Corrective Action Plans

U.S. Department of Housing and Urban Development The Cuyahoga Metropolitan Housing Authority (the Authority) respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 through December 31, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-001 Public and Indian Housing ? Assistance Listing No. 14.850 Recommendation: We recommend the Authority review their recertification process to ensure all necessary documentation is maintained and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review the recertification policies and procedures to ensure that all required documentation is maintained in tenant files. Name of the contact person responsible for corrective action: Bo Truett Planned completion date for corrective action plan: December 31, 2023 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Bo Truett at 216-348-5000.

Findings and Questioned Costs Related to Federal Awards Finding Number: 2022-001 Contact Person: Dr. Shelley Isai, Assistant Superintendent for Education Services Anticipated Completion Date: November 21, 2022 Planned Corrective Action: The District reviewed the procedures used to determine Title I, Part A eligibility in the Grants Management System as well as a process that includes maintaining records. The process was redefined for the fiscal year 2023 grant application but will change slightly in future years due to a change in the options in criteria available used to determine eligibility for fiscal year 2023 grant applications. To complete this process with accuracy, the Director of Federal Projects will communicate the required eligibility criteria to the Director of Nutrition Services. The Nutrition Services department will provide Federal Projects with the necessary information to complete the process. Supporting documentation for the basis of fiscal year 2023 and the future years will be stored in a shared file and readily accessible for reference or audits. This process has been documented to ensure consistency through any department transitions.

Finding 2022-002: TANF Program, CFDA No. 93.558 U.S. Department of Health and Human Services Passed through Colorado Department of Human Services Compliance Requirement: Eligibility, Special Tests and Provisions Grant No.: Not Applicable Type of Finding; Internal Control (significant deficiency) and Compliance (noncompliance) Recommendation: The Department should implement monitoring controls to ensure timely completion of initial assessments in compliance with federal eligibility and special tests and provisions requirements. Action Taken: Costilla County DSS was experiencing turnover so no one was looking at the PEAK program cases on a daily basis. Moving forward, our Colorado Works caseworker will look at all cases coming in on a daily basis to ensure that all applications for Colorado Works are assessed no later than 30 days after an application date. If there are questions regarding this plan, please call the responsible parties listed below. Sincerely yours, Julie Albert Chief Financial Officer Costilla County, Colorado Tommy Vigil Department of Social Services Director Costilla County, Colorado

Finding 2022-005 Eligibility Administration for Children and Families CFDA 93.566 Refugee and Entrant Assistance ? State Administered Programs Finding Summary: One instance was identified where two check copies were not retained within the case file to support the checks were received by the refugee family. Responsible Individuals: Tim Jurgens Corrective Action Plan: Procedures are being reviewed to ensure case file reviews include follow-up on incomplete files. Anticipated Completion Date: December 31, 2022

Finding 2022-002 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA Number: 93.498 Finding Summary: The County?s final expenditure listing identified as eligible and claimed under the Provider Relief Fund program was not reviewed and approved by a separate individual outside of the preparer. In addition, the County?s special reports submitted to the Department of Health and Human Services for Periods 2 and 3 TIN #426004597 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Dani Ettema, Sunnycrest Administrator Corrective Action Planned: Moving forward, the Finance Director and/or Administrator will review and approve the expenditures and reports prior to being submitted. Anticipated Completion Date: June 30, 2023

Finding 2022-003 Cash Management Material Weakness in Internal Control Over Compliance Federal Agency Name: Department of Health and Human Services Program Name: Immunization Cooperative Agreements CFDA Number: 93.268 Finding Summary: The County?s requests for reimbursement submitted to the Iowa Department of Public Health were not reviewed and approved by a separate individual outside of the preparer. In addition, on two occasions the County held grant funds in excess of seven weeks. Responsible Individuals: Allie White, County Health Department Executive Director Corrective Action Planned: The VNA will submit the claim to the Health Department for approval before submitting going forward. Anticipated Completion Date: June 30, 2023

Finding 2022-1: 85/15 Reporting (Voc. & Ed. Counseling for Service Members) Criteria: The 85/15 rule prohibits paying Department of Veterans Affairs (VA) benefits to students enrolling in a program when more than 85 percent of the students enrolled in that program are having any portion of their tuition, fees, or other charges paid for them by the Educational and Training Institution (ETI) or VA. The 85/15 calculations must be submitted using the Statement of Assurance of Compliance With 85 Percent Enrollment Ratios form no later than 30 calendar days after the start of the regular term (excluding summer terms). Condition: Our testing of the Institution's submission of the Statement of Assurance of Compliance With 85 Percent Enrollment Ratios form disclosed two instances where the form was submitted past the 30 calendar day deadline. Effect: Without updated 85/15 information, it is not possible for the VA to determine the institution?s eligibility to enroll VA eligible students. Recommendation: The Institution needs to ensure that it adheres to its policies and procedures and VA reporting compliance requirements. Actions Taken or Planned: We have implemented an operational calendar with a distribution list of all the deadlines that goes to several people at ICOHS College to ensure checks and balances are in place. In addition, another person in the office has been trained to provide the 85.15 reporting to ensure back-ups when the main person is on vacation and or sick. Furthermore, the Executive Director is provided the reporting statistics on the 3rd week of the month.

2022-005: The Authority continues to strengthen its procedures surrounding tenant rent calculations at initial and recertification reviews. A second review, conducted by a Public Housing Manager, will be required for all such calculations. For the file in question, a correction was made with a retroactive effective date of May 1, 2022.

2022-001 Eligibility Condition and Criteria: The Authority?s purpose for existence is providing decent, safe and affordable housing to low-income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family?s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following: a. As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant?s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA?s tenant selection policies. e. Reexamine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary. Population and Items Tested: Testing of thirteen family files revealed the following deficiencies: 1. One file used an incorrect utility allowance but was subsequently corrected. 2. One file used an incorrect income amount 3. Two files calculated an incorrect housing assistance payment Auditor?s Recommendation: This is a repeat finding. A thorough review of tenant files should be performed for the purpose of eliminating the deficiencies. Grantee Response: We will comply with the auditor?s recommendation. Anticipated Completion Date: June 30, 2023

2022-002 Special Tests and Provisions Condition and Criteria: The Authority?s purpose for existence is providing decent safe and affordable housing to low-income persons. As such, HUD requires the Authority to comply with special tests and provisions relating to its Housing Choice Voucher program. The Authority must inspect the unit leased to a family at least annually to determine if the unit meets Housing Quality Standards (HQS) and the Authority must conduct quality control re-inspections. The Authority must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). Population and Items Tested: Testing of thirteen family eligibility files revealed one file lacked documentation of a passed HQS inspection. The COVID waiver covering housing quality control re-inspections expired December 31, 2021. No quality control re-inspections were performed during the year ended June 30, 2022. Auditor?s Recommendation: The Authority should ensure documentation of a ?passed? housing quality inspection is maintained. A thorough review of tenant files should be performed for the purpose of eliminating the deficiencies. The Authority should perform housing quality control re-inspections according to HUD guidelines. Grantee Response: We will comply with the auditor?s recommendation. Anticipated Completion Date: June 30, 2023

CORRECTIVE ACTION PLAN Program Name: Foster Care Title IVE Finding: 2022-001 Name of Contact: Keri Jerrell, Child Welfare Program Manager Corrective Action Plan: As children enter foster care, a DSS-5120 is required to be completed in order to determine foster care funding eligibility. Once determined, the eligibility is used in a variety of ways, including, administrative coding and payment for room and board services. As both of these areas involve fiscal operations and county, state, and federal funds, proper determination is imperative. Once satisfied that the proper determination has been made, proper communication and transfer of that determination is of equal importance. In order to assure that a prompt and efficient foster care funding determination is made for each child entering custody of the Alexander County Department of Social Services, the Department is adopting the following plan: 1. Internal guidance for completing the initial DSS-5120 and all subsequent DSS-5120 reviews will be developed and implemented. Guidance will include specialized training for identified staff and a multi-party review process. Projected completion date: 12-31-22 2. 100% of Alexander County DSS cases will be reviewed to ensure that the original funding determination cited on the DSS-5120 is reflected on the respective DSS-5094. Projected completion date: 11-30-22 3. Existing internal guidance document involving the use of the PQA-020 report will be reviewed with involved staff, stressing the importance of consistent documentation of funding source. Projected completion date: 11-30-22

CORRECTIVE ACTION PLAN FOR THE FISCAL YEAR ENDED JUNE 30, 2022 Finding: 2022-002 Name of Contact Person: Trena Riddle, Economic Services Program Manager Corrective Action/Management?s Response: 1. The cases sited in error could not be corrected in the system as they were applications & had alaready been processed. We did complete budgets outside the system to ensure the families remain eligible as the errors did not effect eligibility. On Sample 18 the income was not projected but when we did a new budget the family remained eligible. The online verifications (OVS) were ran for Sample 23 & Sample 26 and the missing child support evidence was added to Sample 7 & Sample 27. There was no change in benefits for these cases. 2. The CIP/LIEAP Supervisor is having a unit meeting on Nov. 14, 2022 to do a refresher training for CIP/LIEAP budgeting. The supervisor will include a test as well to test the workers knowledge. Proposed Completion Date: November 14, 2022

Finding 2022-001 (Assistance Listing 14.881) Eligibility and Reporting (Form HUD-50058 MTW) Public Housing and Rental Assistance Demonstration (RAD) Corrective Action Plan: ? Summary of Finding ? Eligibility and Reporting ? Internal Controls ? There were four Public Housing tenants and three RAD tenants for which control deviations were noted (8.8% overall MTW deviation rate). In the case that a recertification was to be performed in 2022, the nature of the control deviations are as follows: ? The examination/re-examination checklist was not initialed by the certification specialist (CS); therefore, the Authority did not retain evidence that the CS inspected all relevant forms (three instances). ? The examination/re-examination checklist was initialed by the CS, but forms were missing and/or not signed (one instance). ? Relevant forms were signed after the effective date and submittal to HUD (three instances). ? Relevant forms were missing and/or missing signature by the tenant and CS (five instances). ? Summary of Finding ? Eligibility and Reporting ? Compliance In addition, there were twelve compliance exceptions noted out of 100 tenants selected for the MTW program (12.0% overall MTW exception rate). ? The recertification was to be performed in 2022, relevant forms were missing and/or missing signature by tenant and recertification clerk (eight instances). ? The recertification was to be performed in 2022, third-party income support was not available and/or on file (four instances). ? The recertification was to be performed in 2022, third-party income support did not match the calculation amount (one instance). ? The recertification was to be performed in 2022, but was not performed within a reasonable timeframe (two instances). ? The recertification was to be performed, proper documentation was not available and/or on file to tie key line items within Form HUD-50058: total annual income, date of birth, and social security number (two instances). ? The recertification was to be performed in 2022, the reexamination file could not be located (one instance). ? Planned Actions: On March 31, 2023, a comprehensive, in-person training on the `Perfect File Folder? was conducted. It was inclusive of Private Property Management (PPM) firms for both Public Housing and RAD properties. By the end of 2023, each site will have and be required to maintain (and update as needed) a blank Perfect File Folder for site reference. Additionally, the Authority will require certification by the PPMs that 100% of the tenant files that have been reviewed in a calendar year have also been audited and purged. The Authority?s Portfolio Management team will conduct regular audit sampling from the files that have been certified as audited by the PPMs. Contact Person: Eric Garrett, Chief Property Officer Anticipated Completion Date: Q4 2023

WorkNet Pinellas, Inc. management and MIS Team reviewed the monitoring issue with the WIOA team and provided training on the subject. WorkNet Pinellas, Inc. has improved the enrollment process, hired an eligibility specialist and implemented Quality Control (QC) processes to include a review by the eligibility specialist, Career Counselor, and WIOA Lead or MIS QC prior to enrollment to ensure eligibility and accuracy and to ensure "training services be limited to individuals who are unable to obtain other grant assistance for such services including Federal Pell Grants."

Identifying Number 2022-001 Finding: Documentation of rent reasonableness could not be located for three selected clients due to a flood that occurred at the Organization?s offices during December 2022. Action Taken: Management is using Rentellect.com software to verify rent reasonableness for all clients currently in the continuum of care program and is now maintaining a copy of all documentation that supports program eligibility of the clients in the cloud. If there are questions regarding this plan, please call Stephannie Garrett, CFO or Ashley Kline, Chief Program Officer at 330-374-0740.

Finding 2022-004 Student Financial Assistance Program Cluster - Department of Education Federal Financial Assistance Listing/CFDA #84.268 Federal Direct Student Loans - 2021/2022 P268K211430 Federal Financial Assistance Listing/CFDA #84.063 Federal Pell .Grant Program - 2021/2022 P063P201430 Special Tests & Provisions: Enrollment Reporting Significant Deficiency in Internal Control Finding Summary: Two instances were noted where enrollment effective date reported to the National Student Clearing House as first effective was not the same as the student's last date of attendance. Responsible Individuals: Kristi Bagstad, Registrar Registrar's Office Corrective Action Plan: The financial aid office will establish a review process to spot-check and confirm that the Enrollment Effective date will coincide with the Last Day of Attendance reported for student records. Anticipated Completion Date: Ongoing

Enrollment Reporting to NSLDS Planned Corrective Action: Errors may have occurred due to transition in staff and insufficient processes related to identifying student non-attendance. Error reports from the National Student Clearinghouse are reviewed after every submission and errors are corrected. Second, processes related to identifying students who have stopped attending classes were strengthened during the Fall 2022 semester. Person Responsible for Corrective Action Plan: Chris Vetter - Interim Provost Anticipated Date of Completion: December 30, 2022

2022-005 Head Start Cluster, Federal Assistance Listing No. 93.600 Special Tests and Provisions Recommendation: The auditors recommend that the Organization should establish policies and procedures to ensure all applicable special tests and provisions are completed accurately and timely. Actions Taken or Planned: The Organization has created a written plan to provide appropriate training and technical assistance on the Head Start performance standards that is sufficient to ensure that the governing body and policy council can fulfill their responsibilities under the Head Start Act. Training is to take place within 180 days of the beginning of the term of a new governing body or policy council. The training: i) includes methods on how to collect complete and accurate eligibility information from families and third party sources; ii) explains program policies and procedures that describe actions taken against staff, families, or participants who attempt to provide or intentionally provide false information; and, iii) incorporates strategies for treating families with dignity and respect and dealing with possible issues of domestic violence, stigma, and privacy. Person Responsible: The Howard Area Community Center Executive Director, Jason Kaiser, Early Childhood Education Director Nancy Salvador, and ERSEA Tech Maria Hernandez. Estimated Date of Completion: The Organization?s Board of Directors received training for FY23 on July 28, 2022. The next training for the policy council will be completed on March 16, 2023 and the HACC Board Training for FY24 is scheduled to be completed by March 30, 2024.

2022-001 Sliding Fee Discount Determination Name of Contact Person: Cheryl Petersen Pine, CFO Corrective Action: Bay Area Community Health will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions Proposed Completion Date: January 31, 2023

FINDING 2022-006 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Real time reporting will be compiled by the Data Management Specialist (currently Stephanie Jackson) and will be reviewed by the Title I Grant Coordinator (currently Tim Rayle). Annual Financial reports will be compiled by the Director of Business Affairs (currently John Szabo), and prior to submission those reports will be reviewed by the Title I Grant Coordinator. Anticipated Completion Date: July 2023

Oversight Agency: U.S. Department of Aging Community Crisis Center, Inc. respectfully submits the following corrective action plans for the year ended June 30, 2022 Auditor: Dugan & Lopatka, CPAs 4320 Winfield Road Suite 450 Warrenville, IL 60555 Audit Period: For the year ended June 30, 2022. The finding from the schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the numbers assigned in the schedule. Findings- Federal Award Programs Audit Department of Justice 2022-001 Crime Victim Assistance Program Auditor's Recommendation: We recommend Community Crisis Center, Inc. review its client files to ensure that all client files contain the required confidentiality forms. Action Taken: The Center's midnight Case Manager staff will work through all the intake paperwork for the day to ensure all forms are present, including the confidentiality form for clients. If the funding agency has questions regarding this plan, please call me at 847-742-4088

Finding No. 2022-001 ? Activities Allowed or Unallowed; Allowable Costs; and Reporting Identification of the federal programs: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Award Numbers: Not applicable Pass-Through Award Period of Performance: 07/01/2021?06/30/2022 Views of responsible officials and planned corrective actions: Although not in place the entire period of performance, effective March 31, 2022, the Financial and Data Analytics Director began conducting spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting and retains evidence of this testing.

Finding No. 2022-002 ? Activities Allowed or Unallowed; Allowable Costs and Eligibility ? Significant Deficiency in Internal Control Over Compliance Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Program) Pass-Through Award Numbers: Not applicable Pass-Through Award Period of Performance: 07/01/2021?06/30/2022 Views of responsible officials: December 31, 2022, the Company completed its evaluation of additional EPIC automated processes and opportunities to add documentation to evidence HRSA claim reviews. Additional opportunities to add documentation in EPIC were not identified. Testing and treatment claims under the above federal program are no longer accepted after March 22, 2022 and vaccine claims are no longer accepted after April 5, 2022. Should the program return, the Company would support either internal claim compliance spot testing, with evidence of this testing retained, or an EPIC system software audit of the automated processes.

Recommendation: We recommend that DCF have internal controls in place to mitigate this from happening in the future. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The first case is from Feb. 2008 and the other one is from May 2014. While there were several documents provided from those two cases, missing from that, was nonrecurring expense documentation. The staff persons identified with both cases were from the SN County (NE Region). Neither staff member identified is still currently employed with DCF. KDCF has a policy that all casefiles contain documentation to support any state expenditure, as well as documentation to support all payments, (reference Policy #0430 Contents of Foster Care, Adoption and Independent Living Services Case Records). Internally, we have quarterly meetings with adoption staff and specialists, as well as monthly meetings with Regional Foster Care Administrators. We will discuss the audit findings and the importance of properly maintaining all the adoption and subsidy related paperwork. It is vital all of documents can be accounted for in the adoption files. We will stress that files be double-checked to make sure they have all items in place before being filed. Name(s) of the contact person(s) responsible for corrective action: Corey Lada, Adoption Program Manager Planned completion date for corrective action plan: March/April 2023

Recommendation: We recommend that KDHE reviews the process of redeterminations being sent to the household and identify any problem areas in the process which could undermine the redetermination frequency. We also recommend that KDHE reviews the training materials to ensure that all staff who make eligibility determinations are aware of the required supporting documentation to be saved for both initial eligibility determinations and redeterminations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Due to the current COVID-19 Public Health Emergency (PHE) and the continuous enrollment requirement mandated by CMS, no action has been taken on cases to correct the issue of annual redeterminations as it would cause adverse action with active recipients of Medicaid. At the conclusion of the continuous enrollment requirement, all active recipients will receive a redetermination and updated information based on changes in circumstances will be addressed to determine on-going eligibility. As redeterminations have not been conducted for the past three years, the State of Kansas has utilized the ?downtime? to enhance both KEES and training in preparation for the resumption of redeterminations. From a KEES perspective, numerous updates have been made to redetermination functionality/logic to ensure households receive the required redeterminations appropriately. Throughout the course of day-to-day activities, tickets can be submitted to Helpdesk when a potential problem area is identified in KEES. These tickets are then tracked, prioritized, and analyzed to determine the root cause. The State of Kansas has continued to utilize this information to fix on-going defects that prevent undermining the redetermination frequency. Additionally, validations have been implemented within KEES and visuals added to assist eligibility staff in how redeterminations are completed as part of the review process. A complete redesign has also been completed regarding the Transitional Medical program to ensure KEES is following policy. As mentioned in previous Corrective Action Plans, to prevent untimely redetermination processing in the future, enhancements have been made to the reviews batch and the reviews data available. This will be utilized as redeterminations resume in the State of Kansas. KDHE enhanced the reviews batch process to ensure beneficiaries are sent their review earlier. This allows more time to determine ongoing eligibility prior to the beneficiary losing coverage. Reporting enhancements were made that provide previously unavailable data. The enhanced data allows for greater analysis of mailed and return volumes, which is then used to allocate staff for reviews processing in a more effective manner. From a training perspective, all redetermination training materials were updated and sent through the approval process based on current policies and procedures. These materials are now housed on a document repository (KanShare) that is accessible by all eligibility staff. In February and March 2023, all eligibility staff who will be tasked with processing redeterminations when they resume in April 2023 attended redeterminations training to ensure their comprehension of policies and procedures. This training was divided into three (3) sections: Part 1 is the policy and procedures of determinations; Part 2 is the application of policy and procedures and Part 3 was a post-assessment to gauge the understanding of redeterminations. Lastly, due to the already made enhancements in KEES surrounding redeterminations, all eligibility staff completed `KEES Reviews Update? training in March 2023. This allows eligibility staff to put together redeterminations from beginning to end and ensure all required documentation is maintained with KEES. All active recipients will receive at minimum one annual redetermination by April 2024.This will allow the State of Kansas to gauge recent efforts to mitigate errors identified during the FY22 SSA. Name(s) of the contact person(s) responsible for corrective action: Donna Wills Planned completion date for corrective action plan: April 2024