Corrective Action Plans

Corrective Action Plan Federal Award Findings and Questioned Costs For the Fiscal Year Ended June 30, 2022 Finding 2022-001 ? A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; E. Eligibility; N. Special Tests and Provisions Federal program information: Federal Program: 93.461, HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (COVID-19 Uninsured Program) Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Locations: Various Award Numbers: Various Award Period: July 1, 2021 through June 30, 2022 Summary of finding: UC Health did not design or appropriately document internal controls to monitor the terms and conditions and underlying HRSA COVID-19 Uninsured Program regulations during the COVID-19 pandemic. Additionally, UC Health did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program?s allowability and eligibility requirements. While management has processes in place to review claims for potential insurance coverage before initial billing, evidence of insurance reviews and subsequent verification of lack of coverage was not retained. Refunds required to be made to the HRSA COVID-19 Uninsured Program were not identified timely. Planned corrective action: Management has reviewed claims submitted to the HRSA COVID-19 Testing for the Uninsured Program for potential payments for ineligible services and timely processed refunds as appropriate. In March 2022, HRSA announced the discontinuance of the HRSA COVID-19 Testing for the Uninsured program and, therefore, remediation of internal controls in no longer applicable. Completion date: December 31, 2022 Responsible contact person: Crag Cain, Vice President of Revenue Cycle Management

Similar to other DHS programs, DHS has implemented an after-action review of information submitted, using a contracted vendor. DHS faced challenges implementing a program with 67 counties and no central eligibility determination system. DHS has learned that implementing the supportive services and multi-sector partnerships was challenging in the context of the global pandemic and workforce shortages. This made DHS dependent on local county reports to maintain program oversight and compile statewide data for submission to US Treasury. DHS plans to strengthen this control as we plan for future emergency or pandemic programs related to rental assistance. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Joel O?Donnell, Director, Bureau of Program Support, OIM

In Response to Federal Award Finding, Finding 2022-003 ? Material Weakness and Material Noncompliance ? Special Tests ? Sliding Fee. Health centers must obtain sliding fee applications so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. We tested 60 sliding fee encounters and noted that 1 of 60 sliding fee encounters tested received the wrong slide. We noted 6 of 60 sliding fee applications were missing an approving sign off. We noted 2 of 60 sliding fee applications were missing and not on file. We noted 1 out of 60 sliding fee applications did not properly document an extension in the slide eligibility period. We noted 1 out of 60 sliding fee encounters was not properly charged a lab visit fee in accordance with the policy. Lastly, we noted 1 out of 60 sliding fee encounters had a wrong correcting adjustment applied to the patient account. Responsible Person: Stephanie Smith, CPA, Chief Financial Officer Corrective Action Planned: Management will ensure sliding fee applications are completed and properly approved and that discounts for eligible patients are properly calculated, documented in files, processed and extended correctly when applicable, for each sliding fee patient. Management has carefully revised training materials for staff as well as new staff, and will work to ensure controls are followed to verify sliding fee discounts applied are correct based on the patient application. To help ensure compliance, the organization has already begun conducing sampling throughout the year to verify sliding fee applications are obtained, completed correctly, and applied accurately to accounts. Anticipated Completion Timeframe: To be completed by 3/31/23.

Finding 2022-004 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure worker is knowledgeable of policy requirements. Training will also be provided to ensure all files include online verifications, work number searches, register of deeds search, documented resources of income, and ensure those amounts agree to information entered in NCF AST. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were four (4) technical errors cited with a review date from a prior fiscal year.

Finding 2022-003 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Staff will be trained on state communications as it relates to applicants' benefits and the importance of sharing information with all areas which the participant receives benefits. Currently the lead worker manages the notifications received to ensure timely processing of SSI terminations. Agency processes have been reviewed to monitor SSI terminations to prevent recertifications from becoming overdue. " Proposed completion date: "Training will be provided the week of November 7, 2022, to review findings and corrective action items. State communications will continue to be monitored. One (1) technical error cited for an untimely SSI Exparte Review was for a prior fiscal year. "

Finding 2022-002 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure worker is knowledgeable of policy requirements. Training will also be provided to ensure all files include online verifications, documentation of resources of income, and ensuring those amounts match information entered into NCF AST. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications. Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were four (4) technical errors cited with a review date from a prior fiscal year.

Finding 2022-001 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure the worker is knowledgeable of policy requirements. Training will be provided to ensure all files have accurate information entry to include correct household composition and correct income calculations. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications. " Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were six ( 6) technical errors cited with a review date from a prior fiscal year.

Finding: 2022-011 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the access and security reviews. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: June 30, 2023

Finding: 2022-009 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. The department will work with NDIT to ensure they restart and maintain the risk analysis and security review for MMIS. Contact Person: Tory Brabandt, Medicaid Enterprise Director Anticipated Completion Date: December 31, 2023

Finding: 2022-019 Department of Human Services Response/Corrective Action Plan: The Department agrees with the recommendation. Due to Medicaid continuous enrollment requirements ending on March 30, 2023, the SPACES system will be converted back to its normal rules and this issue should not happen again. The Department will do a review of CHIP eligibility to ensure incorrect claims are identified and corrected. Claims paid in error will be adjusted to reflect the proper category of eligibility, so the applicable fund code is applied, which will apply the correct FMAP. Contact Person: Erik Elkins, Assistant Director, Medical Services Anticipated Completion Date: April 30, 2023

2022-002 Recertifications 14.881 Moving to Work Demonstration Program ? Award No. OCD26401344019MTW 14.871 Housing Choice Voucher Program (Housing Voucher Cluster) ? Award No. OCD26401344019HCV Responsible Official John Hillis Director of Inspections & Property Owner Services, Systems, and Compliance Plan Detail After a detailed RFP process, Metro Housing has selected an outside vendor (Nan McKay) to assist with completing a backlog of regular reexaminations amassed during calendar years 2020 and 2021. The contract was signed on September 27, 2022. By clearing up this backlog of work, Metro Housing staff working on the completion of regular re-exams for the Section 8 HCVP and MTW programs will be able to renew their focus on completing current work timely and accurately. Metro Housing is also making changes to decrease caseload sizes for Program Specialists while also streamlining workflows to better internal and external communication needed to complete our tasks. The roll-out of this new setup should be complete before the end of the current calendar year. Anticipated Completion Date June 30, 2023 ? All reexaminations will be current, and past due percentages will be lowered to acceptable levels.

October 31, 2022 Corrective Action Plan Finding: 2022-001 Condition Found: The Center has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Ken ?JR" Porter Executive Director, Toni Howard Billing manager Planned Corrective Action: ? Update the sliding fee discount program policy to more clearly define family size and income, including examples of source documents ? Create and use a form to document the calculation of the household income entered into the EHR ? Review the complexity of the discount schedule and consider whether it would be beneficial to change the schedule from percentage discounts to flat dollar amounts for Category B, C, D and E ? Develop routine internal monitoring procedures to perform periodic testing of sliding fee discounts to help ensure the discounts are provided consistent with the Center?s sliding fee discount program Anticipated Completion Date: December 2022 Sincerely, Ken ?JR? Porter Executive Director White Mountain Community Health Center 298 White Mountain HWY, Conway, NH 03818 Phone: 603-447-8900 X321 Fax: 603-447-4846 jrporter@whitemountainhealth.org

2022-Single Audit 01 Department of Social Services Title IV-E Adoption Assistance A sample of 40 children that received Title IV-E adoption subsidies during FY2022 was tested for compliance with the above criteria and the observations were noted below. ? 40 out of 40 children - Met the eligibility requirements, had special needs that prevented them from being placed without a subsidy, and could not return home. ? 40 out of 40 children - RDSS made reasonable efforts to place the children without the subsidy or waived the requirement as it was not in the best interest of the child. ? 40 out of 40 children ? The adoption assistance agreements were signed prior to the final adoption decree, the authorized amounts were in line with the State?s rates, and payments were issued in accordance with the agreements. ? 9 out of 40 children ? Sufficient evidence of the completion of the required criminal background and child abuse and neglect registry checks for the adoptive parents and adult household members was not in the adoption case files. The home studies and report of investigations narrative indicated the required checks were completed for the adoptive parents and household members but did not identify when they occurred. Also, in some cases, it was not noted if the adoptive parents met the eligibility requirements for the criminal record checks. As such, the auditors were unable to confirm when the checks occurred, and supporting documentation was not provided prior to the completion of fieldwork. In addition, during the initial file review, documents such as court orders, negotiation documents, and annual affidavits were missing from some of the files. The Adoption Unit was ultimately able to retrieve and provide the missing items. However, an opportunity exists to improve the adoption case file documentation. Recommendations: ? We recommend that the Children, Families, and Adults (CFA) Deputy Director develop and implement a quality control process to ensure that the required documentation is maintained in the adoption case files. ? We recommend that the CFA Deputy Director develop and implement standard documentation requirements for documenting the completion of the background checks in the adoption case files. Explanation of disagreement with audit finding: n/a ? no disagreement Action planned/taken in response to finding: Audit Recommendation: We recommend that the Children, Families, and Adults (CFA) Deputy Director develop and implement a quality control process to ensure that the required documentation is maintained in the adoption case files. RDSS Corrective Action Plan: The Reunification and Permanency Program Manager or designee will conduct quarterly adoption case reviews using the VDSS Guidance Section 3.9.3 - Adoption Records. The quarterly case sample represents 10% of the case and all cases will be reviewed at least once annually. Any findings will be documented to include corrective actions, person responsible and timeframe for correction. The Reunification and Permanency Program Manager or designee will review cases to confirm corrections. Audit Recommendation: We recommend that the CFA Deputy Director develop and implement standard documentation requirements for documenting the completion of the background checks in the adoption case files. RDSS Corrective Action Plan: All RDSS Adoptions files must include the VDSS Adoption File Checklist and the child?s adoptive family documentation. The required adoptive parent documentation includes: o Criminal Background Check Results - Licensed Child Placing Agencies ( Non-Conviction and/or Conviction Letter); Local Department of Social Services (Office of Background Investigations Determination Letter) o Sworn Statement of Affirmation o Child Abuse and Neglect Central Registry Check results for adoptive parent and adult household members. The Adoption and Resource Families Supervisors are responsible for monitoring compliance with documentation requirements for completion of the background checks, including insuring that documentation is requested from child ?placing agencies and third parties. Standard documentation requirements regarding background checks will be included in the quarterly review by the Reunification and Permanency Program Manager or designee. Name(s) of the contact person(s) responsible for corrective action: Brinette Jones, Deputy Director, Division Children, Families and Adults Lavinia Hopkins, Reunification and Permanency Program Manger Planned completion date for corrective action plan: Ongoing, beginning 2nd quarter 2023 If there are any questions regarding this plan, please contact Brinette Jones at (804) 646-4543.

2022-Single Audit 02 Department of Social Services TANF Eligibility A sample of 40 FY2022 TANF cases was tested for compliance with the above criteria and the observations were noted below. ? 24 out of 40 cases files tested did not contain adequate documentation to verify eligibility requirements and approval of benefits. Approximately, 55% of the reviewed files lacked evidence that the workers verified the relationship between the minor children and the applicant and that the children were living in the home. ? 1 out of 40 case files tested, the assistance unit captured a child that was not living in the household, which inappropriately increased the monthly benefit amount. ? 1 out of the 40 cases tested did not contain evidence that the eligibility worker inquired about the applicant?s indication on the application that they were not in compliance with probation/sentencing terms prior to approving the application. Recommendations: ? We recommend that the Economic Support and Independence Deputy Director develop and implement a quality control process to ensure the required eligibility verifications are conducted and properly documented in the case files. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action planned/taken in response to finding: All supervisors within the Economic Support & Independence Division of the Richmond Department of Social Services (RDSS) will be expected to complete a minimum of three case readings per month for each direct report assessing eligibility within the TANF program. In addition, all team members who assess TANF eligibility will be required to complete refresher trainings on uploading documents to the Document Management Imaging System (DMIS), Documentation and Verifications, and Application Processing, which will include categorical requirements and conditions of eligibility. Name(s) of the contact person(s) responsible for corrective action: Sarah Raring & Tricia Wyatt Planned completion date for corrective action plan: June 30, 2023 If there are any questions regarding this plan, please contact Sarah Raring at (804) 646-3332 or sarah.denhamraring@rva.gov.

In regard to the two students who were never reported as graduated, the College did in fact submit the required documentation to the National Student Clearinghouse (?NSC?) for further processing to the NSLDS, but the updates were reported as rejected due to errors by the NSLDS. The College has updated the students' records on the NSC and will monitor the NSLDS portal weekly to ensure that all student updates are processed and correct on both the campus and program levels. In regard to the publication of the length of the Master?s level program, the College is revising its documentation and publication of the length of the Master?s program to reflect adjustments to the program that reduced the amount of time needed to complete the program. In addition, the College?s student information system was reviewed/updated to accurately reflect the published length for each program. To assure that the information is being transmitted correctly, the College will monitor the next six months of enrollment updates to ensure that each student, in the different programs, has the correct publication program length.

The District publishes or solicits proposals for all contracts equal to or in excess of $25,000. Vendors are required to include a Certification Regarding Debarment, Suspension, and Other Responsibility Matters and SBA will verify vendor certification at https:www.beta.sam.gov/

Finding Reference: 2022-003 Federal Agency: Department of Treasury Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: 21.023 ? Emergency Rental Assistance Grant Award: ERAPI Charles County Condition/Context: SMTCCAC did not provide proof of review of the shared document among participating ERAP agencies in Charles County to avoid duplication of benefits for four (4) of the 60 rental assistance claims selected for testing. Criteria: Internal Control: Per 2 CFR section 200.303(a), a non-Federal entity must: Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should comply with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Cause: SMTCCAC did not adequately monitor controls to ensure proper review of the shared document among participating ERAP agencies in Charles County resulting in the potential duplication of benefits. Effect: Failure to review the shared document used among participating ERAP agencies in Charles County could result in duplication of benefits. Questioned Costs: None Recommendation: We recommend that SMTCCAC consistently verify the shared document used among participating ERAP agencies in Charles County to avoid duplication of benefits. Views of Responsible Officials and Planned Corrective Actions: See Corrective Action Plans section.

Finding Reference: 2022-002 Federal Agency: Department of Treasury Compliance Requirement: Allowable Costs (Non-Payroll) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Federal Program: 21.023 ? Emergency Rental Assistance Grant Award: ERAP I Charles County Condition/Context: FSTA selected a sample of sixty disbursements of rental assistance claims for testing and noted the following errors: ? SMTCCAC mistakenly processed a duplicate payment of $7,700 for an eligible claim, which was one (1) of the 60 rental assistance claims selected for testing in Charles County ERAP I grant. ? SMTCCAC made a payment of $31,800 to a landlord for one (1) of the 60 rental assistance claims selected for testing, for which another agency had made a payment for the same claim before SMTCCAC. Criteria: Internal Control: Per 2 CFR section 200.303(a), a non-Federal entity must: establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should comply with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Compliance: Under OMB guidance, Public Law (Pub. L.) No. 107-300, the Improper Payments Information Act of 2002, as amended by Pub. L. No. 111-204, the Improper Payments Elimination and Recovery Act, Executive Order 13520 on reducing improper payments, and the June 18, 2010 Memorandum on Enhancing Payment Accuracy - Any payment that should not have been made or that was made in an incorrect amount, including an overpayment or underpayment, under a statutory, contractual, administrative, or other legally applicable requirement; and includes ? (i) any payment to an ineligible recipient;(ii) any payment for an ineligible good or service; (iii) any duplicate payment; (iv) any payment for services not received; and (v) any payment that does not account for credit for applicable discounts. Cause: Due to staff turnover, the claim of $7,700 was submitted to Finance for payment twice. SMTCCAC did not sufficiently monitor controls to detect the duplicate payment. Additionally, SMTCCAC did not adequately monitor controls to ensure proper review of the shared document among participating ERAP agencies in Charles County to avoid the duplication of benefits for the claim of $31,800. Effect: The duplicate expenditure included in the program cost was deemed unallowable. The landlord involved in the rental assistance claim confirmed receiving two checks, each totaling $7,700. SMTCCAC did not require the landlord to return the duplicate funds, nor did it establish a repayment plan after the landlord expressed a willingness to establish a repayment agreement. Ultimately, the landlord chose to apply the duplicate payment of $7,700 towards future rents for the applicable tenant. During FY2023, Charles County identified the duplicate check and promptly requested the return of duplicate payment of $7,700 from SMTCCAC. During a program file audit by Charles County, it was determined that a duplicate expenditure included in the program cost was deemed unallowable. In FY2022, SMTCCAC paid $31,800 to a landlord who had already received payment from another participating ERAP agency. Despite notifications from SMTCCAC, the landlord has not/was not willing to return the duplicate funds to SMCTTAC. Charles County has notified SMTCCAC on numerous occasions about the need to reimburse the County for the duplicated funds. Once the funds are received, Charles County will return the monies to the State of Maryland. In March of 2023, the County also sent an invoice of $31,800 requesting SMTCCAC to return the $31,800. Questioned Costs: $7,700 ? duplicate payment made to a landlord for a rental assistance claim selected for testing. $31,800 ? duplicate payment made to a landlord for a rental assistance claim selected for testing. Recommendation: We recommend that SMTCCAC implement effective controls to prevent duplicate payments. Additionally, we recommend that SMTCCAC consistently verify the shared document used among participating ERAP agencies in Charles County to ensure that a claim has not been applied for and paid by other agencies. Views of Responsible Officials and Planned Corrective Actions: See Corrective Action Plans section.

Our agency has implemented a scanning system which prints bar codes on each document that automatically goes to the correct tenant file. After documents have been signed they are scanned in. This will help alleviate misplaced documents/files. Staff has also been instructed to always put any type of correspondence with tenants in the electronic tenant file.

Identifying number: 2022-001 Identification of the federal program: U.S. Department of Education Student Financial Aid Cluster Finding: Uniform Guidance for Student Financial Aid (SFA) Programs {III. Compliance Requirements, N. Special Tests and Provisions, 4. Enrollment Reporting ? Compliance requirements (34 CFR 685.309 (b)(2)(i))} stipulates that unless it expects to submit its next updated enrollment report to the secretary within the next 60 days, the school must notify the Secretary within 30 days after the date the school discovers that a loan under title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the school, and the student has ceased to be enrolled on at least a half-time basis or failed to enroll on at least a half-time basis for the period for which the loan was intended. The University did not properly provide to the National Student Loan Data System (NSLDS) notification for one student who withdrew or graduated during FY 2022. Anticipated Completion Date: Action Already Taken Person Responsible: Colin Hilton-MacFarlane, Executive Director of Institutional Research and Effectiveness Corrective Actions Taken or Planned: The Office of Institutional Research and Effectiveness reports graduated students to the National Student Clearinghouse upon degree conferral. The concern about solely relying on a third-party to submit to the National Student Loan Data System was identified in the FY2021 audit with a management response involving reconciling extracts directly from NSLDS to validate that all graduated students were successfully reported (and updating directly within NSLDS for any that failed to be submitted by NSC). The finding in this FY2022 audit occurred prior to the management response and associated business process implementation from the FY2021 audit. The institution remains confident this direct reconciliation within NSLDS will resolve future instances of a lack of timely reporting. This finding also involved a rare case of a student completing a master?s level degree program and immediately enrolling in a subsequent master?s level degree program. The institution believes this uncommon circumstance may have contributed to this specific failure in NSC reporting the graduated status to NSLDS, so although the new business process of reconciliation should prevent the general case of this issue, specific review within NSLDS of students immediately moving from one degree program to another upon graduation will be conducted to ensure no additional mitigations are necessary beyond what has already been implemented to address the general case.

Reporting views of responsible officials and planned corrective actions Management will put controls and procedures in place that ensure all tenant files are maintained in accordance with the HUD Handbook.

1. Current Findings on the Schedule of Finding, Questioned Cost and Recommendation a. Finding 2022-001 (14.157 ? Supportive Housing for the Elderly ? Section 202 Capital Advance) Tenant Files Condition: Move-ins: 1. In one (1) instance out of nine (9) tenant files tested, the employment income reported on Form HUD-50059 was $11,400; however, the supporting documentation verified in the tenant file, indicated $15,678 ($10,05 per hour for 30 hours per week, over 52 weeks). 2. In one (1) instance out of nine (9) tenant files tested, the ?Non-Smoking Lease Addendum? was not signed by management. 3. In one (1) instance out of nine (9) tenant files tested, the ?Non-Smoking Lease Addendum? identified the Project as Terra Quest, Inc. 4. In three (3) instances out of nine (9) tenant files tested, the Security Deposit Agreement was not maintained in the tenant?s file. 5. In three (3) instances out of nine (9) tenant files tested, the Security Deposit Agreement was not signed by management. Recertification: 1. In one (1) instance out of eight (8) tenant files tested, the Notice and Consent for the Release of Information (Form 9887) was not dated by the tenant. 2. In one (1) instance out of eight (8) tenant files tested, the Applicant?s/Tenant?s Consent to the Release of Information (Form 9887-A) was not dated by the tenant. 3. In one (1) instance out of eight (8) tenant files tested, the Verification of Criminal Background Check form was not signed by the tenant. 4. In one (1) instance out of eight (8) tenant files tested, the Form HUD-50059 was not dated by the tenant. 5. In one (1) instance out of eight (8) tenant files tested, the ?EIV? document was not maintained in the tenant file, for verification of the tenant?s income. 6. In one (1) instance out of eight (8) tenant files tested, the Housing quality inspection form was not maintained in the tenant?s file. 7. In one (1) instance out of eight (8) tenant files tested, the ?Lease Addendum, for Violence Against Women and Justice Department Reauthorization Act of 2005? was not dated by the tenant. 8. In five (5) instances out of eight (8) tenant files tested, the ?Notification of rent increase resulting from recertification process ? Section 202 PRAC?s form? was not maintained the tenant?s file. 9. In one (1) instance out of eight (8) tenant files tested, the ?Notification of rent increase resulting from recertification process ? Section 202 PRAC?s form? was addressed to another tenant. 10. In one (1) instance out of eight (8) tenant files tested, the Quality Assurance Information form was not dated by the tenant. Move-outs: 1. In one (1) instance out of three (3) tenant files selected for testing, the tenant file could not be located. 2. In one (1) instance out of two (2) tenant files tested, the security deposit disposition notice was not maintained in the tenant file. (1) Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor?s recommendation that Ridgeview Terrace, Inc. process applicants and tenants, including recertification of tenants in accordance with guidelines established by the Department of Housing and Urban Development prior to the tenant occupying the unit. By performing these procedures, the risk of incurring questioned costs will be significantly reduced. (2) Actions Taken on the Finding. Corrected going forward.

Recommendation: We recommend that the University disburses the remaining award to the student and implement procedures to ensure awards are properly disbursed to students who have more than a three-term budget. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The remaining award was disbursed to the student when the issue was identified. The correction to the student was completed on June 22, 2022. EOU Financial Aid will enhance their procedures to include the development of an exception report. The EOU Financial Aid Office will coordinate with the Information Technology department to create a report, which will be scheduled to automatically be delivered daily during the first four weeks of each term (before our Pell Recalculation Date (PRD), or institutional census date). After this date, the student enrollment levels cannot be changed. Anytime the student's disbursement amount does not match what it should be for the student's enrollment level on the report, the Financial Aid staff assigned, will be notified and will immediately adjust the disbursement level to match on any miscalculated awards, locking the period to ensure the correct amount is disbursed.. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Interim Director of Financial Aid Planned completion date for corrective action plan: April 2023

To Whom It May Concern: This letter includes the corrective action plan in response to the audit finding from the Single Audit for the 2020-2021 Award Year. Audit Finding: 2022-001: Under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program, providers are required to submit reporting to the Health Resources Services Administration (HRSA). During the single audit, it was determined that roughly $2.4 million of expenses were reported as general expenses in Period 2, were also included as general expenses in Period 1 reporting. We agree with the audit finding and action will be taken to improve this gap going forward by updating procedures for these kinds of requirements. Controls will be implemented whereby there will be a secondary reviewer along with the appropriate sign-off validating the data has been accurately reported to ensure we are in compliance. The contact person responsible for the corrective action plan is James Salerno. The corrective action plan has been implemented as of January 1, 2023. Please let me know if you have any additional questions.

See Corrective Action Plan for chart/table