Corrective Action Plans

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with client eligibility requirements for child care services paid with the Child Care and Development Fund and Temporary Assistance for Needy Families funds. Questioned Costs: Assistance Listing # 93.558 93.575 93.575 COVID-19 93.596 Amount $5,689 $5,078 Status: Corrective action in progress Corrective Action: The Child Care and Development Fund (CCDF) program was previously managed by the Department of Social and Health Services and the Department of Early Learning. Since the program transitioned in 2019, the Department has been making efforts to strengthen internal controls over payments to child care providers and other CCDF grant requirements. In response to the finding, the Department established overpayments and referred them to the Office of Financial Recovery for collection. As part of process and internal control improvements, the Department implemented the Fair Start for Kids Act (FSKA) on October 1, 2021, to simplify rules and expand eligibility. The FSKA: ? Raises the State Median Income threshold, increasing the number of eligible two-parent households. ? Caps copayments at $115 for applicants and $215 for reapplicants, reducing the copay amounts for two-parent households. ? Acts as disincentives for fraud as families are less likely to report the non-custodial parent who is not a household member. The Department continues to review cases for accuracy following these new rules and policies. In September 2022, the Office of Child Care (OCC) released a document to help CCDF lead agencies simplify the format and content of child care assistance applications, which includes guidance on defining, collecting, and verifying eligibility information. The Department continues to follow guidance from OCC to update policies and procedures within the authority under the Revised Code of Washington and Washington Administrative Code. This includes: ? Updating policies and procedures for cases with simplified eligibility such as families experiencing homelessness or families with children receiving protective services. Public Benefit Specialist (PBS) staff received training in the winter of 2022, which included the use of systems data to establish household composition. ? Developing a guide for staff to more effectively use the Employment Security Department (ESD) quarterly reported data for eligibility determinations. The ESD data is directly reported by the employer, secured, and reduces delays in benefits by eliminating the wait for employment verification. It is also simple to use for the PBS staff and the auditors, thereby reducing income calculation errors and removing the need for consumers to provide documentation to support the eligibility determination. This procedural change and training are expected to be completed by the summer of 2023. The conditions noted in this finding were previously reported in findings 2021-035, 2020-039, 2019-032, 2018-030, 2017-026, 2016-023, 2015-026, 2014-026, 2013-017 and 2012-30. Completion Date: Estimated October 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Type of Finding: Significant Deficiency in Internal Control Over Compliance ? Eligibility Recommendation: The Organization should ensure that controls exist to document and provide evidence of review procedure in effect to ensure that eligibility requirements are met beyond the initial inquiries and information gathering process. Views of Responsible Officials: There is no disagreement with the audit finding. Eligibility requirements are obtained and documented based on the requirements of the individual grants. The program staff are well versed in the requirements and ensure the participants are eligible under the grant. In August 2021, to enhance the existing practice, a Case Management system was implemented which assists in ensuring that proper documentation and approval are maintained. In September 2023, the case management system was looked over and rules were put into place to minimize or eliminate room for human error.

March 27, 2023 HOME SHARE HUD PROJECT NO. 092-HD017 Corrective Action Plan Finding: 2022-001 ? Compliance and Controls over Compliance ? Eligibility Supportive Housing for Persons with Disabilities (Section 811), CFDA No. 14.181 Material Weakness & Noncompliance In 2022, Home Share did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual making the initial determination or annual recertification. Actions Taken or Planned: Management agrees with this finding. Beginning in January 2022, management has contracted out the eligibility determination process to a third-party contractor with significant experience in affordable housing and similar processes. Management is working with the contractor to include a second individual in this process so that there will be a review performed by someone other than the individual making the initial determination or annual recertification. Contact Persons: Ernest Johnson, Housing Associate Director Robert Pickering, Chief Financial Officer

Re: Corrective Action Plan Freeport Housing Authority 2022 Audit Finding 2022-001 ? Eligibility Auditee?s Response and Planned Corrective Action Planned Implementation Date of Corrective Action: December 2023 Person Responsible for Corrective Action: John Hrvatin, Executive Director The following reflects the Planned Corrective Action Plan pursuant to find 2022-001: ? Effective immediately, the Executive Director will review monthly all files, and documentation with respect to eligibility. ? Effective immediately a copy of monthly EIV's will be maintained on a PDF file. ? Effective immediately, all monthly EIV's will be maintained in separate binder. In the event you have any questions please do not hesitate to contact me. Sincerely, John Hrvatin Executive Director

Finding 2022-003: Enrollment Reporting Award Information Cluster: Student Financial Assistance Agency: Department of Education Award Name: Federal Direct Student Loans, Federal Pell Grant Program Award Year: July 1, 2021 ? June 30, 2022 Assistance Listing Numbers: 84.268, 84.063 In August 2021, prior to the Workday Student implementation "go live" in September 2021, the University was working with their implementation consultants to help with the initial configuration of enrollment reporting in Workday. Since implementation, they have been continuously making updates to the system and processes to prevent errors from occurring. The Registrar?s office has spent significant time working to understand and refine the way that enrollment status data is captured and processed in the system. The Registrar's Office works collaboratively with partners on campus (Financial Aid and Information Technology) on identifying and resolving issues. After turnover and an extended vacancy in the Assistant Registrar position, the new Assistant Registrar started in July 2022, took over the reporting and has worked diligently to more timely identify and address errors and has noted a decrease in the number of system errors and data kickouts as a result of this work. In addition, in September 2022 the University engaged an NSC Data Specialist with Workday Student expertise to help monitor and ensure that issues are identified promptly and resolved. The Registrar?s office continuously monitors and implements Workday system updates to ensure that our system is up-to-date and staff are informed of challenges that are being identified in the larger Workday community. Finally, the Registrar?s Office continues to work closely with its financial aid counterparts, including their Director of Systems, Reporting, and Compliance, to ensure data is processed and reported within the Federal Guidelines. The last phase of this work is finalizing our review of the process and data related to degree transmission, such work as is expected to be completed no later than May 2023. The Assistant Registrar, James Smith, who can be reached at datarequest@simmons.edu, is responsible for the implementation of this corrective action plan.

The local ministry has added an additional question to the intake packet and process to affirm CDC qualification. Additionally, the local Health Ministry program coordinator will include a certification that all participants meet the CDC qualifications, explicitly listed on the cohort data and reimbursement form submitted to System Office quarterly.

The Patient Business Service centers are actively reviewing any potential HRSA credits to ensure refunds are processed timely. As the HRSA program has concluded, our teams are now focusing our efforts on reviewing previous HRSA payments to ensure accuracy and that any refunds identified are processed timely.

Federal Award Findings and Questioned Costs (continued) Finding: 2022-003 Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management?s Response: Congregate Nutrition ? Second Party Review Process The following Second Party Review process was implemented July 2022: Each month the Business Manager reviews two completed CRFs for each SMO site. The two CRFs that are selected from a site should be different types (example: one new CRF and one annual re-assessment, or one annual re-assessment and one termination). There is a spreadsheet where these audits are tracked in the secure SNS Z:drive. It will be stored by fiscal year then Internal Audit then SMO Audit Log. In the spreadsheet, the Business Manager enters the site, the first and last name of the client, the review/audit date, and site. In addition, the following items will be reviewed and documented: ? Dates Match: new registration date or change of information date is included and matches date on the back at the bottom of the document - key date ? Type of CRF: new/returning/annual/change/termination ? Term. Reason: if terminated, the termination date and reason are both indicated ? Complete: all boxes/sections are completed or marked refused to answer if option available ? Signed: CRF is signed by both client and site supervisor ? Timely: update is completed each year (indicated on the bottom of the back page) during the same month that the client started unless there is a change of information ? Electronic Signature of person completing internal review: first initial, last name (types in excel sheet) Second party reviews with checklists and reviewer signatures were already in place for remaining Aging Cluster services. Proposed Completion Date: Immediately and ongoing.

The University created additional reporting to identify student grade level reported on student system (SGASTDN) to the calculated grade level (ROASTAT) and any blanks. In addition, to the report which was created prior to this citing, training directly from the software provider has been scheduled. The University will review the option of creating a specific budget or packaging group for students in certificate programs. This would afford rules to award only level one loan limits regardless of calculated grade level. Standard cost of attendance (coa) is posted by system processing rules. In certain situations, the coa may be adjusted manually by staff. The student information system does track and log these updates. The University will increase training regarding coa adjustments, strengthen standard posting of changes and why. A report has been created to identify any change to the standard budget component. This will be added as a point of review for the compliance coordinator. The primary risk area is summer since it is a manual process. The use of algorithmic budgeting will assist with changes to coa as well. In addition, the University is working with software provider to establish algorithmic budgeting rules. This option allows cost of attendance (coa) to be completed by enrollment period versus aid periods. The benefit is coa can be estimated at full-time and prior to disbursement adjust coa to part-time. The office of student financial services is working with the University to identify and address additional human resources needed to best address increased volume and greater compliance. Cari Wickliffe, Assistant Vice President and Director of Student Financial Services, is responsible for addressing the above items by July 1, 2023.

Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior to the submission of the July ? September 2023 claim.

Finding No. 2022-001 Significant Deficiency Personnel Responsible for Corrective Action: Jim Slattery, Chief Financial Officer Anticipated Completion Date: March 31, 2023 Corrective Action Plan: Management for the St. Louis Public library will review all processes associated with checking out equipment and make necessary revisions to processes and procedures to ensure all staff are properly trained to successfully execute all transactions.

C. Corrective Action Plan: ACED will use JDE?s actual fringe bene?t rates rather than the blended rate provided to the Department by the County?s Budget Of?ce each year. On August 22, 2023, ACED reached out to the Controller?s Of?ce Senior Analyst and the Assistant Manager of the J DE Service Center to request a ReportsNow report to help with this task. The report will provide ACED with JDE grand totals for a job for a given period as well as employee details from payroll to help the Department report more accurately on actuals for correct cross-charges.

Condition - Peak Vista determines the sliding fee discount charged to patients based on the patient's annual gross income and household size. We found two encounters where applications were not retained. Therefore, we could not determine if the sliding fee discount applied was in accordance with the guideline. We found two separate encounters where the patient did not meet the guidelines to receive a discount. We found one separate encounter where the patient was charged an incorrect co-pay. Recommendation - We recommend that Peak Vista's procedures be strengthened to ensure income is properly verified and adequately documented and retained. Peak Vista should strengthen processes surrounding monitoring of the program to ensure the Center's policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions - Management agrees with the finding. Peak Vista has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the enrollment and eligibility process, including our Enrollment, Reception, and Billing teams will be retrained on the process with emphasis on proper documentation. Peak Vista management plans to incorporate into our quality assurance audits the documentation for single service date discount applications and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion - In progress, estimated completion 12/31/2023. Action Taken - We have reviewed the recommendation and have a corrective procedure in place for addressing this issue. Will continue to monitor improvement. Person Responsible for Corrective Action Plan - Ryan Spillane, CFO

Condition: Monthly Claim for Reimbursement included second meal claims in excess of two percent of the number of first meals served to children for each meal type. Plan: Implement additional procedures to ensure the accuracy of meal counts prior to the submission of the monthly Claim for Reimbursement such as but not limited to training and conferences. Additionally, the District should contact the Illinois State Board of Education for further recommendation on this finding. Anticipated Date of Completion: 6/30/2023 Name of Contact Person: Thomas Akers, Superintendent Management's response: There is no disagreement with this finding and procedures will be implemented. The District will contact the Illinois State Board of Education for further recommendation.

Findings 2022-001 through 2022-007 During 2020 and 2021, the Organization had gone through a significant amount of turnover at the management level and in the Finance department. These changes have resulted in the identification of a significant lack of internal controls as well as a lack of resources. The Organization has gone through a process of hiring new Finance positions and engaging outside consultants as needed. With a change in leadership and an increase in resources, the Organization is in the process of implementing a system of internal controls that will focus on segregation of duties related to all significant transaction cycles (including monthly close procedures), increasing communication and transparency of transactions within the Organization, and a heightened sense of documentation to support all transactions, including grant funded activity. The goal of implementing this system of controls is to mitigate the risk of any wrongdoing, intentional or unintentional, at the Organization and to allow for proper compliance with restrictions set forth by government agencies. Responsible party: Scott Forbes; Executive Director; (978) 873-0916 Anticipated completion date: June 30, 2023

2022-001 ? ALN 14.871 ? Section 8 Housing Choice Vouchers Program - Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Tyronnda Bethune, Executive Director Projected Completion Date: September 30, 2023 2022-002 ? Significant Deficiencies in Internal Controls over Financial Reporting Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Tyronnda Bethune, Executive Director Projected Completion Date: September 30, 2023

2022-002: Lack of Documentation for Review of Tenant Files Name of contact person: Nancy Cashman, Executive Director Corrective Action: The Corporation created written policies and procedures for affordable housing program compliance and review of the applicable tenant files in fiscal year 2023 and is in the process of adopting these policies and procedures. Proposed completion date: The Organization plans to complete the plan by September 30, 2023.

MATERIAL WEAKNESS 2022-009 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Activities Allowed or Unallowed Condition Students were awarded HEERF aid in June 2022 based upon their outstanding account balance, and they were not given the option to take the disbursement as anything other than a credit to their account. Recommendation We recommend that the institution carefully review guidance regarding new funding sources in order to ensure that all applicable requirements are being met. Actions Taken As of April 1, 2023, the College has contacted the Department of Education in order to determine how best to remedy the situation and will take all actions recommended.

SIGNIFICANT DEFICIENCY 2022-007 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered that two students were over awarded subsidized direct loans. Recommendation We recommend that the institution implement controls to ensure that direct loan award amounts are reviewed for accuracy prior to making awards to students. Actions Taken As of March 23, 2023, the College has begun to implement a review of student awards that will include reviewing all aid and credits that the student is receiving and double checking NSLDS loan amount limits.

SIGNIFICANT DEFICIENCY 2022-005 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered one student was incorrectly awarded Pell, and two others did not receive Pell disbursements for both eligible semesters attended during the year. Recommendation We recommend that the institution implement controls to ensure that all scheduled disbursements are ultimately posted. In addition, when calculating Pell awards, the Payment and Disbursement Schedule that matches the student?s enrollment status should be carefully selected and applied. Actions Taken As of March 23, 2023, the scheduled Pell awards for the two noted students have been posted and disbursed. In addition, an additional review step has been implemented to take place before any aid disbursements are made.

FINDING NO. 2022-002: Section 202 Supportive Housing for the Elderly, CFDA 14.157 Recommendation: The Project should verify initial tenant income through the EIV system in a timely manner and ensure all required background checks are performed prior to a tenant moving in. Action Taken: Managers have been retrained on procedures for using the EIV system to verify tenant income and to perform background checks timely. Compliance will conduct periodic checks to see if reports are pulled and maintained in the tenant file, as required. If the Oversight Agency for Audit has questions regarding these plans, please call Christine Harris at 954-835-9200. Sincerely yours, Christine Harris Accounting Manager

Finding Number: 2022-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Robert Benson Todd McMurray Corrective Action Planned: Chisago County will implement additional procedures to provide reasonable assurance that all necessary documentation is properly inputted or updated in MAXIS. This will include internal staff training/updates at monthly unit meetings on the importance of accuracy in our case files. Our agency will also be implementing internal supervisory case reviews to ensure accuracy practices are being followed. Anticipated Completion Date: Our corrective action plan will be implemented immediately and ongoing.

2022-004 Community Health Centers Grant ? Assistance Listing No. 93.224/93.527 Recommendation: Management should refine and expand its internal audits of patient visits to identify instances where a patient was either assigned to the incorrect sliding fee category or billed the incorrect charges. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has instituted some measures and procedure to mitigate the risk of having patients being assigned to incorrect sliding fee category or billed the incorrect charges. These additional measures and procedures include but are not limited to providing training and more oversight of the front desk and billing staff. More oversight such as regular and ongoing internal audits of the front desk and billing staff will be contacted on a quarterly basis. The objective of the regular audit is to ensure that all policies and procedures are being followed and to ensure any instances of non-compliance are timely identified and corrected. Name(s) of the contact person(s) responsible for corrective action: Matthew White, Shannon Courson, Asante Muyungga Planned completion date for corrective action plan: August 7, 2023

2022-001 Eligibility ? Tenant Files Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 ? Housing Choice Vouchers 14.879 Mainstream Vouchers Material Weakness in Internal Control, Material Noncompliance Repeat finding of finding 2021-002 from the prior year September 30, 2021 Condition: Out of a total tenant population of approximately 573 tenants, 25 files were selected for testing. Exceptions were noted as follows: ? 1 file that did not contain a 214 affidavit for one member of the household, however they did have a birth certificate showing they were an eligible citizen. ? 2 files where the 214 affidavit was not checked for one member of the household certifying they were an eligible citizen, however they did have birth certificates to verify their citizenship. ? 5 files that did not contain a signed Form 9886 for at least one member of the household age 18 or over. ? 1 file where the tenant?s income was calculated correctly but had the wrong amount reported on the 50058, which would have decreased HAP rent by $11. ? 1 file where the prior year utility allowance schedule was used instead of the current year, however this had no effect on HAP rent. ? 1 file where there was no support that an inspection had been done for a new admission. ? 1 file that did not contain a tenancy addendum to support the contract rent and HAP rent for a tenant with a project-based voucher. ? 2 files where there was no support that an EIV report had been processed. In addition to the above, we noted the following during our new admissions testing ( new admissions tested): ? 3 files that did not contain a passed inspection completed prior to move-in. ? 1 file that did not contain a signed lease agreement or tenancy addendum. ? 1 file where the request for tenancy approval was not executed until the day after the voucher had expired. 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: Errors were corrected in the tested files where corrections could be made. Meaning for example Form 9886 cannot be regenerated for this audit period but will be obtained during future annual recertification (also known as the personal declaration/application) periods. Adjustments will be made to the tenant accounts. Staff was informed to obtain Form 214 during all recertification re-examinations to ensure the required form is in the file. This way, if it was never obtained or if it was inadvertently purged, the file will always have a copy in the file for the review period. File Audit: A file audit (not a 100% audit) was completed for the Housing Choice Voucher Program. A procured third-party vendor performed this process. However, previous staff members did not make the file corrections. For months, there was only one staff member in the HCV Department. The department, at this time, is fully staffed. The current staff is making the file corrections as they come across various issues while moving the program/department forward. Of importance to note is the hire of a new Chief Operating Officer with over twenty (20) plus years of HCV experience who will oversee the Section 8 Department. We believe the new leadership, to include CEO and COO positions will provide the necessary oversight of the HCV program that will improve the overall performance of staff and the program. Quality Control Review: After completion of the file audit, the Housing Choice Voucher Program Manager and their supervisor will be responsible for documented monthly quality control reviews of 10% of files completed during the month. Effective Date: June 22, 2023 Contact Information Marcus Goodson, Interim Executive Director Sanford Housing Authority 1000 Carthage Street Sanford, North Carolina 27330 (919) 776-7655

Project Legal Name: Geneva Avenue Elderly Housing, Inc. HUD Project No.: 023-EE-110 Audit Firm: Cohnreznick LLP Period covered by the audit: 7/1/2021 ? 6/30/2022 Corrective Action Plan prepared by: Name: Amy Lawton Position: Regional Manager Telephone Number: 617-209-5266 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendation in the finding. b. Action(s) Taken or Planned on the Finding In order to verify that all EIV reports are being run in accordance with HUD regulations, an internal audit will be performed on a routine basis. This audit will be conducted by a Senior Manager, a Regional Manager, or by a member of the Compliance Department. This internal audit will be performed at the end of each fiscal quarter. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations N/A