at a minimum of 62. Communication has been made to property staff regarding the proper/correct age restriction. Management is also adopting the auditor?s recommendation of requesting a waiver from HUD in order to maintain the economic soundness of the property. Anticipated correction date: 7/15/2022. Responsible official: Jerry Burkholder, Monarch Properties, Inc. Management Agent.

Cluster name: TRIO Cluster Assistance Listing number and name: 84.042 TRIO ? Student Support Services 84.047 TRIO ? Upward Bound Award numbers and years: P042A200873, September 1, 2020 through August 31, 2025 P042A201342, September 1, 2020 through August 31, 2025 P042A200859, September 1, 2020 through August 31, 2025 P047A171009, September 1, 2017 through August 31, 2022 P047A171082, September 1, 2017 through August 31, 2022 Federal Agency: U.S. Department of Education Compliance Requirements: Eligibility Questioned costs: $14,678 Name of contact persons: Kristina Winterstein, Associate Controller Anticipated completion date: December 31, 2023 The District is aware of the importance of maintaining effective internal control over its federal awards and ensuring compliance with applicable federal regulations. The District will review and, as necessary, revise current policies and procedures relating to student eligibility as it relates to the TRIO?Upward Bound programs as well as the policies and procedures relating to documenting the calculation and payment of student stipends to ensure compliance with applicable federal regulations. The District will enhance communication and training efforts to ensure records are maintained that demonstrate appropriate review and approval of student eligibility prior to awarding program services.

Finding: 2022-001: Plan: A second staff member will review certifications and annual certifications to ensure accuracy based on the required back up documentation. Contact: Christina Morin, Program Director Anticipated completion date: March 15, 2023

Corrective Action Plan: This finding was also found during the past two fiscal year?s Single Audit and is a carryover issue stemming from the same underlying problem. The RESEA Program has been in a state on ongoing transition coming out of the COVID-19 pandemic as the Department needed to close the Program for a significant period during the pandemic and then subsequently transitioned to more of a virtual / flex program in calendar year 2021 and 2022. The Department has taken additional steps to try and correct this finding. For example, the Department instituted a mandatory check list for staff to complete as cases are closed. This was developed and provided to staff in June 2022. The RESEA supervisor continues to conduct random sampling on casefiles for accuracy reviews and will continue to provide ongoing supervisor feedback and staff training. Scheduled Completion Date of Corrective Action Plan: June 30 , 2023 Contacts for Corrective Action Plan: Cameron Wood, UI Director Cameron.Wood@vermont.gov

The Department acknowledges and accepts this finding, and as this is a repeat finding from last year?s ACFR audit, the Department maintains the same response and corrective action plan. The Pandemic Unemployment Assistance (PUA) program did not exist prior to the COVID-19 global health pandemic. Unlike the unemployment insurance program, which has been in existence since 1935, the PUA program did not have the inherent checks and balances built into the system to ensure proper program administration. Instead, state workforce agencies were expected to build the PUA program from the ground up with little guidance from the USDOL all the while managing through a pandemic that caused unprecedented upheaval in the employment status of millions of citizens. It is accurate that the Vermont Department of Labor was not able to implement the necessary checks and balances into the PUA program to ensure proper program eligibility. As has been pointed out in the audit finding, it was not until nine months after the start of the PUA program that Congress passed legislation that required documentation to be provided to substantiate program eligibility. At that time, due to the significant and unprecedented strains on the Department of Labor?s resources, the newly established documentation requirements were not able to be implemented prior to the end of the PUA program. The Department acknowledges that the lack of the ability to review claimant financial eligibility may have resulted in improper payments. It is important to point out that UIPL 16-20, Change 4 was issued on January 8, 2021, providing no time for UI programs to implement the required changes while still continuing to provide vital economic assistance to tens of thousands of individuals. The only other recourse available to the Department at that time would have been to stop program payments from issuing until the new eligibility requirements were reviewed. This would have left claimants without benefits for months while the Department used our limited financial and staff resources to implement the necessary changes. This is the result of the continuously changing eligibility requirements built from hastily implemented legislation and program design. In calendar year 2022, the Department began the process of retroactively reviewing all PUA claims that were filed and paid after the date of UIPL 16-20, Change 4 to ensure that proper documentation was provided to ensure program eligibility. Where appropriate, claims are being placed into an overpayment status and collection efforts will ensue. Corrective Action Plan: As mentioned above, the Department was aware that it was unable to implement the documentation requirement for the PUA program as required by the amendments to the CARES Act. The Department had every intention of going back and retroactively reviewing PUA claims for documentation and requiring submission for those claims that lacked adequate documentation retroactively. The USDOL Regional Office is aware of the process identified by the Department to resolve this issue retroactively. The Department has begun this work in early 2022 and will continue this review for PUA program eligibility for as long as USDOL provides the funding to do so until the Department has reviewed all PUA claims filed in calendar year 2021. Scheduled Completion Date of Corrective Action Plan: June 30, 2024 Contacts for Corrective Action Plan: Cameron Wood, UI Director Cameron.Wood@vermont.gov

Finding No. 2022?001 ? Special Tests and Provisions ? Return of Title IV Funds Condition found. The return of Title IV funds as calculated by the University was performed after the required 45 days, in the following case: Student Id. No. Determination date Refund date 92710 6/24/2022 8/24/2022 Management Response The University agrees with the finding. Corrective Action Plan The University affirms its understanding of its obligation to submit the return of Title IV funds due to a total withdrawal to the Department of Education no later than 45 days after the determination date, the date that the school became aware that the student withdrew. In this case, the disbursement of Title IV funds was posted at the same date and time the R2T4 was processed, and one process blocked the other. To avoid this issue, officials must be aware that process that involve return of funds should be processed on different days than the disbursement of Title IV funds are processed. Name of the Contact Person Responsible for Corrective Action Elaine Nu?ez, Financial Aid Office Director Anticipated Completion Date During fiscal year 2022-2023

SECTION III ? FEDERAL AWARD FINDINGS AND QUESTIONS COSTS FINDING 2022-002 ? CONTROLS AND NONCOMPLIANCE OVER ELIGIBILITY AND DISBURSEMENT Management?s Response The College accepts this finding and will continue to undergo updates in procedures regarding documentation retention. Plan SSC Student Financial Aid is in the process of developing an electronic document retention system. In the meantime, all documents are being retained in student files via hardcopy format under the supervision of the Manager. Each Friday the Manager (Coordinator in the absence of Manager) and Director audit files of students receiving FSEOG to verify document retention. Additionally, the College is implementing a Colleague rule to prevent disbursement of FSEOG to any student who does not have a $0 EFC. This is in addition to the existing rule that requires a student to be receiving a Federal Pell Grant in order to have a Federal SEOG disbursement paid to their College account. Anticipated Date of Completion 1/1/2023 Name of Contact Person Avianca Taylor

R2T4 Planned Corrective Action: ETBU Registrars office is now informing the Financial aid office of any student who withdrawals or that is reported as not attending in courses from the second FLEX terms. Financial aid is awarded based on total payment period enrollment and any notification of change in enrollment will result in a review and recalculation of aid eligibility if necessary. Reports were revised to reflect changes in enrollment after primary term census. Person Responsible for Corrective Action: Troy White, Registrar and Linda Slawson, Director of Financial aid. Anticipated Date of Completion: Already implemented.

Finding Number: 2022-002 Planned Corrective Action: Cost of attendance budgets will be established prior to any financial aid awarding. Person Responsible for Corrective Action Plan: Director of Financial Aid Compliance, Elease Cox Anticipated Date of Completion: Already implemented, Fall 2022

Recommendation: The County Children and Youth Services department should implement a file checklist to ensure copies of all Adoption Assistance recipients are complete. Program directors should review the file checklist and compare to the file when determination of eligibility is complete. Checklists should be signed and dated to ensure the approvals are completed. Staff should be trained on eligibility file record requirements and use of checklists to ensure consistent application of the policies. Action Taken: Starting in February 2023, the County Human Services Department hired a consultant that is completing an internal reconciliation of and review of all 2022-2023 records. Adoption file requirements and checklists have been implemented by the consultant to ensure consistent and complete files. The County CYS office will implement the checklists and policies of the consultant in file management. In addition, action is being taken to digitize all records for active adoption assistance recipients to ensure access is maintained and changes to Adoption Assistance files are kept updated. Responsible Individual for Corrective Action: Angelique Hiers, County of Delaware Department of Human Services Director Completion Date: December 31, 2023

Views of Responsible Officials and Planned Corrective Actions: During the pandemic, the TEFAP program was expanded using COVID-19 relief funds. Three Square had a misunderstanding in the classification of these supplemental commodities, and believed them to be part of COVlD-19 relief and as such did not necessitate an executed TEFAP Agency Partner Services Agreement. The four entities mentioned in the finding who received TEFAP commodities only received these supplemental COVlD-19 commodities. This finding was not pervasive throughout the organization, but rather isolated to a temporary program, which has now ended. To ensure effective internal controls, Three Square has designed a system to ensure an executed TEFAP Agency Partner Services Agreement is obtained prior to any TEFAP distribution to an Agency Partner. Moving forward, our agency services team will review all orders containing any federal commodity, regardless of the federal program. They will verify eligibility before approval is given to the warehouse to deliver the products.

Finding: 2022-006 Name of contact person: Brittany Majors (Program Manager), Meredith Farmer (Leadworker) Corrective Action: In this instance, the work number was being ran manually on their website and this informaiton was housed in the County's former document management system, Compass. This verification was lost and was unable to be recovered from the Cyber Incident in 2020. The State has since updated NCFAST functionality to include the running of work number through the NCFAST website. Therefore, moving forward all results will already be housed in that State supported system. The County would like to State that results returned recently support the action taken. Unit meeting was held to remind the workers to run work number in NCFAST. Proposed Completion Date: 9/30/2022

Finding: 2022-005 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson (Leadworker) Corrective Action: Due to a higher volume of vacancies and new hires with no previous Income Maintenance experience it has taken the Adult Medicaid unit some time to get all positions filled and staff trained adequately enough to assist with the processing of cases. During the time of extreme turnover the case workers in place prioritized cases which resulted in the client receiving a greater benefit as advised by the administrative letters issued by DHB given due to the PHE continuity of beneifts was in place. During this time frame the State only allowed specific reduction of benefits/terminiations. Therefore, these individuals would have continued to recieve the same benefit regardless of the SSI review being completed or not. The County has since filled all IMC II positions in that unit and hired a contracted trainer to assist with training in the Adult Medicaid unit. Workloads have been evaluated and specialized based off of program to reduce/eliminate processing errors moving forward. Proposed Completion Date: 9/23/2022

Finding: 2022-004 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers) Corrective Action: Adult Medicaid Supervisor updated the cover sheet/ checklist and documentation outline utilized by all caseworkers when making their determination of eligibility in hopes of reducing/eliminating any oversight which occurred during the past evaluations. The County would like to state that although data entry data occured in regards to resource evidence there where no benefits granted in error. Proposed Completion Date: 10/20/2022

Finding: 2022-003 Name of contact person: Brittany Majors (Program Manager), Donna Rimmer (AM Supervisor), Joanna Thompson and Meredith Farmer (Leadworkers) Corrective Action: Some of the verifications missing were lost in the County 2020 Cyber Incident. The County consulted with State Medicaid Reps who advised the County would be in error to request information previously used to make those determination of eligibility which were lost due to not being able to 100% recover from the Cyber Incident. Therefore, the County implemented a new procedural requirement regarding document management and retention of verification used to determine eligibility. Effective January 2022, all economic benefit programs at Person County DSS were required to upload all verifications used in determining eligiblity into NCFAST. In regards to incorrect data being entered as evidence the Management team conducted individual and unit meeting/trainings to inform parties of the errors discovered and how to reduce/eliminate in future processing. The County would like for it to be notated that eligibility would not have been affected due to the data entry level. Proposed Completion Date: 9/30/2022

Corrective action plan: In December 2021, HHSC implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). HHSC is confident that as the LTC providers are enrolled and re-validated through PEMS, the errors for documentation will be corrected. The LTC process will mirror the sampled acute care providers which were found to be 100 percent compliant during this review, further supporting that the process is working. Implementation date(s): December 2021 Responsible persons: Deputy Associate Commissioner, Operations Management

Corrective action plan: TDA maintains an internal policy that requires SOC reports to be reviewed annually and document complementary user entity controls included in each SOC report. TDA?s contract with Colyar LLC requires the vendor to produce a SOC report annually. The vendor was late in providing the SOC report as a 2022 contract deliverable. TDA took actions to ensure vendor accountability for submitting the late contract deliverable and the vendor was required to complete a corrective action plan. TDA will review and assess the SOC report as soon as it is delivered by the vendor to ensure CLA?s recommendations can be followed and will consider additional procedures to ensure internal controls are assessed in the absence of a SOC report. Implementation date(s): June 2023 Responsible persons: Chief Information Officer and the Director for Food and Nutrition Program Support

Corrective action plan: FDCM/OI investigators will review PIRTS reports on a regularly scheduled basis to ensure that Boards are uploading all required documentation related to childcare improper payments and taking collection efforts. The PIRTS system is in the process of being updated and is currently undergoing User Acceptance Testing. The updated system should allow for more robust reporting and controls. Additionally, FDCM/OI will provide more robust training and retraining to Boards that fall out of compliance. FDCM/OI will also develop an escalation policy in cases where Boards are not responsive to investigators? requests for status updates or document uploads into PIRTS. FDCM/OI investigators will ensure that SRM monitors are fully briefed on childcare improper payment cases at a Board as part of SRM?s annual monitoring review of the Board. Finally, FDCM/OI will ensure that all relevant controlling documents, e.g. Workforce Development Letter 21-16, Change 3 and its attached Child Care Fact-Finder?s Desk Aid; and the TWC?s Child Care Services Guide are updated to incorporate these new procedures. Implementation date(s): June 1, 2023 Responsible Persons: Jason Stalinsky, Deputy Division Director, Division of Fraud Deterrence and Compliance Monitoring

EA Application/Determination Corrective action plan: DFPS will ensure that INV/AR staff receive ongoing communication/training regarding EA and how to correctly document and record income within the IMPACT. DFPS will update the current EA policy and publishing a new resource guide for staff. DFPS staff will be provided training, tip sheets and ongoing support regarding the new policy and resource guide. The policy will be published by April 1, 2023. DFPS will continue to strengthen our internal quality assurance review of cases eligible for EA to ensure that INV/AR staff are complying with federal guidelines and internal policies. DFPS has submitted an IT ticket request to resolve the condition for the participant that had the incorrect income range of $0-$10,000 selected to the correct income range of $20,550 to $40,549 to align with the investigation report. The participant remains eligible for assistance regardless as the family unit makes less than $63,000. CPI will initiate a request for an IT project to conduct analysis of any limitations with verifying Emergency Assistance eligibility in the IMPACT system regarding why two of the three EA statements now show not answered. DFPS staff will be researching the issue to determine next steps by 2nd quarter FY 2024. Implementation date(s): Ongoing communication ? will vary, first communication by April 1, 2023; IMPACT research January 31, 2024. Responsible persons: Jerome Green PEAF Corrective action plan: DFPS uses an established recoupment process to address overpayments. A Kinship Development Worker writes a letter to the kinship caregiver regarding the overpayment and details the steps needed to return funds. This letter is also sent to accounting for follow up. DFPS maintains a proactive approach to strengthening/enhancing IMPACT limitations to ensure accurate data is maintained for accurate payments/disbursements through continuous program improvement. Implementation date(s): On January 13, 2023 ? staff initiated the above described recoupment process to recoup the second payment for the subject children. Responsible persons: Debbie Bouldin

Corrective action plan: To prevent similar errors from occurring until program closure, TRR management shared these findings with the external application review vendor on January 26, 2023, reiterating the processes for reviewing and approving rental assistance according to all program policies and procedures and ensuring that appropriate documentation related to review of applications is maintained in the files. Eligibility errors are expected in all programs, and TRR has developed different processes to address errors when identified. For these particular cases, TRR management requested the vendor take corrective action for each case as applicable (e.g., by requesting a return of funds for overpayment or by requesting additional information from applicants). Implementation date(s): January 26, 2023 Responsible persons: Danny Shea, TRR Senior Program Manager