Corrective Action Plans

Finding 2022-002 - Eligibility - Significant Deficiency in Internal Control Over Compliance - Recommendation: We recommend the University amend procedures so in the event that packaging is done manually, there are added reviews over the student's aid awarded. - Corrective Action Plan: We accept Moss Adams' recommendation and if a situation arises where we must manually package a student, the procedure will include an additional review by another individual, either the Director or a Counselor, to review the package for accuracy. An internal review of FY22 indicated this was an isolated incident. - Anticipated Completion Date: Management will complete the Corrective Action Plan by June 30, 2023. - Individual Responsible: Oscar Jones, Director of Financial Aid.

2022-002 ALLOWABLE COSTS AND ALLOWABLE ACTIVITIES ? COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: We recommend that the County include consideration of any expenditures that may be part of other federal programs as part of their review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review their procedures to ensure expenditures coded to federal grants are not already claimed by other grant programs. Name of the contact person responsible for corrective action plan: Deborah Erickson, Administrative Services Director Planned completion date for corrective action plan: December 31, 2023

2022-006 SPECIAL PROVISIONS ? STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: We recommend that income verification be reviewed for each eligible case files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work on training new staff on requirements, and continue to perform case file reviews. Name of the contact person responsible for corrective action plan: Deborah Erickson, Administrative Services Director Planned completion date for corrective action plan: December 31, 2023

FINDING 2022-004 Finding: Non-Public School: No documentation could be found to support non-public school students qualifying for Title I on the 2020-2021 and 2021-2022 Applications. These numbers determine equitable share distributions to these non-public schools. Contact Person Responsible for Corrective Action: Carrie McGuire Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Non public schools will be consulted prior to the initial Title I(a) application being submitted at the start of each grant cycle. Non-public school consultation forms and spreadsheet(s) for any equitable share calculations will be uploaded into the Title I application center as attachments. These will be verified by the corporation treasurer before the Title I application is submitted annually. Prior to the submission of the Title I application annually, the federal grants coordinator with consult with all non-public schools within our district boundaries as listed by the IDOE in the grant application portal. The signed consultation forms will be uploaded to the IDOE?s Title I Programs Application Center as attachments. The corporation treasurer will verify that all consultation forms are signed and uploaded in the Application Center before the initial grant application budget can be submitted for review. A form will be created so that when files are downloaded from the Child Nutrition Program (CNP) website and subsequently uploaded into Mealtime, there will be places for a signature of the person who downloaded the file, a signature for the person who uploaded the file, and a reviewer. Anticipated Completion Date: September 15, 2023

The Department of Human Services (DHS) agrees with the findings. DHS will reach out to the four (4) STAY DC payees to formally request the return of improper payments to the District of Columbia. This will be tracked to ensure the return is recorded against ERA within the District?s financial system. To address any documentation gaps, DHS introduced new Standard Operating Procedures (SOPs) for Family Rehousing and Stabilization Program (FRSP) in FY23. The new SOP implements stricter internal control procedures, regular audits, and streamlining the eligibility determination process. The District will reclass all identified errored payments off of the ERA fund to Local funding by the closeout of FY23, Sept. 30, 2023. DHS also completed a reconciliation of data reported to U.S. Treasury for ERA1 closeout reporting and ERA2 2023 Q2 reporting to ensure that no errored payments were included. See Corrective Action Plan for chart/table

Department: Health and Human Services Title: Internal control over P-EBT Food Benefits needs improvement Questioned Costs: Known: $61,507,558 Likely: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding and does not believe that corrective action is warranted. During the course of the audit, the Department provided the Office of the State Auditor (OSA) with the complete population of recipients as well as the supporting information necessary for OSA to conduct testing to verify compliance with federal program requirements. The only remaining action that is required is for OSA to perform their testing. Completion Date: N/A Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104

Condition Found: During audit fieldwork, the auditors spoke to City Staff about the Illinois Environmental Protection Agency (IEPA) Loan reimbursements the City had received during FY2022. The question was whether or not the expenditures we asked to be reimbursed for were eligible because the expense was incurred prior to the loan being approved. The expenditures in question had already been reimbursed to the City from the IEPA and were considered eligible expenditures. When the request from the auditors came for the account numbers that the expenditures had been paid out of, City Staff realized that the majority of these older invoices had been paid with proceeds from the 2015 GO Note issuance, and as such were not eligible to be reimbursed by the IEPA. City Staff relayed this discovery to the auditors and recorded an adjustment to reduce the receivable from the IEPA ($260,749.30) that were not eligible. The City has worked with the consultant managing the project at Baxter and Woodman, and the IEPA, to remedy the issue with a reduction to the City's next distribution. The IEPA loan has not been closed out as of this date, allowing for the reduction without significant impact. Corrective Action Plan: Going forward, the Public Works Department will forward the IEPA Loan draw requests to the Finance Department to be reviewed before being submitted to the IEPA for reimbursement. The Finance Department was not included in the draw request prior to this finding. By having the Finance Department review the draw requests, we can ensure that all items submitted for reimbursement are eligible. Staff at Baxter and Woodman, who package invoices for submittal to the IEPA on behalf of the City, will also be reviewing invoices more closely before submittal as an independent verification. Implementation Date: This change is effective immediately and the Finance Department has already started reviewing the next invoices being submitted to the IEPA for reimbursement.

The DHS and DHCF DCAS team agree with the findings noted in this report. DHS self-reported these findings as part of the Agencies ongoing effort to maintain integrity with all eligibility determinations. The root cause for each of the eleven (11) issues with the ADP system for SNAP varied. For bullet point #1 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. In March 2023, a request to run this report was made. The run took place in April 2023 and ultimately found that the report could not be derived. Ultimately the request/ticket below will be closed. For bullet point #2 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. DCAS system will be fixed no later than FY2024 Q3. For bullet point #3 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Implementation of DCAS Release Part 2 was completed on March 26, 2023. The District requested FNS close this finding. Implementation of DCAS Release Part 2 was completed on March 2023. The District is requesting that this finding be closed. For bullet point #4 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation: Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. The data needed from DCAS to determine the scope/magnitude has not yet been provided. However, DCAS considers this as a high priority ticket for Releases 4 and 5. See Corrective Action Plan for chart/table

Reporting views of responsible officials and planned corrective actions Management will put in place procedures to ensure verification of tenant assets is done during recertification.

2022-002 Eligibility ? Maintain good standing or satisfactory academic progress Contact: Jeffrey C. Straits Title: Chief Financial Officer Phone Number: (202)885-8684 Anticipated Completion Date- Done Corrective Action Wesley Theological Seminary will ensure that students maintain a good standing or satisfactory academic progress in order to be eligible for Federal direct student loans per the OMB Compliance Supplement. Wesley acknowledges that before the outsourcing of our financial aid processing, there was a breakdown in the seminary following policies, procedures, and controls, which allowed this error. The Seminary will review all policies and procedures related to this control and develop ways to strengthen these controls. Wesley will also complete a review of all active federal loans for the fiscal year 2022 to identify if there are further processing errors allowing loans to students without maintaining good standing or satisfactory academic progress to be eligible for Federal direct student loans. Wesley management will also implement quarterly testing of randomly selected student loan transactions. The testing will include the verification of eligibility for aggregate loan totals, good standing, and satisfactory academic progress. The results of this testing will be reviewed by the CFO and maintained by Wesley?s management. Status as of November 2022 Wesley Theological Seminary outsourced our financial aid processing in January 2022. The error found was processed by our internal Financial Aid Director before the outsourcing of financial aid. Wesley has reviewed our policies and procedures related to this issue. We will add to the policies and procedures that the CFO will also approve all appeals approved by the Financial Aid Committee for lack of a student?s adequate satisfactory academic progress. The CFO?s approval will also be maintained with the appeal records of the Financial Aid Committee. We completed the review of all students who received Federal financial aid in the fiscal year 2022. There were no other students with inadequate satisfactory academic progress other than the one previously identified by BDO. Our outsourced financial aid processor will ensure the review of satisfactory academic progress prior to processing a loan, as required in our policies and procedures. To verify ongoing compliance of our outsourced financial aid processor with our financial aid policies, procedures, and controls, we are adding a requirement of quarterly random testing of students? records for the verification of eligibility for aggregate loan totals, good standing, and satisfactory academic progress. Wesley management has completed the fiscal year 2023 first quarter review of random students? transactions, and we did not find any errors. The testing results were reviewed by the CFO and maintained by Wesley?s management.

2022-001 Eligibility ? Aggregate Loan Limits for Subsidized and Unsubsidized Loans Contact: Jeffrey C. Straits Title: Chief Financial Officer Phone Number: (202)885-8684 Anticipated Completion Date- Done Corrective Action Wesley Theological Seminary will ensure that the loans disbursed by the Institution are within the loan limits prescribed in the OMB Compliance Supplement. Wesley acknowledges that before outsourcing our financial aid processing, there was a breakdown in the Seminary following policies, procedures, and controls within financial aid, which allowed these errors. The Seminary will review all policies and procedures related to this control. We will also complete a review of all active federal loans for the fiscal year 2022 to identify if there are further processing errors allowing loans above the aggregate loan limits. Wesley management will also implement quarterly testing of randomly selected student loan transactions. The testing will include the verification of eligibility for aggregate loan totals, good standing, and satisfactory academic progress. The results of this testing will be reviewed by the CFO and maintained by Wesley?s management. Status as of November 2022 Wesley Theological Seminary outsourced our financial aid processing in January 2022. Wesley will ensure the work prepared by outsourced personnel is reviewed properly and such review is documented properly. All of the errors found were processed by our internal Financial Aid Director before the outsourcing of financial aid processing. We completed the review of all students who received Federal financial aid in the fiscal year 2022. There were seven students with awards over the aggregate maximum (including those previously identified by BDO). The total amount awarded over the per-person aggregate limit was $79,159. Our outsourced financial aid processor will ensure the review of total student debt prior to processing a loan, as required in our policies and procedures. Wesley management has reviewed our policies and procedures related to this issue. To verify ongoing compliance of our outsourced financial aid processor with our financial aid policies, procedures, and controls, we are adding a requirement of quarterly random testing of students? records for the verification of eligibility for aggregate loan totals, good standing, and satisfactory academic progress. Wesley management has completed the fiscal year 2023 first quarter review of random students? transactions, and we did not find any errors. The testing results were reviewed by the CFO and maintained by Wesley?s management.

Recommendation: We recommend the District review the requirements of 2 CFR Section 200.213 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. Action taken: The district entered into a shared services agreement with Capital Region BOCES in March of 2022 for management of the School Nutrition program. It was assumed that this was a procedure they followed; however, documentation was not provided and the external auditors included it as a finding. Todd Barker is the new School Nutrition Director with BOCES and he will provide documentation to the district that due diligence has been done to meet this requirement. Anticipated completion date: 11/1/2022

Identifying Number: 2022-001 Finding: A student was improperly awarded and disbursed a TEACH grant. Corrective Actions Taken or Planned: In April 2021, Financial Aid Staff collected TEACH Grant counseling for two academic years (20-21 and 21-22) at the same time and awarded the grant for both academic years based on the GPA as of that date. The student was eligible for 20-21, but at the end of the 20-21 academic year, their GPA had dropped below the 3.25 requirement, making them ineligible for the grant in 21-22. The Financial Aid Staff did not double check the GPA after 20-21. The TEACH Grant was refunded to the Department on 6/30/22. An additional step was added to our manual that requires all TEACH Grants set up prior to the first origination will be double-checked to verify eligibility. Persons Responsible and Completion Date: Mark Freed, Director of Financial Aid, June 30, 2022

Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding. As noted, a turnover in staff happened right at the time when the verification for FY22 was due and the new staff member did not realize the required verification had not occurred. The School followed proper procedures each year prior to FY22. The School identified the FY22 error at the beginning of the 2022-2023 school year prior to the audit. Immediate action was taken to ensure this error would not reoccur in the future when the School experienced a staffing change. In so doing, the School implemented a step-by-step tutorial of procedures, including reporting dates and deadlines. Necessary staff members have attended, and will continue to attend, training for items related to the application of Educational Benefits. The verification process was checked by a supervisor to ensure proper processes were followed for the 2022-2023 school year and they were.

CORRECTIVE ACTION PLAN To Whom It May Concern: This letter includes the corrective action plan in response to the audit finding from the Single Audit for the 2021-22 Award Year. Audit Finding 2022-001: Student received an incorrect amount of Pell award and was over awarded by $200. The amount was returned to the U.S. Department of Education in July 2022. Corrective Action Plan: This was an unusual case where a third disbursement was added manually late in the year due to a Professional Judgement appeal. In order to avoid an over-award in the future, the Financial Aid Office will implement the following: - The Financial Aid Office will request training from our Ellucian consultant on how best to add unusual disbursements. - Otherwise, staff should consistently use the Pell auto-package functionality within the Colleague system. - If a disbursement must be added manually due to a functionality error, the award change must be reviewed by a senior staff member. - The grant amounts will be audited at the end of the year. The contact person responsible for the corrective action is Cheryl Gillies, Executive Director, Financial Aid. The corrective action has been implemented as of July 31, 2022. Please let me know if you have any additional questions. Sincerely, Cheryl Gillies Executive Director, Financial Aid ArtCenter 1700 Lida St. Pasadena, CA 91103 626.396.2204

Finding 2021-004 Name of contact person: April Rollins, Income Maintenance Administrator II Corrective Action: Refresher training will be held for Medicaid staff on the topic of obtaining verifications, reading verifications, and entering complete and accurate documentation when determining and redetermining eligibility and entering said information verifications accurately in NC Fast. Second party reviews in excess of the state's mandated 98 will be conducted quarterly. Proposed completion date: 11/30/2022

Finding 2022-003 Name of contact person: April Rollins, Income Maintenance Administrator II Corrective Action: Refresher training will be held for Medicaid staff on the topic of timely reacting to notifications and obtaining verifications, reading verifications, and entering complete and accurate documentation when determining and redetermining eligibility and entering said information verifications accurately in NC Fast. Second party reviews in excess of the state's mandated 98 will be conducted quarterly. Proposed completion date: 11/30/2022

Finding 2022-002 Name of contact person: April Rollins, Income Maintenance Administrator II Corrective Action: Refresher training will be held for Medicaid staff on the topic of obtaining verifications, reading verifications, and entering complete and accurate documentation when determining and redetermining eligibility and entering said information verifications accurately in NC Fast. Second party reviews in excess of the state's mandated 98 will be conducted quarterly. Proposed completion date: 11/30/2022

Finding 2022-001 Name of contact person: April Rollins, Income Maintenance Administrator II Corrective Action: Refresher training will be held for Medicaid staff on the topic of obtaining verifications, reading verifications, and entering complete and accurate documentation when determining and redetermining eligibility and entering said information verifications accurately in NC Fast. Second party reviews in excess of the state's mandated 98 will be conducted quarterly. Proposed completion date: 11/30/2022

Oversight Agency for Audit, Pine Grove Housing Development Corporation respectfully submits the following corrective action plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: October 1, 2021 through September 30, 2022 The finding from the September 30, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS ? MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2022-001: Section 202 Supportive Housing for the Elderly, CFDA 14.157 Recommendation: The Project should implement procedures to ensure the verification of eligibility by obtaining all required documents for potential tenants, verifies initial tenant income through the EIV system in a timely manner and maintain all required tenant documentation. Action Taken: Automatic alerts have recently been activated in OneSite, based on individual tenant move in dates to remind the manager it is time to pull the 90 day EIV Income Report. Managers have been trained that the 90-day EIV Income reports are required and must be pulled, reviewed, and placed in the tenant file. If the audit Oversight Agency has questions regarding these plans, please call Christine Harris at 954-835-9200. Sincerely yours, Christine Harris Accounting Manager

Upon discovery of the over award, funds were returned for the student immediately. Moving forward, the Financial Aid team will implement a review process at the beginning of each term that will identify students nearing aggregate loan limits to ensure students are not over awarded.

Finding 2022-001 Condition: The Town charged the same invoice twice to the federal award. Corrective Action Planned: The Town has contacted the Commonwealth of Massachusetts Executive Office for Administration and Finance regarding the duplicate invoice. We are awaiting a response as to how to resolve the overpayment. Anticipated Completion Date: June 30, 2023 Contact: Amy Craven, Town Accountant

2022-001 Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Housing Authority has reorganized roles and responsibilities to ensure that all reporting is accurate and all tenant files are correctly maintained. The Compliance Officer and Director of Finance have received training and certification in Rural Development and Multifamily Compliance and handle all tenant files and uploads. Planned Completion Date for CAP Changes were implemented immediately. 2022-002 Contact Person Derek Johnson, Managing Agent Correction Action Plan No action planned on the finding. The Authority and board feel that the additional costs to the Authority would not be significantly beneficial. The Authority does mitigate this situation through the review of the draft financial statements and accompanying notes to the financial statements. Planned Completion Date for CAP None. See above. 2022-003 Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority?s management and Board of Commissioners will review proposed audit entries and approve them. Any common adjustments, such as those identified in the current year, not likely to be recurring, will be reviewed and approved by appropriate Authority personnel. The Director of Finance drafts the journal entries, which are reviewed and approved by the Executive Director. Planned Completion Date for CAP Immediately 2022-004 Contact Person Derek Johnson, Managing Agent Correction Action Plan The Authority has hired a Deputy Director who completes quality control audits on all tenant files periodically. The Deputy Director holds monthly meetings with all eligibility staff workers to ensure compliance with policies and procedures. Planned Completion Date for CAP Immediately

Name of auditee: Housing Authority of the City of Calexico Name of audit firm: Smith Marion and Co. Inc. Period covered by the audit: Year Ended June 30, 2022 CAP Prepared by Name: Teresa Nava Position: Executive Director Telephone Number: (760) 357-3013 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations. 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation: The Authority concurs with the finding. b. Action(s) Taken or Planned on the Finding In order to address this noncompliance, the Authority is taking measures to ensure compliance with the requirements of the Capital Fund Program. We will review eligible activity requirements pursuant to the auditors recommendation and implement controls to ensure compliance. In addition, management has taken immediate steps to identify costs in each budget line item (BLI) and have ensured that costs are properly allocated as such going forward. All actions will be completed prior to the completion of our next fiscal year ending June 30, 2023.

Responsible Contact Person(s): Steven Hanoka, Chief Information Security Officer John Kissel, Deputy Director of Innovation and Technology Sarah Haggie, Strategic Initiatives Advisor Mike Alston, HCD Division Director Cat Pelletier, Operations Lead for Finance Cindy Olson, Eligibility and Enrollment Director Corrective Action Planned: DMAS IT Access Control Policy was revised January 2023 to be compliant with the COV security standard. IM Security will revise security training to also reflect this change. Training and reminders will be provided to ensure the divisions and managers understand the importance of the system workflow and timely notification to initiate the process for disabling access. DMAS is in the process of updating the off-boarding system requirements to ensure system access is removed timely. Additional staff was requested to have system access removal rights to support the system access administration and resolve workload and staffing issues. Estimated Completion Date: 2/28/2023