Corrective Action Plans

Finding: 2022-004 Inaccurate Information Entry Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, & Angel Joyner/Medicaid Supervisors Corrective Action: Files will be reviewed internally by Medicaid Supervisors and Quality Control workers to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. The workers have also been provided an agency/State approved checklist that includes everything that should be included in a case. All files will include online verifications, documented resources of income and those amounts will match information in NCFAST. The workers have been provided a State approved automated budget that will be completed and compared to the information in NCFAST. The results found or documentation made in case notes will clearly indicate what actions were performed and the results of those actions. Workers have been provided an agency/State approved documentation template to use for each case. "Proposed Completion Date: Training and corrections will be completed by January 15, 2023. Case record reviews are currently being conducted and will be ongoing."

Finding: 2022-003 IV-D Non-Cooperation Name of contact person: Tina Radford & Veronica Lyons/Family & Children's Medicaid Supervisors Corrective Action: Tina Radford & Veronica Lyons will retrain all Family & Children's Medicaid staff on the importance of following MA-3365 Child Support in making referrals to Child Support to avoid issuing benefits to ineligible participants. Child Support referrals will be made on all cases in error and case notes documented in NCFAST. To prevent recurring errors in the future, caseworkers will check their work by using an agency/State approved checklist that includes everything that should be included in their case. Supervisors and Quality Control staff will review a monthly sample of cases to ensure proper information is in place and necessary procedures are taken when determining eligibility. "Proposed Completion Date: Training and corrections will be completed by January 15, 2023. Case record reviews are currently being conducted and will be ongoing."

Finding: 2022-008 Significant Deficiency over Eligibility Name of contact person: Lynda Kennedy and Narkeisha Bryant, TANF Supervisors Corrective Action: Files will be reviewed internally by TANF Supervisors and Quality Control Workers to ensure all required evidence is received and documented properly. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. Workers will be retrained to ensure that all files include verifications, documented sources of income and verify that those amounts will match information in NCFAST. The workers will be retrained to ensure that the results found or documentation in case notes will clearly indicate what actions were performed and the results of those actions. Proposed Completion Date: Training and corrections will be completed by March 1, 2023. Case record reviews are currently being conducted and will be ongoing.

Finding: 2022-009 Significant Deficiency over Eligibility Name of contact person: Donna Barnes and Linda Jackson, FNS Supervisors Corrective Action: Files will be reviewed internally by FNS Supervisors an Quality Control Workers to ensure that records containt all required evidence and is received and documented properly. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. Workers will be retrained to ensure all files will include verifications, documented sources of income and verify that those amounts will match information in NCFAST. The workers will be retrained to ensure that results found or documentation in case notes will clearly indicate what actions were performed and the results of those actions. Proposed Completion Date: Training and corrections will be completed by March 1, 2023. Case record reviews are currently being conducted and will be ongoing.

Recomendation: Ongoing staff training of District and colleges Financial Aid staff related to implemented business process related to submission of information to NSLDS via NSC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Enrollment file reported to NSLDS is submitted on behalf of the District by the National Student Clearinghouse (NSC). The enrollment file is generated from the recently implemented ERP PeopleSoft data system. While the District submits its monthly enrollment reports as required, there have been some discrepancies between what the system reported and what was reported to the NSLDS. The District developed and implemented a business process to maintain documentation with the colleges Financial Aid Offices of what is submitted to NSC to ensure informafion is being reportted to NSLDS accurately. The NSC/NSLDS reporting process within PeopleSoft: Campus Solutions is a delivered process developed by Oracle and is used by most other institutions reporting to the NSLDS. Staff training will continuee to be conducted to emphasize the need for District and colleges staff to follow the existing processes and controls to ensure timely and accurate reporting to NSLDS.

FINDING NO. 2022-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure the verification of tenant income through the EIV system in a timely manner and maintain all required tenant documentation. Action Taken: Management has conducted training on EIV and the importance of meeting the deadlines as well as maintaining EIV reports in tenant files. If the audit Oversight Agency has questions regarding these plans, please call Christine Harris at 954-835- 9200. Sincerely yours, Christine Harris Accounting Manager

The income verification process has been reviewed the Director of Food Service. She understands that the verification must be an official document of earnings (i.e. paystub).

2022-004 ? Selection from the Waiting List Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to maintain the waiting list and track all correspondence with potential tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA acknowledges the continuing issues associated with this finding. The COVID-19 pandemic has placed unprecedented stress on companies across the country. The PBCHA was no exception. This stress negatively impacted the PBCHA?s management, workforce and operations which resulted in sudden changes in working arrangements, shortages due to workforce sickness, staffing vacancies and turnover all while dealing with increased housing demand due rising rental costs, and decreased housing supply and housing instability. Despite these challenges, the PBCHA remains strongly focused on continued and improved operations, increased compliance, and accountability. The PBCHA will continue to develop, train, and enforce procedures related to efficient waitlist management for families placed on the list for the HCV programs; the ongoing maintenance of the waiting lists; and selection of enough families from the list to maximize the PBCHA?s use of available funding. The PBCHA has elected to open its waiting lists beginning in June 2022 for its HCV programs and to leave lists open indefinitely to accurately depict the demand for affordable housing. This will require that PBCHA staff ae trained and annually comply with the procedures outlined in the Administrative Plan related to updating, removal and selection from the wait lists, admission, and eligibility, and that all steps are documented within the tenant file and agency business system accordingly. The PBCHA make decisions, develop strategies, implement policies/procedures, and utilize all available resources during this period of prevailing uncertainty and volatility. Any action taken to address the noted deficiency will be based on careful analysis, innovative thinking, restructuring, flexibility and/or revised strategies to adapt to everchanging business circumstances. Name(s) of the contact person(s) responsible for corrective action: Tyler Rasmussen. Carol Jones-

Eligibility 2022-001 ? Eligibility Housing Choice Voucher Cluster ? Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and unit the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA acknowledges the continuing issues associated with this finding. The COVID-19 pandemic has placed unprecedented stress on companies across the country. The PBCHA was no exception. This stress negatively impacted the PBCHA?s management, workforce and operations which resulted in sudden changes in working arrangements, shortages due to workforce sickness, staffing vacancies and turnover all while dealing with increased housing demand due rising rental costs, and decreased housing supply and housing instability. Despite these challenges, the PBCHA remains strongly focused on continued and improved operations, and increased compliance and accountability. The PBCHA will continue to utilize all available resources to recruit, retain and train HCVP staff on the HCV program guidelines, to include training to determine what is included and excluded from annual income, how to identify and calculate assets, correctly calculate adjusted income by applying the HUD defined allowances and expenses, recognize the requirements for verification of income, allowances, and expenses and calculate total tenant payment and housing assistance payment (HAP). The PBCHA make decisions, develop strategies, implement policies/procedures, and utilize all available resources during this period of prevailing uncertainty and volatility. Any action taken to address the noted deficiencies will be based on careful analysis, innovative thinking, restructuring, flexibility and/or revised strategies to adapt to everchanging business circumstances. Board of Commissioners Paul Dumars, Chairman Phyllis Choy, Vice Chair Digna Mejia Charlie Fetscher CEO and Executive Director Carol Jones-Gilbert 3432 West 45th Street West Palm Beach, Florida 33407 Office: (561) 684-2160 ext. 104 Mobile: (561) 628-9387 Fax: (561) 455-9965 Name(s) of the contact person(s) responsible for corrective action: Tyler Rasmussen, Carol Jones- Gilbert

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid Program. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department concurs with the finding. As of June 2022, individual providers are no longer contracted through the Department and now contract with Consumer Direct of Washington. As a result of this change, this type of error will not occur for individual providers moving forward. As of March 2023, the Department reviewed all providers in the monthly exclusion report. The Department verified that the provider identified in the finding for missing enrollment documentation was never employed and did not receive any payments. Completion Date: March 2023 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

Contact Person - Jason Vold, Superintendent Corrective Action Plan - The District will establish a policy and procedure over the submission and retention of all source documents used in filling out Impact Aid applications. Completion Date - Immediately

2022-002 Eligibility ? Tenant Files Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 ? Housing Choice Vouchers 14.879 Mainstream Vouchers Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Repeat finding from June 30, 2021 as Finding 2021-001 (initially reported June 30, 2010) Condition: Out of a total tenant population of approximately 2,100 tenants, 25 files were selected for testing. Exceptions were noted as follows: ? 1 error where the wrong amount was used to calculate tenant?s wage income. This had no effect on HAP rent. ? 1 error where overtime earnings was not included in calculating tenant?s wage income. This caused HAP rent to decrease by $11. ? 1 error where the utility allowance was calculated incorrectly. This caused the HAP rent to decrease by $61. ? 1 error where the prior year utility allowance schedule was used instead of the current year. This had no effect on HAP rent. ? 1 error where adoption subsidy benefits were calculated incorrectly as well as the amount excluded from income. This decreased HAP rent by $9. ? 1 error where $1,753 in unreimbursed medical expenses was carried forward from the prior year 50058 and file had no support for any medical expenses in current year. This decreased HAP rent by $22 ? 1 error where there was no EIV report in file In addition to the above, we noted the following during our new admissions testing (21 new admissions tested): ? 1 error where there was no signed 214 affidavit in the file for one member of the household Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding and has implemented a robust file review process, enhanced quality control procedures, and provided training on errors noted along with annual program training for all staff. The cited files were corrected.

Finding No. 2022-001: Allowability Corrective Action Planned The Uninsured Testing and Treatment Program ended as of March 31, 2022. As a result, Wake Forest has not implemented additional controls beyond the increased frequency at which we review accounts that are HRSA eligible and the increased education for our Financial Counseling Unit and Cash Control staff and leadership. In order to ensure compliance with future programs of this nature, Wake Forest will establish the controls necessary to review and monitor each account and ensure compliance is met with the program requirements. Each control will then be tested to ensure operating effectiveness.

Views of Responsible Officials and Corrective Action Planned: The Seminary hired a third-party financial aid servicer, Financial Aid Services, LLC (?FAS?) who will do the enrollment reporting as part of their contract. The FAS contract was signed May 2022 for the upcoming fiscal year 2022 to 2023. This contract was approved by the Administrative Council in May 2022. The Seminary?s current part-time financial aid coordinator sent out the April 2022 enrollment roster which included student status changes on October 17, 2022.

Caritas Villa respectfully submits the following corrective action plan for the year ended June 30, 2022. Name & address of public accounting firm: Jones & Roth CPAs 260 Country Club Rd. Ste. 100 Eugene OR 97401 Audit Period: June 30, 2022 Major Federal Award Findings: Finding Reference #: 2022-001 Significant deficiency Recommendation: We recommend management review the current internal control procedures and implement additional procedures to ensure annual recertifications are performed as required by HUD. Corrective Action: Management will work with Cascade Management to improve the internal control procedures to ensure annual recertifications are performed as required by December 31, 2022. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.

Contact Person Dawn Bacon, Executive Director Corrective Action Plan Staff will perform quality control review for the Public and Indian Housing program. Going forward a sample of files will be reviewed on a semi-annual basis. Planned Completion Date for CAP FY2023

Contact Person Dawn Bacon, Executive Director Corrective Action Plan Error occurred due to lack of oversight in review of calculation of annual income and underlying support. We continue to confirm that all total tenant payment (TTP) calculations are matched to verification of income and deductions documentation in tenant files. Planned Completion Date for CAP FY2023

The District should ensure that students reported as low income meet eligibility requirements.

FY2022 Granite City Community Unit School District No. 9 Corrective Action Plan Finding Number: 2022-001 Finding Synopsis: During the year ended June 30, 2022, the District could not provide adequate supporting documentation for the public and nonpublic enrollment and low income counts that were used to allocate Title I services to District buildings. Action Steps: The District will implement additional controls in order to ensure that all necessary calculations are correctly computed and supported by appropriate supporting documentation. Contact Person(s): Zack Suhre, Director of Finance Anticipated Completion Date: 6/30/2023

Name of Auditee: Neighborhood Legal Services, Inc. Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2022 CAP Prepared by: Lauren Breen, Executive Director Phone: (716) 847-0650 (A) Current Finding on the Schedule of Findings and Questioned Costs Finding 2022-001 (a) Comments with the finding and recommendation - NLS agrees with the finding. NLS also agrees with the recommendation, please see below for action taken. (b) Action taken - In April 2023, Neighborhood Legal Services (NLS) will conduct an office-wide training emphasizing the importance of careful file tracking. In addition, the Housing Unit shall develop a tracking system which will be implemented through the use of NLS?s new case management system. In the event that a staff member unexpectedly leaves on a temporary or permanent basis, inventory of the staff member?s open cases and matters shall be conducted prior to departure, where possible, and where an inventory prior to departure is not possible, it shall be conducted as soon as practicable, but in no event more than two weeks following the staff member?s temporary or permanent departure from the agency. NLS will implement additional office-wide procedural changes in 2023 to ensure that policies and procedures are effectively communicated to staff and that regular internal review of cash files ensures these procedures are followed in practice by staff.

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid and Children?s Health Insurance Program. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority agrees that ProviderOne sends revalidation notifications one day after the due date rather than before the due date. A system revision to correct this issue is expected to be in place by the beginning of 2024. The Authority does not concur with the remainder of the audit finding as stated in the description of condition. The auditor did not provide sufficient information for the Authority to review the identified exceptions and associated questioned costs. Due to the lack of information provided, the Authority is unable to agree or disagree with the results of the audit. The Authority will work with the auditor to obtain sufficient supporting information to review the exceptions and questioned costs. Once this process is completed, the Authority will work with the Centers for Medicare & Medicaid Services on finding resolution. The conditions noted in this finding were previously reported in findings 2021-047, 2020-046, 2019-048, 2018-042, 2017-033, and 2016-035. The auditors determined 2016-035 as resolved. Completion Date: Estimated March 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-5337 Kari.Summerour@hca.wa.gov

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure clients were eligible for the Children?s Health Insurance Program. Questioned Costs: Assistance Listing # 93.767 93.767 COVID-19 Status: Corrective action not required Corrective Action: The Authority does not concur with the finding. The Authority pursued and was notified of approval for the 1115 disaster waiver from the Centers for Medicare & Medicaid Services (CMS). The waiver will approve Children?s Health Insurance Program (CHIP) funding for clients aged 19 and over during the public health emergency, retroactive to March 18, 2020. Once the official approval letter is received from CMS, the issue will be resolved, and the approval letter will be provided to CMS Audit Resolution. The Children?s Health Insurance Program Reauthorization Act (CHIPRA) postpartum period is state-funded and the Authority processes manual journal vouchers to move federal funding to state funding each quarter. For this audit, the auditors did not allow sufficient time for accounting staff to provide the journal vouchers for inclusion in the audit results. The Authority will work with CMS during the audit resolution process and provide the journal vouchers as needed to demonstrate that state funds were used for the postpartum expenditures. Effective July 1, 2022, the Authority added coding to ProviderOne which automates the accounting process for CHIPRA postpartum client funding. The conditions noted in this finding were previously reported in finding 2021-046. Completion Date: Not applicable Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

Caritas Plaza respectfully submits the following corrective action plan for the year ended June 30, 2022. Name & address of public accounting firm: Jones & Roth CPAs 260 Country Club Rd. Ste. 100 Eugene OR 97401 Audit Period: June 30, 2022 Major Federal Award Findings: Finding Reference #: 2022-001 Significant deficiency Recommendation: We recommend management review the current internal control procedures and implement additional procedures to ensure annual recertifications are performed as required by HUD. Corrective Action: Management will work with Cascade Management to improve the internal control procedures to ensure annual recertifications are performed as required by December 31, 2022. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure group care facility employees had cleared background checks before having unsupervised access to children. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department partially concurs with the finding. The Department is committed to ensuring the health, safety, and well-being of all children in our care. As stated in the Effect of Condition on the audit finding, the auditors found all group care facility staff sampled during the audit had a cleared background check prior to working in the facility. While the Department agrees the use of definitions such as ?effective date? and ?start date? in FamLink could be misleading, the Department does not concur internal controls were not adequate to ensure group care facility employees had cleared background checks before having unsupervised access to children. The Department is confident that all staff who work with children and youth have cleared background checks. Effective April 1, 2023, the Department implemented a new process for processing background checks for group care facilities to strengthen internal controls, documentation, and clarification on the ?effective date.? The updated process is outlined below: ? A new form was created with clear instructions for the group care facilities to provide the applicant/employee information, including the background check confirmation code, directly to the Department?s Background Check Unit (BCU). ? The BCU works with the applicant/employee through the fingerprint background check process. ? The results are sent directly to the BCU at which time they complete a child abuse/neglect history check and, if needed, a suitability assessment. The BCU documents the results in FamLink with the date the background check is completed. ? The BCU emails the results to the group care facility and the Department?s Licensing Division (LD) group. If the applicant/employee is cleared and is not a renewal, LD staff adds the applicant/employee to the group care facility in FamLink with the clearance information attached. Completion Date: April 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure staff properly considered the income information obtained from data matching when determining client eligibility and benefits for the Temporary Assistance for Needy Families program. Questioned Costs: Assistance Listing # 93.558 Amount $0 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The Department has established processes in place to ensure income information is properly considered during client eligibility and benefits determination for the Temporary Assistance for Needy Families (TANF) Program. During eligibility determination at application intake, the eligibility worker: ? Interviews the client to determine income. ? Compares client reported information and cross matches against the Income Eligibility and Verification System (IEVS) per the Code of Federal Regulations (CFR). ? Resolves discrepancies for all new or previously unverified information received. ? Uses the information to determine if the client income is below the maximum earned income limits for TANF per WAC 388-478-0035. ? Verifies all circumstances as required in WAC 388-490-0005 and follows requirements when discrepancies exist, which include taking appropriate actions if the information is questionable, confusing, or outdated. The Department utilizes Spider, which is a tool that combines several different data matches including IEVS. In addition, the Department uses templates to appropriately and comprehensively document the eligibility determination to ensure consistency, accuracy, and that lean processes are followed. ? The Earned Income Template o Addresses income received within 30 days of the application date and any discrepancies found between the case record, online verification systems, previously projected income, and income type. o Does not require documentation if there is no income reported and when no discrepancy is found in cross matches. ? The Final Narrative Template o Includes completing check boxes to document types of cross matches reviewed during application intake and a summary of the transactions that occurred. In all seven exceptions identified by the auditors, the client?s situation did not require the eligibility workers to use the Earned Income Templates due to: ? No income reported. ? No income found in IEVS and other cross matches. ? No discrepancies. ? No changes within 30 days. The eligibility workers did create documentation using the Final Narrative Template for all seven cases with notation stating: ?Reviewed the following system(s): Spider.? All these actions were consistent and aligned with the Department?s "Standard Remarks and Narrative Documentation? procedures. Alerts are not generated for all income fluctuations but as appropriate when a review and potential action is required. This is to minimize creating unnecessary alerts which would take staff time away from other required and mission-critical actions. The Department asserts that the system is working as designed, which is evidenced by the fact that the Department accurately determined eligibility in all seven cases identified as exceptions by the auditors. The Department will continue to: ? Review IEVS information at application intake and verify and document any discrepancies between what is reported by the household and what is shown in the cross matches. ? Use templates to ensure documentation supports the eligibility decisions. ? Generate alerts when an applicant is budgeted with zero income, but the IEVS data match shows income. ? Use the final narrative documentation template, that includes check boxes, to notate cross matches reviewed during application intake. Completion Date: Not applicable Agency Contact: Rick Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov