Corrective Action Plans

2022-001 Reporting ? Assistance Listing No.: CFDA Nos.: 10.553 School Breakfast Program, 10.555 National School Lunch Program, and 10.559 Summer Food Service Program for Children Condition: The District?s supporting documentation for meal counts used to submit for reimbursements from the State inconsequentially did not agree to the meal counts submitted. Audit Recommendation: In order to prevent future occurrences of this deficiency, we recommend that management ensure that good record keeping is kept at all buildings of where the meals are served. We also recommend the records are reviewed effectively and efficiently each month for accuracy. Corrective Action Implemented: In the 2022-2023 school year, the district resumed using the cafeteria management system for daily recordkeeping of meals sold. Further, the district adopted the use of a backup recordkeeping tally sheet that includes multiple levels of verification to strengthen this control. Person Responsible for Implementing the CAP: Pamela Strompf, Food Service Director Implementation Date: 2022-2023 school year

2022-004 Child Nutrition Cluster (10.55X) Condition and Cause: The District was required to verify one application for program eligibility and properly report results. During our review, the District did not properly update the School Food Authority Verification Collection Report for 2021-2022 based on the results of the verification sample. Criteria: By November 15th of each school year, the District must verify the current free and reduced price eligibility of households selected from a sample of applications that it has approved for free and reduced price meals. Results of this verification must be properly reported in the School Food Authority Verification Collection Report. Effect: Because of improper reporting, the District?s verification report did not accurately reflect the results of the verification sample. In addition, the District could be inaccurately providing free or reduced lunches to students. Auditor?s Recommendation: The District should review the federal requirements for completing verification of applications to ensure that future verifications completed by the District are complete and appropriate and properly report on the verification report. Grantee Response: A new process will be put in place for future income verifications to ensure the entire verification process will be completed accurately and timely. Contact Person: David Boland Anticipated Completion: On-going

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Voucher Cluster Assistance Listing Number: 14.871 & 14.879 Passed Through: Direct Award Pass Through Number: N/A Compliance Requirement Affected: Special Provisions Award Period: 2022 Type of Finding: Material Weakness in Internal Control over Compliance. Recommendation: We recommend that the Authority design and implement internal controls over special provisions. Other provisions, such as reasonable rent, housing quality standards inspections, and HQS enforcement, should be reviewed by someone independent of the initial preparation/inspection. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will evaluate implementing reviews over tenant files, financial and performance reports, and other special provisions. Name of the contact person responsible for corrective action plan: Kim Wallace, Executive Director Planned completion date for corrective action plan: December 31, 2023

We are looking at ways to streamline/standardize our expenditure procedures so that documents live in consistent places that we can locate as necessary even if staff turnsover. We are also looking at additional training for staff and managers. Finally, the increase in finance team mentioned above should help review documentation on a more contemporary basis. Anticipated Completion Date: September 30, 2023 Responsible Contact Person: David Maloney, Shelter House Controller

Program: Emergency Rental Assistance Program Assistance Listing No.: 21.023 Federal Agency: U.S. Department of the Treasury Passed-through: Direct Award Award Year: 2021/2022 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency, Instance of Noncompliance Views of Responsible Officials: We concur with the finding. Corrective Action Plan: The Emergency Rental Assistance Program (ERAP) is closed. It was a temporary program and the deadline to expend funds has passed. Should the County consider implementing a similar program in future, this recommendation will be included. Responsible Individual(s): Anne Putney, Principal Management Analyst Anticipated Completion Date: N/A

Program: Temporary Assistance for Needy Families Program Assistance Listing No.: 93.558 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Social Services Award Year: 2021/2022 Compliance Requirement: Allowable Costs, Eligibility and Special Tests and Provisions Type of Finding: Material Weakness, Instances of Noncompliance Views of Responsible Officials: We concur with the finding. Corrective Action Plan: Finding Part 1: Two (2) out of 60 cases tested were missing the annual redetermination for the reevaluation of their benefits and eligibility requirements. Solano County has policies and procedures as well as systematic processes set up to ensure that redeterminations are processed annually. It is Solano County?s policy that the SAWS 2 Plus, Rights and Responsibilities and the Child Support Questionnaire and Notice and Agreements be processed which require workers to: ? Conduct a telephone interview with the recipient, print the forms, and document the County Use Section which requires worker?s signature and date. ? Mail the forms to the recipient for signature ? Upon return, review the SAWS 2 Plus and additional forms for completeness ? Initiate the required case action based upon information provided on the forms A redetermination of eligibility of the recipient shall be completed at least once every twelve (12) months. The annual CalWORKs Redetermination requires a face-to-face or telephone interview with the parent or person responsibility for the child or the person having responsibility for the care and control of the child. The Division Managers implemented a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent these errors in the future: ? The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the eligibility redetermination handbook with verbiage to emphasize the following: o The renewal be authorized only after required forms are received by the county and scanned into the document imaging system. o Ensure that redetermination dates are correct in the system at application and renewal. o Highlight these requirements when training this topic ? The CalWORKs Program Specialist will discuss the findings and redetermination requirements in the following ways: o Monthly Program Support Forum conducted with managers, supervisors, and lead workers o Issue a reminder memorandum to all staff o Written material will be published in the Monthly Program Support Newsletter to all staff Finding Part 2: In 31 out of 60 cases, we found that the review of the IEVS was not documented during the application or annual re-determination applicable to the fiscal year. However, we found that the related recipients/cases were eligible. It is Solano County?s policy to maintain program integrity. All CalWORKs (TANF) cases are required to be reviewed to assist with the eligibility determination using the Income and Eligibility Verification System (IEVS) at application and annual redetermination. ? IEVS is a computer cross match of State wage data, Unemployment Insurance Benefit data, wage data maintained by the Social Security Administration, and unearned income data maintained by the Internal Revenue Services and/or Franchise Tax Board. ? Staff is required to initiate the required case action and notices based on information received from the report, which includes generating adequate and timely notice. ? IEVS is system-generated at application. Effective February 2021, the CalWIN system auto-generates IEVS at least 15 days prior to the beginning of the redetermination due month. Specific corrective actions are outlined below to prevent these errors in the future: ? An ad-hoc report will be developed to generate monthly to help ensure the reports are reviewed and signed off by workers. A process will be put in place to ensure supervisors and lead workers follow up with the completion of these reports. ? The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the eligibility handbook sections for Application, Annual Redetermination, and IEVS Interfaces. ? The CalWORKs Program Specialist will discuss the findings and IEVS requirements in the following ways: o Monthly Program Support Forum conducted with managers, supervisors, and lead workers o Issue a reminder memorandum to all staff o Written material will be published in the Monthly Program Support Newsletter to all staff Responsible Individual(s): Daniel Horel, Employment and Eligibility Services Manager Thomas West, Employment and Eligibility Services Manager Anticipated Completion Date: June 30, 2023

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-004?Eligibility Program: Medical Assistance Program (ALN 93.778) Type of Finding: Material Weakness in Internal Control over Compliance; Other Matter Compliance Finding Condition: During our testing, we noted the following instances of noncompliance in the sample of 120 case files tested: ? One MAXIS case file had assets greater than their applicable household size asset limit. While beneficiaries may reduce their assets to continue to qualify, there was no documentation in the case notes showing the applicant reduced their assets subsequent to renewal in order to continue to qualify for benefits. ? One MAXIS case file had different bases of eligibility in MAXIS and MMIS where MAXIS indicated the beneficiary was ?EX? (age 65 or older) while MMIS indicated the beneficiary was ?DX? (disabled). ? One METS case file included documentation of verification of income that did not match the information entered into METS. ? One METS case file did not have a SSN entered at either the initial application date nor any of the subsequent renewal dates. No exemptions to the requirement to submit a SSN was noted in the case within METS. In addition, the County does not have effective internal controls over eligibility of the Medicaid program: ? The County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the MAXIS and METS systems. ? We were not able to review and test the automated application controls and the related ITGCs within the MAXIS, METS and MMIS systems, all of which are state systems that are administered by the state and required to be used by the County, to determine whether the system controls are adequately designed and implemented and operating effectively for the determination of eligibility. Hennepin County?s Corrective Action Planned in Response to Finding: Program staff will design internal controls to ensure eligibility inputs are correctly entered, and information required by contract is retained. Hennepin County Employee Responsible for the CAP: Jackie Poidinger Planned Completion Date for CAP: December 31, 2023 Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS, METS, and MMIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2020-005?Eligibility Program: Foster Care Title IV-E (ALN 93.658) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While we were able to test manual compensating controls over activities allowed or unallowed, allowable costs/cost principles and eligibility, we were not able to review and test the automated application controls and the related ITGCs within the MAXIS and SSIS systems that reside within the State of Minnesota, but are utilized by the County, to determine whether the system controls are adequately designed and implemented and operating effectively. Hennepin County?s Corrective Action Planned in Response to Finding: Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS and SSIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-002?Eligibility Program: WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (ALN 10.557) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While testing the eligibility requirement, we noted procedures and controls were not operating as designed to ensure that only those eligible were approved for WIC. In our sample of 40 cases, two cases had no evidence that an independent review of the eligibility determination occurred. In addition, while we were able to test manual compensating controls over eligibility determination, we were not able to review and test the automated application controls and the related information technology general controls (ITGCs) within the HuBERT system, a state system that is administered by the state and required to be used by the County for eligibility determination, to determine whether controls are adequately designed and implemented and operating effectively. Hennepin County?s Corrective Action Planned in Response to Finding: Program staff will establish a process to strengthen eligibility determinations. Hennepin County Employee Responsible for the CAP: Jill Wilson Planned Completion Date for CAP: December 31, 2023 Hennepin County will encourage the State to provide an independent audit of the design and implementation of HuBERT system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

Finding Number: 2022-004 Condition: The notifications related to the direct loan borrowers did not include information on the right to cancel or instructions on how to cancel the loans. Planned Corrective Action: The University?s new financial aid module does not have the capability to send emails. That functionality does exist in the University?s new student information system. Consequently, effective for Fall 2022 semester, the Office of Financial Aid partnered with Office of the Controller ? Student Accounts to generate emails on a weekly basis to any student who receives a disbursement of Title IV funds. By May 1, 2023 the University will create similar procedures to identify disbursements of Parent PLUS loans and then coordinate with Office of the Controller - Student Accounts to leverage the student information system to send notifications to parent borrowers. Contact person responsible for corrective action: Marshall Rumsey, Senior Associate Director, Office of Financial Aid Anticipated Completion Date: Completed September 8, 2022 (student), to be completed May 1, 2023 (parent)

Finding Number: 2022-005 Condition: The University awarded incorrect Pell awards to certain students based on the Pell Payment and Disbursement Schedule. Planned Corrective Action: The University?s new financial aid module was modified to use the census date for Pell recalculation rather than an arbitrary number of days into the term that did not match the University policy. The correction for this finding was implemented prior to aid being disbursed for the Fall 2022 semester. Contact person responsible for corrective action: Cheryl Whitman, Associate Director, Office of Financial Aid Anticipated Completion Date: Completed August 31, 2022

Statement of Condition: In connection with our lease file review, we noted one out of three tenants did not have a recertification performed timely or the income verification with the use of the HUD Enterprise Income Verification ("EIV") performed timely. Corrective Action: Due to either tenant non-compliance or challenges with scheduling meetings with tenants or obtaining verifications, some recertifications were completed late. REACH has policies in place to complete recertifications timely, and will be providing ongoing training and guidance to staff to make sure the policies are being followed.

Finding ? Return of Funds Condition Out of forty students selected for testing, nine students were under awarded Pell grants based on their EFC and COA. This is not a statistically valid sample. Views of Responsible Officials and Planned Corrective Actions The University begins to award students prior to the new Pell Grant schedule release in late March. In April our software provider, Ellucian, releases an update for us to upload with the new Pell Grant schedule. This update was completed but some of the Pell Grants that had been packaged prior to the update were not reprocessed and repackaged with the new Pell Grant amounts. This error was due to a loss of personnel that had previously managed the reprocessing of the Pell Grants. Management has already reprocessed any students for 2022-23 to ensure correctness of Pell awards for the current year. Additionally, management has adopted new step by step procedures in writing to assist with the reprocessing/repackaging of Pell Grant awards to ensure that proper practices will be followed on a forward basis. Management is also in the process of reviewing 21-22 Pell awards and will disburse any shortfalls by December 31, 2022 to impacted students. Responsible Official: Frank Mullen Completion Date: 10/26/2022

Corrective Action: Supervisors and Lead Workers randomly conduct 2nd party reviews on case actions completed by IMC workers. All new hires go through and extensive training plan and are only released when error rate is 5% or less. Workers must continue to maintain an overall rating of 95% to be released from all of their work being 100% 2nd party reviewed. Work issues and errors are corrected immediately when discovered and Lead Workers and Supervisors provide training to the unit or individuals, as needed. The County remains proactive in resolving all errors cited while battling issues with turnovers, limited staff, and inexperienced staff. An effective training plan has been implemented and is administered by the Staff Development Specialist and the Lead Worker Unit. Monthly and one-on-one conferences are conducted to discuss error citing found and coaching or refresher trainings are conducted. Proposed Completion Date: Immediate actions have been taken to resolve issues cited. The County continues to complete 2nd party reviews on each worker and evaluate error trends cited for corrections needed through coaching, refresher courses or training. Trainings pertinent to the specified findings will be completed by 12/01/2022.

Corrective Action: Lead Workers will run the exparte logs weekly and assign them to workers and send notifications to respective supervisors to oversee. Lead Workers and Supervisors will monitor the reports to ensure reviews are completed within 30 days of receipt. Lead Workers will have the overall responsibility to ensure that report and reviews remain in compliance and are worked thoroughly and correctly. Lead Workers and Supervisors will monitor and train new workers and ensure workers are able to retain policy knowledge and apply said knowledge to case actions accurately. The Supervisor over the Lead Workers will conduct conferences and discuss and monitor report findings for continued timely completion. Proposed Completion Date: Immediate action taken to resolve issues found. This task will be ongoing and will be mitigated through training and implementation of more effective fiscal controls, with a proposed completion by 12/01/2022. These case citing?s resulted from tasks being assigned to workers who were no longer employed or moved to new positions and failed to complete case actions before leaving or moving from assigned job post. This citing was also a result of limited staff to monitor the tasks once position was vacated. The County has made every effort to minimize and mitigate the issues and findings cited and to strengthen the training process for the Medicaid Unit.

Identifying Number: 2022-001 Audit Finding: Eligibility Requirements for Refugee and Entrant Assistance, Federal Assistance Listing Number 93.566 for 2022 issued by the US Department of Health and Human Services. (Repeat) Corrective Action Planned: Management of the Organization is requiring regular ongoing training for all federal programs. All files will be reviewed on a regular basis by a supervisor to ensure eligibility checklists have been used and completed and that all required documentation is contained in the files. The checklists themselves are being reviewed on a regular basis to ensure they reflect current federal guidelines. The biggest reason leading to this finding is that the checklists had not been signed off documenting review procedures were in place. We are now requiring staff to sign off on all checklists and are working to improve the checklists documentation to ensure that all internal controls are documented properly. We note that due to the large increase in the number of people being served, the organization has recently hired additional staff to maintain the content of the files to achieve compliance. Compliance managers will be assigned whose sole duty is to verify the required documentation exists in the files. The compliance managers will report to a supervisor who is independent of the program leadership. The name of the contact person responsible for the corrective action: Jeff Gulde, Executive Director The anticipated completion date: To be completed by March 31, 2023.

IU Health designed and implemented internal controls over the allowability of expenses and amounts submitted in the HRSA and ARP reports. These internal controls were precise enough to ensure that the submissions were compliant with HRSA reporting guidance. In fact, IU Health reached out directly to HRSA to confirm the appropriateness of its election. IU Health remained consistent in utilizing the annual budget as a basis for lost revenue past 2020. As inferred from the annual budget approval date threshold of March 27, 2020, our 2021 and 2022 budgets were prepared using prepandemic years as a baseline expectation. IU Health also conversed directly with HRSA wherein a representative confirmed our use of option 2 as appropriate for Period 3 and beyond, because, according to the representative, the intention of the written regulation did not literally mean budget approval for years past 2020 to have occurred prior to March 27, 2020. As our annual budgets were already naturally materially in line with our long-range plan that was approved in December of 2019, it seemed we were adhering to the spirit of the guidelines set forth. For future periods, IU Health will elect option 3 for lost revenue. Contact Person(s) Responsible for Corrective Action: David Burton Anticipated Completion Date: Effective for Period 5 deadline of September 30, 2023

Finding Number: 2022-005 Condition: The University improperly reported the students that withdrew within the COD System as a result of the COVID-19 national emergency. Planned Corrective Action: The Student Financial Aid (SFA) office agrees with the finding that certain withdrawn students were improperly reported in COD because of the COVID-19 national emergency. SFA evaluated its R2T4 procedures and strengthened its internal controls by discontinuing the practice of automatically adding the COVID indicator to students who withdrew. Contact person responsible for corrective action: Lana Greaves, Senior Associate Director, Student Financial Services Anticipated Completion Date: 4/15/2023

The accurate reporting of campus-level OPEID is required by federal regulation for Title IV students, and although the reporting provides data on Title IV programs, it does not prompt repayment on loans or have any impact on a student's federal aid eligibility. Pursuant to a root-cause analysis conducted by the University, it was determined (and ultimately acknowledged) by the servicer that it had failed to follow established protocols prior to transmitting this information to NSLDS, which led to this finding. The information provided by the University was accurate and consistent with the methodology we use regularly to transmit information to this servicer. The U.S. Department of Education requires independent compliance audits for third-party servicers that help colleges and universities administer Title IV programs and, as part of our on-going due diligence, we reviewed the attestation opinion issued by the independent auditor, who noted no issues with respect to this particular compliance requirement or the servicer?s ability to comply with it. The University has discussed with the third-party servicer its process for submitting Campus-Level information to the NSLDS, and changes are being made by the servicer to ensure its own compliance with the methodology for transmitting data to the NSLDS. The University is also undertaking a detailed review of this servicer?s performance to mitigate the risk of recurrence.

Cluster: Not applicable Federal Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Support Services Award Numbers: T1081685 Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2021 - 2022 Pass-through entity: NH Dept of Health and Human Services Management understands and agrees that there was a failure to follow the documentation requirements of the Opioid STR award during the majority of the time period covered by the audit. In June 2022 the Doorway began implementing a screening tool used at the time of patient intake to determine which patients are eligible under the grant. Additionally, a process will be implemented to perform the required income reassessments every 4 weeks and to track time and differentiate costs between eligible and non-eligible patients. Any patient deemed ineligible in the initial screening or subsequent four week reassessments will continue to be treated, but the associated cost will not be charged to the grant. This documentation will be reviewed a minimum of two times per year by Cheshire?s Compliance Manager, and more frequently if errors are found. Results will be reported to the Chief Operating Officer and the Chief Financial Officer Cheshire has implemented a separation of duties where the clinic administrator will ensure and maintain appropriate documentation, while a senior finance analyst will review and verify appropriateness prior to invoicing the grant. This process will add an additional check to be certain only eligible patients are charged to the grant. Leadership Responsible: Daniel Gross, Chief Financial Officer ? Cheshire Medical Center Anticipated Completion Date: 9/30/2023

Finding 2022-001, Significant Deficiency over Eligibility (Repeat Finding); Medicaid Cluster (Medicaid), Assistance Listing Number 93.778, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Medical Assistance. Recommendation: The County train and monitor employees on the eligibility determination process; also recommend the County review and amend current policies and procedures in place to ensure that all eligibility determination documentation is completed and retained by the County. Corrective Action Plan: The County will complete a quarterly review of errors in income, resources, and social security number and citizenship verification. For those staff identified by the targeted review with errors in these areas, supervisors will provide refresher training on Medicaid policy requirements. Additional targeted reviews will be completed monthly until the deficiencies are corrected. Proposed Completion Date: 1/31/2023 for initial quarterly review 2/28/2023 for refresher training for identified staff 7/31/2023 for additional reviews as needed for identified staff Contact Person: Yolanda McInnis, Economic Services Division Director

Finding 2022-003, Material Weakness ? Eligibility Second Party Reviews; Temporary Assistance for Needy Families, Assistance Listing Number 93.558, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Social Service. Recommendation: The County abide by the State policies in terms of the frequency and amount of case reviews each month; also recommend that policies and procedures are documented surrounding second party reviews and be reinforced to ensure that reviews are being completed and followed up as necessary. Corrective Action Plan: By the 10th workday of every month, the WFFA QA Reviewers will begin to randomly assign cases to WFFA Supervisors and QA team as a checklist in Donesafe for the 25% SPR review. When QA make their assignments on the main form the QA quarter on the checklist should coincide with the month the case was assigned. For example, case was assigned on December 7th for a November action. Case was audited on Jan 3 (Jan 17th deadline) Therefore, this case should be marked as DocuSign Envelope ID: 6BCAC0B4-BD53-4ECF-BA2D-C7510B4F94EC 4th Quarter. QA will attempt to assign the same case for SPR and regular audits whenever possible. The QA Supervisor will send out an email at the start of a quarter to the Program Manager and Auditors to address pending checklists that need to be completed before their deadline. Proposed Completion Date: The Corrective Action will be immediately implemented in response to the auditors? recommendations. Contact Person: Janny Mealor, Assistant Division Director

Corrective Action Plan: Ohio?s corrective action plan for this finding includes system improvements, additional coordination with the Ohio Department of Job and Family Services (ODJFS) on monitoring the processing of IEVS alerts, and additional monitoring of county caseworkers? processing of IEVS alerts by ODM?s Medicaid Eligibility Quality Control (MEQC) unit. ODM and ODJFS continue to meet to analyze the alerts in Ohio Benefits and the group presents recommendations to our vendor for overall system alert improvements; these recommendations were prioritized and corrected in our normal release cadence. The next alert centered release is scheduled for April 2023. Comprehensive alert reduction efforts reduced overall ~29 million backlog alerts and drove a ~22 million annual reduction in new arrival of alerts. ODM, ODJFS and DAS remain committed to improving the alert functionality. ODM and ODJFS meet monthly to discuss triad reviews completed by ODJFS, that evaluate the counties? IEVS alert processing. ODM County Engagement follows up with the counties after these meetings to discuss action plans for working IEVS alerts. ODJFS also conducted a statewide training in July 2022 that focused solely on IEVS alerts processing. Additionally, some counties have taken part in one-on-one IEVS alerts trainings that have proven to be very beneficial. A system release devoted to IEVS enhancements is planned for R4.6.1 (April 2023) which will streamline the process for county staff to process IEVS matches from the IRS Unearned Income interface. There will be both E-Verify enhancements and a change in the match logic which will result in a reduction in the volume of IRS records that are flagged as IEVS matches. As a result, caseworker time spent on processing IRS IEVS matches is expected to reduce. The resulting time is expected to have more value by allowing caseworkers to focus time on matches with an eligibility impact or potential for benefit recovery. During SFY22, the MEQC unit continued to monitor IEVS alerts during the CMS pilot review process. During the review process, if it was determined that a case was processed with an unworked IEVS alert that resulted in a case processing error, it was cited as a technical deficiency and the county was notified. IEVS alerts will continue to be monitored by the MEQC unit going forward. Anticipated Completion Date for Corrective Action: ? The Ohio Benefits system improvement work and IEVS alert training ? Completed and continuing in fiscal year 2023 ? IEVS enhancement system release - April 2023 Contact Person Responsible for Corrective Action: Nathan Bowers, Program Integrity Audit Compliance Coordinator, Ohio Department of Job and Family Services 50 West Town Street, Columbus, Ohio 43215 Phone Number: 614-705-1049, E-Mail Address: Nathan.Bowers@medicaid.ohio.gov

Corrective Action Plan: ODM has either completed or begun corrective action on all of the following recommendations. CDJFS Caseworker Case Processing Weaknesses AOS cited caseworker reliance as an eligibility process weakness. While Medicaid eligibility systems have been updated to bring efficiencies in the Medicaid renewal and enrollment processes, human intervention is integral to ensure cases are processed accurately and appropriately. The dependence on caseworker knowledge and judgement is ongoing and is not perceived as a weakness, but an expectation for a state supervised county administered program. The federal regulation at 42 CFR ?431.10(c) limits the state?s ability to delegate authority to make eligibility determinations to only a government agency which maintains personnel standards on a merit basis. CMS provided additional information in its response to Q32 in the COVID-19 Public Health Emergency Unwinding Frequently Asked Questions for State Medicaid and CHIP Agencies document dated October 17, 2022, indicating that the merit-based personnel standards apply to all eligibility determination functions that require discretion, whereas contractors may be used to support the administrative functions of the eligibility determination process that do not require discretion. This guidance to states supports ODM?s established process that caseworkers are expected to exercise their own judgement with regard to the eligibility determination. Further, it would not be an effective use of federal or state funds to build an eligibility system in such a way that every possible exception scenario can be addressed by system rules and functionality. There are simply too many permutations of household scenarios and eligibility outcomes to make that a feasible option. As a result, caseworker knowledge, judgement, and discretion are integral to the eligibility determination process. AOS cited caseworker training as an eligibility process weakness. ODM, in collaboration with ODJFS, will continue to conduct a variety of trainings throughout the year as described below. While not yet mandatory, all trainings are offered to all 88 CDJFS agencies and are open to caseworkers and supervisors. In addition, high priority trainings are offered live on various days and times and are made available online to view at any time. At this time, we do not yet have the technology available to assign learning plans to county caseworkers and ensure completion, however ODM continues to consider its options for mandating training for county employees, and the advantages and disadvantages of that approach. ? New Worker Training - In SFY2022, the new worker training program underwent a total overhaul to update materials, improve interactivity, and close information gaps between programs. New worker training sessions are scheduled quarterly in 2023 and are offered to all new workers across the state. A new worker training began on February 27, 2023. ? Regularly Scheduled Webinars - ODM hosts monthly webinars and other targeted trainings throughout the year with all 88 counties. The monthly webinars include policy updates, training material, and general guidance or instruction on recent changes and issues. During SFY2022, ODM provided training updates on over 30 policy or procedural topics. Targeted trainings are scheduled to continue throughout 2023. Recordings for presentations are made available to access online at any time. ODM and ODJFS also host Operational System Release Webinars to review implemented system enhancements and fixes. ? On-Demand Inquiry Assistance - Technical Assistance and System support are provided via email for counties to submit questions and receive ODM guidance on both policy and procedures, as well as how to process within the Ohio Benefits system. During the return to routine eligibility operations period, county ?Ambassadors? have access to a Return to Routine Operations Team channel with real-time Q&A support, as well as training materials and desk aids. ? Future Training Plan - Moving forward, training will be a critical success factor for closing the knowledge gap(s) identified during various audits. ODM County Technical Assistance (TA) will identify the training topics, develop curriculum and training delivery methods for the identified training areas. To ensure successful and timely delivery, ODM TA will develop a 24-36 month training schedule of development, review, and delivery milestones to monitor progress. Calendar year 2023 training will focus on returning to routine case processing outside of the PHE, including revisiting conditions of eligibility, electronic verification processing, and proper discontinuance processes. ODM conducted six live sessions in February 2023, addressing returning to routine eligibility operations and will conduct a variety of trainings in April and May on eligibility basics, considering how many case workers have not determined eligibility outside of the public health emergency continuous eligibility restrictions. Recordings of these sessions are available on the County Resources page and will be converted to the Ohio Benefits Program website. The ODM Medicaid Eligibility Quality Control (MEQC) Unit continually monitors Medicaid case processing accuracy. The MEQC Unit reviews CDJFS eligibility determinations, verifies accuracy of recipient information in Ohio Benefits, verifies information is being maintained to support the eligibility decision, and evaluates timeliness of applications. All MEQC error and technical deficiency findings are shared with the CDJFS agencies for review, appeal, and correction if warranted. The federally mandated MEQC Pilot review is currently underway and is expected to be completed in March 2023, at which time regular case evaluations will begin. ODM promptly notifies the CDJFS agencies of errors, and the root cause analysis and corrective action plans are requested. The communication between MEQC and our ODM partners, ensures potential vulnerabilities in the eligibility determination process are being addressed promptly. In addition to the offered trainings and MEQC monitoring efforts, ODM has made significant improvements to the ex parte renewal process during SFY22, to increase the number of Medicaid renewals that occur in the system without county caseworker intervention. These ex parte updates are expected to greatly assist the CDJFS agencies and decrease the burden of processing cases, while also improving accuracy. The MEQC unit has been reviewing a sample of ex parte cases each month to ensure system modifications were effective. System improvements, CDJFS training, and monitoring will be ongoing as the Medicaid program continues to change over time. System Weaknesses Ohio Benefits generates alerts to notify CDJFS caseworkers of actions to be taken on a Medicaid or CHIP case. These alerts may include potential dates of death, notifications that individuals have moved to another state, and information about changes in income. Alerts are an important feature of the Ohio Benefits system. ODM has worked with ODJFS and DAS to reduce the volume of alerts generated in an attempt to improve the usability of the information for CDJFS caseworkers. ODJFS monitors IEVS alert completion. ODM has implemented automation using bots to help work and clear certain alerts. In 2021, multiple small releases, or `sprints? were implemented as part of the plan to reduce the volume of alerts being generated. Alert reduction efforts reduced overall ~29 million backlog alerts and drove a ~22 million annual reduction in new arrival of alerts. ODM, ODJFS and DAS remain committed to improving the alert functionality. The table below shows the impact in each of the sprints during SFY22 and the beginning of SFY23. Sprint Deployment Interface Projected Backlog Reduction Actual Backlog Reduction Projected Arrival Reduction-Monthly Actual Arrival Reduction Per Month Cumulative yearly Arrival Reduction 3 7.8.21 UCB SDX/SSI 936K 936K 399K 451K 4.7M 4 7.8.21 110K 115K 1.3M R3.8 8.14.21 Healthchek, Verification, LTC, DODD, DRC Incarceration, SVES Prisoner, AVS, Buy-IN 300K 736K 66K 63K 792K 5 9.17.22 SSP Document Upload, Companion EDBC 8.3M 9M 90K 100K 1.2M 6 4.15.23 IRS TBD TBD 33K TBD TBD ODM has plans for additional improvements in 2023 to reduce the volume of alerts generated. A sprint is scheduled in April 2023, after monitoring the impact of the initial five sprints. ODM continues to work with DAS and ODJFS on correcting defects and implementing enhancements to the existing alerts. In release R4.3 (August 2022), eight defects impacting alerts were corrected and in release R4.3.1 (September 2022), two alert enhancements were implemented, along with one additional defect fix. This weakness will continue to be remediated through future system modifications. ODM will continue to work collaboratively with DAS to update Ohio Benefits to bring efficiencies in effort to improve Medicaid eligibility determination outcomes. Several releases are scheduled into 2023 to improve system functionality. ODM will continue to evaluate enhancements to assist DAS in determining if the desired outcome was achieved.

Project Legal Name: Partnership for Children and Families Audit Firm: CohnReznick LLP Period covered by the audit: July 1 2021 ? June 30, 2022 Corrective Action Plan prepared by: Name: Kristy Arey Position: Executive Director Telephone Number: 919-774-9496 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation Management understands the importance of full compliance with all regulations found in major programs. Management is aware of this finding and has procedures in place to avoid further findings. b. Action(s) Taken or Planned on the Finding Management has implemented controls to ensure that all child eligibility documents are collected, approved and maintained by the Partnership for the duration of the compliance period. In order to ensure all documentation is collected for each child we have created a checklist that team members will check off and initial when accepting applications from parents. In addition, a third party who did not collect the application will review all applicants to determine if all appropriate documentation was collected and review the application to ensure the child is eligible. Once they have completed their review they will initial and date that the application is complete and ready for placement. All completed and approved applications will be maintained by PFCF for the remainder of the compliance period. This control was adopted and implemented in fiscal year 2022.23.