Corrective Action Plans

Recommendation: The Commission should consider reviewing its current policy regarding rent certifications. The Commission should ensure all persons involved in the certification process are properly trained and understand regulations in order to accurately identify errors. The Commission should adopt policies and procedures that would require a second person to be involved in the certification process to ensure the accountability of tenant files. The reviewer should sign and date the verification form, evidencing the control is being performed.Action Taken: New management has taken over the Commission subsequent to the period under audit and will ensure all staff members involved in the annual recertification and interim examinations are properly trained with respect to the rules and regulations pertaining to this process. Management will also implement stronger internal controls and policies regarding rent certifications. Anticipated Completion Date of Action: June 15, 2023.

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Stonington respectfully submits the following corrective action plan for the year ended December 31, 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: January 1, 2022 through December 31, 2022 The finding from the December 31, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING No. 2022-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that tenant income utilized at move-in is accurate in determining the tenant?s monthly rent, and verification through the EIV system is completed in a timely manner. The Project should have made an immediate correction to form HUD-50059 upon receiving the correct income from the EIV system. Action Taken: Training on income calculations and including the double checking of calculations more than once for accuracy will be conducted with managers. In addition, compliance has created an income calculation worksheet with formulas where managers can enter data and the worksheet will complete the calculations. If the audit Oversight Agency has questions regarding these plans, please call Christine Harris at 954-835-9200. Sincerely yours, Christine Harris Accounting Manager

2022-001 Sliding Fee Discount Determination Name of Contact Person: Chief Financial Officer: Gurjeet Sandhu Cause: COVID made it challenging to collect the information from patients as vast majority of the visits were telephonic and not all the patients have the ability to provide the information electronically. In addition, there was constant turnover in staff and their knowledge may have been limited. Corrective Action: Golden Valley Health Centers 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: October 31, 2022

Identifying Number: 2022-001: Accuracy of Reporting Criteria: Management was responsible for reporting accurate lost revenues based on the terms of the grant agreement. Condition: During compliance testing, it was identified that certain lost revenues included in the final report were not accurate based on the definitions of the grant agreement. Context: The lost revenue amount reported for the period was not accurate. Cause: The supporting documentation retained that calculated lost revenues had certain inaccuracies in the revenues reported for January 2020. Effect: As a result of the condition, the Hospital's required reporting for this grant was misstated, however the Hospital was able to recalculate the appropriate lost revenues and, in conclusion, report that there were enough losses to charge to this federal award to support the propriety of all funds received. Recommendation: In the future, the Hospital should ensure it implements appropriate processes and controls to ensure a review is performed prior to submission to the awarding agency. Contact: Richard Scheinblum, Chief Financial Officer Corrective Actions Taken or Planned: Management acknowledges the finding and will ensure appropriate review of supporting calculations and COVID-related expenditures utilized within the report. An amended report will be filed with the awarding agency, as applicable. On December 27, 2022, management received a confirmation letter from HRSA, Division of Financial Integrity, acknowledging that the procedural finding has been satisfactorily resolved. The Corrective Action is subject to review during the next audit.

Finding #2022-001- Segregation of Duties (Prior Year Finding #2021-001) Condition: A properly designed system of internal control includes adequate staffing, policies, and procedures to properly segregate duties. This includes systems that are designed to limit access or control of any one individual to your government?s assets, and to achieve a higher likelihood that errors or irregularities in your processes would be discovered by your staff. There are key controls related to significant transaction cycles that are important in reducing the risk of errors or irregularities. At this time, the District does not have the following controls in place: -Persons processing accounts payable are not always separate from those ordering or receiving goods or services. -Persons initiating electronic fund transfers are not separate from those authorizing, confirming, or reconciling the transactions. -There are no procedures in place for review and approval of new vendors. -Persons preparing the payroll also maintain employee records, change employee rates, and change data in the payroll system. -The person reviewing free and reduced food service eligibility can also modify information entered into the system to determine eligibility. -Account reconciliations are not performed by someone independent of the processing of transactions in the account. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities as a result of the lack of segregation of duties. Cause: Limited number of personnel. Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or has the ability to both make and conceal an error, whether such error is intentional or unintentional. Recommendation: We recommend that the District consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with this finding but do not believe it is cost effective to increase the office staff in an attempt to bring about a more effective segregation of duties. The Building Principals and the Business Manager approve purchase orders and the Business Manager approves monthly accounts payable checks. Also, the Building Principals or department supervisors approve payroll timesheets prior to processing payroll. The payroll along with the time sheets are then approved by the Business Manager. The Business Manager, Building Principals, and department supervisors will continue to monitor transactions of the District. Contact Person: Greg Benz Anticipated Completion: Not applicable

Finding #2022-001 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Agriculture Food Distribution Cluster: Emergency Food Assistance Program (Food Commodities) Assistance Listing #10.569 Passed through The Houston Food Bank, Montgomery County Food Bank, and Galveston County Food Bank Contract Year: 10/01/21 ? 09/30/22 Recommendation: Communicate and emphasize adherence to contractual requirements for determining and documenting eligibility and retaining documentation and provide training to volunteers as needed to ensure compliance. Planned corrective action: We will implement action plans of retraining of Vincentian food pantry volunteers at the two food pantries that were missing application forms by March 31, 2023. The single audit requirements will be emphasized to ensure volunteers have a complete understanding of the policy and procedures. From April 1, 2023 through June 30, 2023, The Council will conduct internal audits to determine whether the deficiencies have been addressed. Responsible officer: Kirk Vogeley, Director of Finance Estimated completion date: June 30, 2023

Section III: Finding 2022-002 Internal Control Structure Material Weakness ? Eligibility, Reporting and Special Tests and Provisions, Repeat Finding 2022-001 Agree with finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board has reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

Views of responsible officials and planned corrective actions: The accounting department, under the direction of the chief financial officer, will conduct monthly audits of random patients? accounts for whom the sliding fee schedule has been applied, as well as training for receptionists to minimize errors. Receptionists have been mandated, along with assistance from internal billing staff, to review all patients? accounts (including income verification) at least annually.

Finding 2022-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster - Section 8 Housing Choice Vouchers - Mainstream Vouchers Federal Catalog Numbers: 14.871, 14.879 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 2,313 units. Of a sample size of forty-five (45) tenant files, the following was noted: - HUD 9886 Form was missing in 1 file - Verification of income was missing in 2 files - Verification of assets was missing in 1 file - HUD 50058 annual recertification was missing in 4 files - Original Application was missing in 5 files Our sample size is statistically valid. Known Questioned Costs: $215,596 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained, and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Finding 2022-002 (continued): Authority Response: MHA agrees with the findings that some tenant file documents were essentially unavailable for examination at the time of the audit and that a system of consistent document filing, and regular file reviews are necessary. The ?missing? documents were subsequently found but in various electronic locations, thereby making them not easily accessible to the auditors. There were also timing issues, in that a recertification was begun in 2022 but not completed or made effective until 2023 once all documents had been received. ? The tenant documents will now be filed in one place, in Yardi as attachments to the Family Detail Info (FDI) screen in the proper subfolder depending upon subject (e.g. Assets, Income, Member). MHA is working to create and label the subfolders needed for this purpose. ? The contractor and internal staff will receive detailed instructions on how to file all documents, from the receipt of documents from the tenant to the commemoration of the transaction in a HUD Form 50058. All will be required to sign a confirmation they received such instructions. ? All new staff responsible for collecting documents, processing transactions and creating 50058s will obtain training in the correct system of filing such documents as part of their on-boarding packet of trainings. ? MHA will institute a quality control procedure for the regular review of random sample files at least quarterly to ensure that the filing system is being followed and the documents are complete and readily found. Views of responsible officials and planned corrective action: Susanne Joyce, HCV Program Manager, is responsible for implementing this corrective action by December 31, 2023.

Finding 2022-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Federal Catalog Numbers: 14.850 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 456 units. Of a sample size of seventeen (17) tenant files, the following was noted: - HUD 50058 annual recertification was missing in 1 file - Original Application was missing in 2 files - Citizenship Declaration was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: $27,341 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Public and Indian Housing Program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: MHA agrees with the findings that some tenant file documents were essentially unavailable for examination at the time of the audit and that a system of consistent document filing, and regular file reviews are necessary. The ?missing? documents were subsequently found but in various electronic locations, thereby making them not easily accessible to the auditors. There were also timing issues, in that a recertification was begun in 2022 but not completed or made effective until 2023 once all documents had been received. ? The tenant documents will now be filed in one place, in Yardi as attachments to the Family Detail Info (FDI) screen in the proper subfolder depending upon subject (e.g. Assets, Income, Member). MHA is working to create and label the subfolders needed for this purpose. ? The contractor and internal staff will receive detailed instructions on how to file all documents, from the receipt of documents from the tenant to the commemoration of the transaction in a HUD Form 50058. All will be required to sign a confirmation they received such instructions. ? All new staff responsible for collecting documents, processing transactions and creating 50058s will obtain training in the correct system of filing such documents as part of their on-boarding packet of trainings. ? MHA will institute a quality control procedure for the regular review of random sample files at least quarterly to ensure that the filing system is being followed and the documents are complete and readily found. Views of responsible officials and planned corrective action: Nick Zhou, Chief Financial Officer, is responsible for implementing this corrective action by December 31, 2023.

Finding 2022-004: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Continuum of Care Program Federal Catalog Numbers: 14.267 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: No Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 71 units. Of a sample size of twenty-one (21) tenant files, the following was noted: - HUD 50058 annual recertification was missing in 1 file - Income Verification was missing in 2 files Our sample size is statistically valid. Known Questioned Costs: $30,581 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Continuum of Care Program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: MHA agrees with the findings that some tenant file documents were essentially unavailable for examination at the time of the audit and that a system of consistent document filing, and regular file reviews are necessary. The ?missing? documents were subsequently found but in various electronic locations, thereby making them not easily accessible to the auditors. There were also timing issues, in that a recertification was begun in 2022 but not completed or made effective until 2023 once all documents had been received. ? The tenant documents will now be filed in one place, in Yardi as attachments to the Family Detail Info (FDI) screen in the proper subfolder depending upon subject (e.g. Assets, Income, Member). MHA is working to create and label the subfolders needed for this purpose. ? The contractor and internal staff will receive detailed instructions on how to file all documents, from the receipt of documents from the tenant to the commemoration of the transaction in a HUD Form 50058. All will be required to sign a confirmation they received such instructions. ? All new staff responsible for collecting documents, processing transactions and creating 50058s will obtain training in the correct system of filing such documents as part of their on-boarding packet of trainings. ? MHA will institute a quality control procedure for the regular review of random sample files at least quarterly to ensure that the filing system is being followed and the documents are complete and readily found. Views of responsible officials and planned corrective action: Nick Zhou, Chief Financial Officer, is responsible for implementing this corrective action by December 31, 2023.

ELIGIBILITY DETERMINATION INCOME AND ASSET VERIFICATION Federal Agency: U.S. Department of Health and Human Services and U.S. Department of Agriculture Federal Program Title: Medical Assistance Program (Medicaid Cluster) and State Administrative Matching Grants for Supplemental Nutrition Assistance Program (SNAP Cluster) Assistance Listing Number: 93.778 and 10.561 Pass-Through Agency: Minnesota Department of Human Services and Minnesota Department of Agriculture Pass-Through Numbers: 2205MN5ADM and 222MN101S2520 Award Period: Year-Ended December 31, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: It is recommended the County implement procedures to ensure that asset and income documentation in the case files matches the information input into the METS eligibility system as required by federal standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will conduct a training and informational session to show staff proper documentation and entry into METS. Name of the contact person responsible for corrective action plan: Anne Lindseth, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services and U.S. Department of Agriculture Federal Program Title: Medical Assistance Program (Medicaid Cluster), Temporary Assistance for Needy Families (TANF), Title IV-E Foster Care and State Administrative Matching Grants for Supplemental Nutrition Assistance Program (SNAP Cluster) Assistance Listing Number: 93.778, 93.558, 93.685 and 10.561 Pass-Through Agency: Minnesota Department of Human Services and Minnesota Department of Agriculture Pass-Through Numbers: 2205MN5ADM, 2201MNTANF, 2201MNFOS and 222MN101S2520 Award Period: Year-Ended December 31, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the County perform case file reviews on a more representative sample of the total clients served and that adequate documentation be retained of those reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will conduct a training session for health and human services staff regarding procedures required for case file reviews. Name of the contact person responsible for corrective action plan: Anne Lindseth, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

2022-001 Income Certifications Name of contact person ? Angela Riley, CFO Corrective action ? The Corporation agrees with the finding, and has continued to implement strategies to address these issues throughout 2021 and 2022, including: assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications, hired a team of 6 additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications, developed a new training program to onboard site staff, and developed a monitoring program to set expectations and hold employees accountable to those expectations. Proposed completion date ? Management has begun the corrective action and is expected to have additional internal controls and training done by December 31, 2023.

93.767 Children' s Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Reporting 2022-026 Ensure Compliance with Reporting Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response: DOM Concurs. DOM identified this issue during reporting of the March 31, 2022 federal expenditures. Per 45 CFR ?95.1, DOM has two years (seven quarters following the occurrence of the expenditure) to make adjusting entries to claim additional expenditures. DOM Does not Concur. DOM has fully corrected finding 2021-041 on the Schedule of Prior Year Findings. This finding is based on OSA's belief that DOM should be using state tax data to determine eligibility of applicants. However, DOM does not have statutory authority to access this information. DOM utilizes all available tools, in accordance with the CMS approved state plan, to evaluate the eligibility of applicants; thus, this finding is Fully Corrected as DOM is complying with all CMS regulations and the approved state plan. Further, DOM performed training and made operational changes for all other issues noted in finding 2021-041. There are internal controls in place to limit the number of errors and annual training is conducted that includes examples of issues noted, along with preventive and corrective solutions. Human error is a part of any manual process and cannot be completely eliminated. DOM Corrective Action Plan: a. DOM made adjustments to the costs identified in this audit finding in the June 30, 2023 federal reports. In addition, a reconciliation has been added to the spreadsheets used for reporting of federal expenditures to ensure all expenditures are reported properly going forward. b. Christine Woodberry c. Completed July 24, 2023

93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Eligibility 2022-025 Strengthen Controls to Ensure Compliance with Eligibility Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response: DOM acknowledges OSA's concern regarding the initial review of case files and the prompt action to select and provide a new sample of cases. Historically, DOM has provided a hardcopy of the actual beneficiary case files to OSA. Since those cases were active, an inventory control process, which included a notation in the electronic beneficiary file of the request to send the physical folder to the central office, was implemented. Likewise, upon arrival in the central office, notation of receipt of the files are added to the system prior to providing said files to the auditor. Occasionally, there are multiple files depending on the office with whom a beneficiary communicates, and multiple individual files associated with a family case. Additionally, cases in the sample may also be undergoing redetermination. To ensure that OSA has all the documentation needed for their case review, DOM staff reviews the files prior to sending them to central office. If an adverse eligibility determination is discovered, DOM has an obligation to correct at the time of discovery. As such, changes to the files are noted in the case history, which is available to the auditors. DOM will be transitioning to a paperless environment, which should alleviate any concerns during future audits. Use of Tax Return Resources DOM Does Not Concur. OSA compared eligibility data to state income tax returns. DOM is prohibited from accessing state income tax records per Mississippi Code Annotated ?27-3-73 and currently, does not have access to federal income tax records. DOM maintains that for determining eligibility, it has complied with the CMS-approved state plan. Using the approved CMS MAGI Based Verification plan in effect during the audit time period, the state sought to verify the reported income to the standard of reasonable compatibility, as defined by CMS, through all available electronic data sources. Further, DOM is required to accept the information provided by the applicant and utilize the available verification methods as detailed in the CMS-approved state plan to evaluate the accuracy of the information provided. If an applicant does not report self-employment income, and the tools available to DOM do not reveal such, DOM has performed its due diligence in the eligibility process and complied with the requirements of CMS, DOM's federal regulatory and oversight agency. OSA questioning DOM's determinations based on information that DOM was not provided nor have access to is shortsighted and does not align with the federal regulations that are imposed on this agency. While DOM is only required to use tax return information in certain circumstances, the agency continues to pursue the authority to review state and/or federal tax return information. To date, DOM has not been provided statutory authority to access Mississippi Department of Revenue tax information and is still awaiting IRS approval of the Safeguard Security Risks document. DOM plans to continue to follow the approved federal/state plan for eligibility determinations and will utilize additional resources as they become available. One MAGI beneficiary - DOM did not use taxable unearned income reported on tax return DOM Concurs. The application on file states neither parent has earned income. Although, the unearned income was not included in the initial calculation, adding it did not result in the beneficiary being ineligible. One MAGI beneficiary - self-employment income was reported to MDOM, but MDOM did not request a tax return from the beneficiary. DOM Concurs. The tax return was not requested for this particular beneficiary. This was an oversight, and the issue has been corrected. Two of the 180 MAGI beneficiaries - income was not verified through Mississippi Department of Employment Security DOM Concurs. There were multiple transactions associated with each of the beneficiaries identified. As a result, DOM's eligibility vendor is investigating to determine the reason the MDES search was not performed. One of the 180 MAGI beneficiaries - the beneficiary's case file did not contain an application or verification of income. DOM Concurs. This file could not be located. One of the 300 beneficiaries - auditors were unable to verify that any eligibility redeterminations have been performed since 2018. DOM Does not Concurs. A redetermination was not completed prior to the PHE. During the PHE, DOM was not allowed to performed redeterminations, which would have allowed DOM to update this file. Nine instances - resources were not verified through AVS at the time of redetermination. DOM Does not Concur. This is a prior finding from OSA 2021-041. Please note that all redeterminations in question occurred prior to the OSA audit period (FY22) and were suspended due to the public health emergency from March 2020 to June 2023. The eligibility system was updated in June 2022, after finding 2021-041, to include automatic asset checks within the system processing workflow to eliminate the manual request process and facilitate asset verification through AVS. Again, each instance identified above occurred prior to this implementation. In addition, AVS was checked on the 9 instances OSA sited, which resulted in no change in the eligibility determination. One instance - the beneficiary's case file did not contain a current level of care decision. DOM Does not Concur. DOM disagrees with this finding as redeterminations for the category of eligibility in question were suspended due to the public health emergency from March 2020 to June 2023. The date in question is from July 2021, which falls within this timeframe, and the child would have been eligible regardless. Seventy-three beneficiaries were not included on all of the required quarterly Public Assistance Reporting Information System (PARIS) file transmissions for fiscal year 2022. Of the 73 beneficiaries, six beneficiaries were not included on any quarterly PARIS file transmissions during fiscal year 2022. DOM Does not Concur. Per an amendment to DOM's CMS-approved State Plan, DOM is only required to verify Title XIX applicants and individuals eligible for covered Title XIX services. The above members were covered in Family Planning, which is not considered Title XIX, and did not receive Title XIX services. Therefore, these members should not have been included on any of the PARIS file transmissions. DOM Corrective Action Plan: a. All issues identified will be reviewed with regional office staff. Further, examples of these issues will be included in annual training sessions performed by Eligibility. DOM will continue to work with the vendor to ensure that income is verified through MOES, as applicable, and to implement controls that will limit this issue in the future. Further, DOM is implementing an electronic storage system to house all documents associated with applicants/beneficiary files. b. Cindy Bradshaw c. December 31, 2024

21.023 COVID-19 Emergency Rental Assistance (ERA) Eligibility 2022-031 Strengthen Controls to Ensure Compliance with Eligibility Requirements for the Emergency Rental Assistance Program Response: DFA was simply a pass-through agency of the funds and was required to draw down the funds in light of an impending federal deadline. It is not possible for DFA to assess and conduct eligibility determinations as it has not been appropriated any funds nor does it have the personnel or other resources to do so. Corrective Action Plan: A. Mississippi Home Corporation has eligibility and fraud prevention policies in place; however, this grant program is no longer accepting applications. B. N/A C. N/A

10.558 Child and Adult Care Food Program Allowable Cost 2022-027 Strengthen Controls to Ensure Compliance with Allowable Costs Requirements of the Child and Adult Care Food Program (CACFP). Response: The MDE does not concur with this finding. The OSA did not identify weaknesses in the MDE subrecipient monitoring process, such as in the selection of organizations, the monitoring cycle, or monitoring procedures. Instead, OSA identified potential errors made by individual participating organizations. The MDE has a robust system of internal controls and subrecipient monitoring system for the CACFP. In addition to meeting USDA requirements for monitoring, the MDE Office of Child Nutrition (OCN) also employs a risk -based process to select CACFP subrecipients for review and to determine the scope of monitoring. The MDE routinely exceeds the USDA requirement to monitor 33.3% of participating organizations annually. For Program Year (PY) 2021-2022, 60.3% of participating organizations were reviewed to provide additional oversight of subrecipients. When the MDE identifies instances of noncompliance, it requires participating organizations to take appropriate corrective action. For organizations that are very high-risk, the MDE employs the USDA Serious Deficiency process in accordance with 7 C.F.R. 226.6. The MDE already has a process to recover funds from an organization if an error is discovered during subrecipient monitoring. In PY 2022, the MDE assessed $132,207 in repayments of USDA funds and required an additional $40,577 in unallowable costs to be returned to local CACFP accounts. Finally, MDE staff was not included in the reviews of subrecipients by OSA, so the MDE was unable to verify the accuracy of the proposed unallowable costs before publication of the report from OSA. MDE staff will need to review documentation from OSA, and source documentation retained at CACFP sites before it can make a final determination regarding the potential unallowable cost determinations against sponsors. Corrective Action Plan: A. The MDE will review documentation provided by OSA of potential questioned costs and review source documentation held by the subrecipients to determine the amount of unallowable costs. If confirmed, the MDE will recover any unallowable costs in accordance with USDA policies. This review will be completed by January 22, 2024. Susie Evans, CACFP Director for the MDE OCN, will oversee the review. B. The MDE will continue to assess its CACFP monitoring and continue to strengthen the process while remaining in compliance with USDA regulations.

FINDING 2022-003: Under awarded Federal Direct Subsidized Loan A. Comments on Findings and Recommendations: In response to the under awarded Direct Subsidized Loan, Brillare Beauty Institution agrees with the Single Audit Finding 2022-002. B. Actions Taken or Planned: Brillare Beauty Institute has resolved the 2021-2022 award year regarding the under awarded Direct Subsidized loan. The 2021-2022 financial aid award year was re-opened and the under award loan amount was reallocated from Direct Unsubsidized to Direct Subsidized in Common Origination and Disbursement. Brillare Beauty Institute hired an additional Financial Aid Officer in February 2022 to help with administering the Title IV Direct Loan program. At the time of this error, training of the new employee was still in process. Also, Brillare Beauty Institute has contracted with a new 3rd Party Financial Aid Servicer as of December 2022 and as part of this transition, both reviewed and strengthened our Federal Direct Loan policies and procedures.

FINDING 2022-002: Over awarded Pell Grants A. Comments on Findings and Recommendations: In response to the under awarded Pell Grant, Brillare Beauty Institute agrees with the single audit finding 2022-001. B. Actions Taken or Planned: Brillare Beauty Institute has resolved the student under award Pell grant issue. The student was given a check by the Institute to rectify the under-awarded Pell Grant amount to be received. Brillare Beauty Institute has contracted with a new 3rd party Financial Aid Servicer as of December 2022 and as a part of this transition, both reviewed and strengthened our Pell grant policies and procedures. This revision took place after the student's 2021-2022 Pell grant disbursements.

A. Comments on Findings and Recommendations: 2022-001 - Missing Proof of Loan Entrance Counseling. It seems that the student may not have completed entrance counseling. When this student started, MCU was contracted with Weber as its Third- Party Servicer who used to check entrance counseling before processing our students. Since 2020, MCU has been contracted with Campus Ivy whose platform now requires the Financial Aid Department to upload the entrance counseling proof before processing can occur. B. Actions Taken or Planned: 2022-001 - Missing Proof of Loan Entrance Counseling. The student in question has now performed the required Entrance Counseling. Since May 2020, MCU's updated entrance counseling process with Campus Ivy has helped mitigate a risk of gaps with regard to the completion of entrance counseling. MCU will perform an internal review on current students enrolled before May 2020 to ensure entrance counselings are complete.

Finding 2022-001 ? Underawarded Pell Grants: During the audit, it was noted that two students were not awarded the full amount of their allowable Pell grants. It was recommended that the school credit the appropriate students? accounts $1,077. The Institution agrees with the finding. The school has made the appropriate corrections to the student accounts and both students have received their additional funding. The Institute recognized that our 3rd party Servicer was not disbursing the correct amount of Pell grant funds and requested that they complete a full audit of disbursements, the error on their end has been corrected and should not lead to additional findings moving forward.

2022-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Daniel Winokur, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc 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: September 30, 2022

Finding 2022-001 ? Activities Allowed or Unallowed and Eligibility Information 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, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured and the COVID-19 Coverage Assistance Fund Federal Award Numbers: Various Federal Award Period of Performance: 09/01/2021?04/05/2022 Views of responsible officials and planned corrective actions: Management made the adjustments to the report script to ensure all uninsured COVID-19 patient accounts eligible for reimbursement by HRSA are captured for management review and includes accounts with a zero balance and/or have a closed status. The corrective action plan was implemented and in place by December 31, 2021 shortly after the 8/31/2020 Uniform Guidance audit was completed on November 29, 2021. The adjustments will ensure that claims completed after December 31, 2021 are captured. Responsible Official: Michael Mullen, Vice President Revenue Cycle Completion date: December 31, 2021.

2022-001 - Eligibility In our sample of 40 individuals tested for eligibility compliance, five individuals did not have original applications on file with applicant signatures to ensure the existence of the participant. The households for which these individuals applied were eligible for services and the original applications had been entered into an electronic data base for tracking, but the original applications were unable to be located. Corrective Action Plan: ? Provide additional outreach and training to staff in counties outside of Dickinson & Iron ? Conduct semi-annual onsite (or video-conference) reviews of other county client applications ? Review distribution attendance sheets monthly and confirm with other county staff that all CSFP recipients have a current application ? Increase communication with other county staff Person(s) Responsible: Christina Ureta, CSFP/TEFAP Director Timing for Implementation: Immediately