Corrective Action Plans

(A) The Department continues to work with the Fiscal Agent to ensure that the required database matches occur and the interChange properly displays the results of Social Security Number and Federal Employer Identification Number verifications for all providers. The project was completed mid July 2022.

(B) The Department will review and revise, as necessary, its taxi claim billing requirements and rates to ensure that they are consistent. In addition, the Department will devise controls to ensure that taxi claims are paid in accordance with established requirements and rates and explore controls to ensure that only permitted providers bill as a taxi. The Department is working on reductions in the max fee and unit limits for taxi claim billing codes, which it will have completed by the end of October 2021. In addition, the Department is considering systematically pricing the code at each taxi provider?s specific Public Utilities Commission (PUC) rate. This change, if pursued, will require a system change request, which will take a year or more, which is why the Department has selected an implementation date of December 2022. If this proves infeasible, alternate controls will be implemented. HCPF has met with DORA PUC. The Department is trying to establish a process to decide if the PUC taxi rate still applies or an internal rate can be created. Because of these discussions and needed system changes the implementation date has been moved to December 2023. (D) The Department intends to define in rule the types of documentation that NEMT providers must keep on hand and make clear that they must furnish records to the Department upon request. The July 2022 date will allow for the completion of formal rulemaking. The Department further intends to develop and implement a process to perform regular risk-based provider file reviews with a focus on noncompliant providers. These reviews will ensure, at a minimum, that the providers? paid claims are supported with appropriate documentation and represent the least costly option appropriate to meet each recipient?s needs. The Department met with the RAC team on February 22, 2023 to come up with a process to perform small audits for claims from providers that are outside the Intelliride service area. New systems will be implemented which has pushed the anticipated completion date to December 2023. (E) The Department will amend its contract with its NEMT broker by adding a mandatory annual audit so that it can reconcile trip scheduling data with paid claims data. This will help ensure that the Department pays accurately, pays for NEMT services, and pays for the least costly transportation option appropriate for each recipient. The Department chose July 2022 to add the audit through its annual contract amendment and renewal processes. The contract amendment was completed and signed June 30, 2022 that included a clause for an annual audit of claims. (F) The Department will develop a data review process to reconcile interChange data on NEMT trip claims to interChange data on Medicaid medical claims. This process will entail periodic reviews of NEMT claims to see if members have corresponding medical claims on those dates. If they do not, the Department will follow up with the appropriate NEMT provider to investigate. The July 2022 implementation date reflects the potential need for system changes. This is implemented, the Department has been pulling claims data and where corresponding medical claims are not found HCPF is investigating on a case by case basis to find the cause. (G) Department staff will work with the Department?s Program Integrity (PI) staff on processes to investigate and recover, as appropriate, the overpayments and inappropriate payments that the audit identified as known or likely questioned costs, and repay the federal portion, as appropriate. The December 2022 implementation date reflects the time needed to investigate and when appropriate, recover any overpayments. This has been implemented and the federal portion has been returned to CMS. (H) The Department will develop a process to track staff time and productivity to ensure that it has sufficient staff assigned to oversee and administer NEMT. This process will include documenting time spent each week on various tasks to get a sense of where help is needed, and which tasks take up the most staff resources. Based on its findings, the Department will explore staffing options, as needed. The Department selected the July 2022 implementation date to allow for data collection through the end of State Fiscal Year 2021-22. This has been implemented. New NEMT staff was hired November 1, 2022 to act as the liaison to the counties and clients in the 55 counties outside of the Intelliride service area.

(B) The Department will continue our existing proactive approach to minimize this issue. The resolution of a SSN discrepancy is addressed through manual intervention by county eligibility technicians when identified through the system edit implemented in December 2020. The Department will continue the existing process to address duplicate SSNs. The Department has already made significant progress to monitor CBMS through the use of CBMS monitoring dashboards. These dashboards allow the Department to monitor and perform daily analysis. The Department meets bi-weekly to discuss findings and next steps to resolve any issues identified through the dashboard. These dashboards are being implemented over time as areas of improvements are identified. As part of the Department's continual improvement strategy, SSN discrepancy reports are included in the next implementation phase of the monitoring dashboards scheduled for June 2023. The Department will develop and implement policies and procedures outlining how the report will be used to effectively monitor and correct SSN and State ID discrepancies. Once that work is complete, the Department will send updated written guidance to our county and medical assistance sites on how to use system edits, reports, and dashboards to resolve duplicate SSNs. (C) The Department will continue our existing proactive approach to minimize this issue. The resolution of a SSN discrepancy is addressed through manual intervention by county eligibility technicians when identified through the system edit implemented in December 2020. The Department will continue the existing process to address duplicate SSNs. The Department has already made significant progress to monitor CBMS through the use of CBMS monitoring dashboards. These dashboards allow the Department to monitor and perform daily analysis. The Department meets bi-weekly to discuss findings and next steps to resolve any issues identified through the dashboard. These dashboards are being implemented over time as areas of improvements are identified. As part of the Department's continual improvement strategy, SSN discrepancy reports are included in the next implementation phase of the monitoring dashboards scheduled for June 2023. Once that work is complete, the Department will send updated written guidance to our county and medical assistance sites on how to use system edits, reports, and dashboards to resolve duplicate SSNs appropriately and in a timely manner.

(A) The Department and CBMS teams have strengthened their internal controls to ensure payments are only made to providers for eligible members. The Department and CBMS teams will update all member records identified on the Monthly Reconciliation report once the Public Health Emergency ends. TRAILS team has provided additional training to the Case Managers to prevent data integrity issues being submitted to CBMS and interChange; however, the TRAILS team does not plan to update the system's internal controls until funding is available. (B) The Department agrees to review the monthly eligibility reconciliation report and is looking forward to resolving the member records once the Public Health Emergency ends to fully resolve the audit finding.

GSA_MIGRATION

We have prepared the following corrective action plan as required by the standards applicable to financial audits contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Specifically, for each finding we are providing you with the names of the contact people responsible for corrective action, the corrective action planned, and the anticipated completion date. Findings - Financial Statement Audit 2022-101: Eligibility Recommendation: The South Tucson Housing Authority should establish policies and procedures to ensure that tenants? eligibility determinations will be reviewed and approved by an employee that is independent of the initial eligibility determination. Action Taken: The South Tucson Housing Authority concurs and has implemented the recommendation. Completion date: Fiscal Year 2023

(A) The Department agrees with this finding. The Department is moving all adjudication and investigation of program integrity holds into the MyUI+ system, so there will be one system of record. The Department will ensure that all program integrity holds have all documentation through adjudication and investigation, including log notes. The Department anticipates this to be fully implemented by July 2024. (B) The Department agrees with this finding. The department has modified processes to ensure all holds are only routed to the appropriate team to be adjudicated. In addition the Department is working to have all claims identified as fraud delivered in a workflow process in MyUI+ rather than the various processes in place now. Further the department is working with our MyUI+ system experts to implement new technology to strengthen and streamline the fraud indicator escalation process and systems within MyUI+. In working with our MyUI+ system experts, the Department anticipates this to be fully implemented by July 2024. (C) The Department agrees with this finding. The Department will continue strengthening security in this area and internal procedures to periodically monitor the potential for internal fraud activities. Additionally, the Department will periodically monitor and review My UI+ access levels for appropriateness. In consultation with our MyUI+ systems experts, the Department anticipates this finding to be fully implemented by July 2024. (D) The Department agrees with this finding. The Department will reinforce and strengthen the ethics policies in yearly communication to staff and tighten escalation policies to ensure pressures and inappropriate requests are handled in accordance with guidelines. The Department anticipates this will be completed by July 2023. (E) When a PI hold is identified as being highly suspicious for criminally fraudulent activity, it is routed to a specialized unit for review, thereby leaving the standard adjudication process. This is handled by passing the review to the UI Investigations and/or Criminal Enforcement (ICE) unit. The investigator performs their investigation and if no actual fraudulent activity is found they will release the hold. The UI Division also performs several quality control reviews of claims and claim decisions via Benefits Payment Control (BPC), Benefits Accuracy Measurements (BAM), Benefits Timeliness and Quality (BTQ), and internal Quality Assurance (QA) reviews. Claims are reviewed for such criteria as adequate support documentation, benefit payment accuracy, timely processing, and correct claim decision determination on all program integrity holds. The Green Book states in Section 10.14, ? If segregation of duties is not practical within an operational process because of limited personnel or other factors, management designs alternative control activities to address the risk of fraud, waste, or abuse in the operational process.? CDLE believes the reviews represent adequate and sufficient compensating controls for the need for segregation of duties on fraud holds. Changing the current process would hinder our ability to deliver UI benefit services timely to our customers and would put us in jeopardy of fulfilling our federal and state payment timeliness requirements.

(A) The Department will formalize IT security policies and procedures to comply with the Business Owner requirements contained within the Governor's Office of Information Technology's (OIT) March 2022, Colorado Information Security Policies. The Department will further formalize a procedure for product owners to annually review the OIT Colorado Information Security Policies and ensure alignment with the formalized Department IT policies and update any affected formalized IT procedures. The Department will communicate the formalized policies and procedures to Department staff and IT Service Providers, and then any future changes, as deemed necessary. (B) The Department will formalize IT security policies and procedures to comply with the Business Owner requirements contained within the Governor's Office of Information Technology's (OIT) March 2022, Colorado Information Security Policies. The Department will further formalize a procedure for product owners to annually review the OIT Colorado Information Security Policies and ensure alignment with the formalized Department IT policies and update any affected formalized IT procedures. The Department will communicate the formalized policies and procedures to Department staff and IT Service Providers, and then any future changes, as deemed necessary. (C) CDLE agrees with the recommendation and as part of A and B recommendations of this document, the Department will include a requirement from vendors to affirm they have reviewed and will comply with OIT security policies for all new contracts. Furthermore, as the Department becomes aware of changes to OIT Security Policies through its annual review process, these will be communicated to the vendors, and they will be required to reaffirm their compliance with any applicable changes. We will work with our current vendors for MyUI+ and Connecting Colorado to address the compliance issues noted in the audit and ensure they are compliant with OIT Security Policies and IT policies developed in part A and B of this recommendation. If non-compliance is determined to be unavoidable, the Department will file for a security exception with OIT. (D) CDLE agrees with the recommendation and will implement recommendation Part D as noted in the confidential finding. (E) CDLE agrees with the recommendation and will implement recommendation Part E as noted in the confidential finding.

The Department of Local Affairs (Department) agrees with the recommendation. The Department will strengthen its internal controls through the development of an onboarding program that will include different modules that new employees and/or contractors must work through to receive certification. These modules will include all relevant steps associated with the waiting list process.

Name of Contact Person: Sue Ledford, Executive Director. Corrective Action and Proposed Completion Dates: 1. ED monthly 1:1 with Directors meetings to continue. Implemented 5/1/2022. 2. Monthly Group meeting with Directors/Leadership Team to continue. Implemented 5/1/2022. 3. Internal Audit (monitoring) to be conducted quarterly by each Departmental Director. Partner with Leadership Team to complete. Implement by 3/30/23. a. Review mandated contractual compliance, financial compliance, and adequate documentation processes. b. Documentation to filed on FSCA Common Drive. 4. Continue internal audits/monitoring of HUD tenant files with focus on compliance to Administrative Plan, HUD notices, and proper documentation. Implemented 7/1/22.

2022-001: Eligibility Recommendation: We recommend that management implement a control to ensure documentation is maintained to support that all cases have been reviewed when closed. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: We will draft a supervisor case closing checklist. We will distribute the checklist to supervisors once it is finalized. We will then pull a random sample of recently closed cases in October to see if supervisors are completing the review as instructed. Name of the contact person responsible for corrective action: Daniel Lindsey, Chief Litigation Officer Planned completion date for corrective action plan: September 30, 2023

Finding: 2022-002 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: Shelia Triplett, Executive Director Anticipated completion date: September 2023 MYCAP?s response: Concur MYCAP agrees with this finding and provided the following response for corrective action: U.S. Department of Health and Human Services ? Significant Deficiency ? Internal Controls over Compliance ? Eligibility Plan of Action: The Support Specialist will gather all required documents for the TANF program, ensuring the application documents and required income are on file. The Chief Operating Officer (COO) will conduct a second review of all TANF files for proper eligibility requirements including recalculations of income, ensuring all files are eligible, marking the file with initial and approval for processing.

2022-004 Material Weakness in Controls over Compliance: Activities Allowed or Unallowed We agree with the recommendations and have made improvements to our procedures. The schools were not prepared for the rapid expansion of the food program, not only at our two high schools, but our partner schools' which requested contracted breakfast/lunch food services for their students as well. This unprecedented growth coupled with supply chain issues from food wholesalers, and shortage of employees in the hiring pool, only exacerbated our issues. The audit sample showed a large error rate for one of the schools. We have gone through the entire year for the school(s) individual count sheets. In the event the Michigan Department of Education determines that the identified discrepancies warrant a repayment we have recorded an allowance in the financial statements for the year ended June 30, 2021. Staff were not properly trained in how to complete the count sheets; however, supervisors did not take the time once they saw there was a problem due to everyone trying to simply get the meals served to the children. In addition, there was a lack of oversight of the Food Service Manager by her direct supervisor. At the time of the 2021 audit, when the issue was brought to our attention, we developed new procedures. School staff performing counts have been trained in how to properly complete the count sheets. The Business Manager now reviews all count sheets and ties counts to the summary report used to submit claims prior to submittal for reimbursement. Given that training and implementation of procedures did not fully occur until January 2022, there are errors in counts prior to implementation of the procedures and repeat findings in fiscal year 2021-22. In addition, with the end of the pandemic, beginning with the 2022-23 school year, the schools were able to resume using electronic software to accurately capture the meal counts.

Legal Name: Housing and Community, Inc. Audit Firm: CohnReznick Period covered by the audit: January 1, 2022 ? December 31, 2022 Corrective Action Plan prepared by: Name: James Butcher Position: SVP of Finance & Accounting Telephone Number: 210-821-4392 1. Current Findings on the Schedule of Findings and Questioned Costs 2. Finding 2022-001 a. Comments on the Finding and Each Recommendation Management did not certify income through the EIV system as part of the initial certification procedures for new tenants. b. Action(s) Taken or Planned on the Finding The management company is highly aware of the importance surrounding the EIV information and timeline of when these reports need to be pulled for documentation and review. We will make sure to provide additional training to ensure we remain in compliance going forward. We have also mandated manager reminders be put in place every time new tenants move in, ensuring the EIV be pulled within 90 days and 120 days prior to annual recertifications being performed for existing tenants. Management has also reviewed this proposed resolution with the Southwest Housing Corporation, the area HUD representative, and they have approved the aforementioned proposed resolution.

2022-001 U.S. Department of Agriculture, Food, and Nutrition Service Emergency Food Assistance Program CFDA Number: 10.568/10.569 Passed Through: The Arizona Department of Economic Security Pass Through Number: CtR052634 Award Period: July 1, 2021 ? June 30, 2022 Type of Finding ? Significant Deficiency in Internal Control over Compliance Condition/Context ? Internal control procedures over eligibility requirements for 1 of 40 eligibility sheets tested indicated there was no certifying signature by the eligible recipient agency volunteer, and there was no evidence of secondary review by the distribution agency program officials. Contact Person ? Chariti Stern, Chief Program Officer Corrective Action Plan ? United Food Bank has entirely onboarded all TEFAP agencies to be active on Link2Feed; however, a handful of agencies still use sign-in sheets due to technology limitations. At the 2022 Agency Conference, a presentation was done that conveyed the importance of checking all signatures on United Food Bank documents. The 2022 Partner Agency Handbook explains that a signature is required for the reports and sign-in sheets to be authorized and accepted by United Food Bank. Re-training United Food Bank staff has also occurred to ensure that all reports have the correct signatures and that the United Food Bank staff?s initials are on all documents to ensure that the reports were reviewed.

U.S. Department of Housing and Urban Development, passed through the Massachusetts Housing Finance Agency Section 8 Housing Assistance Payments Program ? Assistance Listing No. 14.195 Significant Deficiencies 2022-001 Condition: 1) 1 of the 40 tenants selected for testing had an incorrect amount reported for social security income on Form HUD-50059. 2) 1 of the 40 tenants selected for testing had an amount reporting for medical expenses on Form HUD-50059 that was not supported by documentation in the tenant?s file. Auditor's Recommendation: We recommend that an internal control procedure be implemented to ensure that all HUD-50059 forms are completed accurately and all required information is obtained and maintained within the tenant files. Action Taken: 1) Management will meet with the tenant to properly investigate causation for the finding noted above. Pending the outcome of the investigation, Management will correct the July 2022 Annual Certification with the expectation of correcting the income used to tabulate the tenant?s level of rental assistance, the tenant will not be charged for the error, and HUD will be reimbursed for subsidy accordingly. 2) Management removed the active medical expense from the expense tab on the management software. The medical expenses do not impact the level of rental assistance since the amount did not exceed 3 percent of the tenant?s household income. Nevertheless, Management reclassified the medical expense as inactive to ensure the medical expense is not part of the future certifications.

Finding 2022-001 - Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: GHA will implement the following immediate and on-going actions to correct internal control over participant files in the Housing Choice Voucher program: Immediate Response: GHA is guided by seven core values. The first of which is Integrity. Upon discovery of forged documents, in March 2023 it was clearly communicated and reiterated that any actions, such as alternation, falsification, or fabrication is unacceptable and the appropriate disciplinary would be taken. A prompt and thorough investigation resulted in a team member being terminated for forging documents and a change is senior leadership. A third-party consultant was brought in immediately to complete an assessment and review of the voucher programs internal process to provide immediate process improvement along with reviewing an additional sample set of participant files. Ongoing Response: GHA will improve internal controls in the area of file review and quality control and assurance by completing multiple examinations of applicants/program participants calculations at initial move- in, interim, and re-examination anniversary. In addition to the two-prong reviews being completed by team members, a third-party compliance company may be used to review all initials, and up to twenty-five percent (25%) of all interim and re-examination of program participants' files. Internal/external training will be provided to each team member involved with the determination of rent and maintaining tenant files, as well as programmatic eligibility and administration of the housing choice voucher program in 2023. Voucher Administration leadership will continue to work closely with the Compliance Department to ensure that GHA's program files are compliant with all federal regulations, rules, HUD guidelines as well as GHA's policy and procedures. Anticipated Completion Date: The above plans will be implemented immediately and will be continuously monitored. We anticipate a completion date of December 2023. Responsible Person: Meredith Daye, Chief Operating Officer

Views of the Responsible Officials and Planned Corrective Actions: During the pandemic, SVDP distributed Emergency Rental Assistance Program funding that was a new, specific response to the COVID pandemic. Due to significant staff turnover with the team administering these services, there was misplacement of participant income verification documentation for six cases. SVDP subsequently confirmed the income eligibility for these six participants and is therefore confident that the participants were in fact eligible for the assistance received. However, we recognize that the income eligibility documentation for these six participants could not be found at the time of the audit and as a result are undertaking quality assurance and compliance measures to ensure participant files are always fully compliant in order to prevent this type of error from occurring again. These measures include: (a) instituting a new compliance scorecard for internal chart reviews, (b) monthly peer chart reviews, (c) frequent case management supervisor chart reviews, (d) spot chart auditing by SVDP?s internal Quality Assurance Specialist, and (e) updated training for case management staff on procedures for participant case files and for the retention of forms and other documents.

We agree with this finding that certifications of direct assistance provided to individuals were not obtained. We have taken steps to correct the issues identified and during June 2023 we modified our procedures for certification of direct assistance received by clients. We will review our process and procedures for obtaining signatures from clients receiving gift cards and other forms of direct assistance, including non-financial assistance as well as rent and utility assistance, to ensure that amounts received, and dates received are attested by clients via signature or via an acceptable alternative electronic attestation.

Management Response and Corrective Action: HACLA administers the third largest Housing Choice Voucher program in the United States with an allocation of 52,646 vouchers and 44 percent of all HACLA certificate and voucher resources are housing formerly homeless individuals and families. The average income of all program participants is $19,815 per annum while the rents in Los Angeles are high. These participants have extremely low incomes, are at-risk households, living in a high-rent market, and without the subsidy would not be able to afford decent, safe, and sanitary housing. Further, the program is a valuable resource because in any given night there are more than 75,000 unsheltered residents in the Los Angeles area. HACLA?s highest priority is to house individuals which without the assistance of the program would be unable to pay rent and fall into homelessness or forced back to homelessness. With that said, program compliance is also a high priority for HACLA. As stated in Title 24 Code of Federal Regulations (24 CFR) ?982.516(a) the public housing authority must conduct a reexamination of family income and composition at least annually. Given HACLA?s very large program and the population it serves it is impossible to complete the annual reexamination within 12 months for 100% of the participants. Due to extenuating circumstances such as health issues, the death of the head of household and other challenges the family may be facing, it is impossible to have 100% compliance with this CFR. The housing authority must provide flexibility and extensions. The alternative would be for the housing authority to move forward with terminating the assistance in order to be fully compliant with the CFR--a position that HACLA does not take lightly given the humanitarian crisis in Los Angeles. The CFR is simply no longer in line with the realities of administering the program, and the expectation of the community. HACLA believes that HUD recognizes this in its monitoring practices for SEMAP. Nonetheless, HACLA?s goal is to complete all annual reviews within 12 months and will strike an appropriate balance to do so. These audit findings will assist HACLA in further advocating with HUD to adjust the regulatory requirement on annual reexamination completion time periods to be more in line with the reality of the homeless families that HACLA serves. HACLA?s Section 8 Department has the controls in place to ensure annual reexaminations are completed timely. Management will continue to proactively work with staff on an ongoing basis to ensure that participant families submit documentation timely or begin the intent to terminate process. This is a fine line, however, as HACLA is in the business of housing not terminating families. In line with HACLA?s Vision Plan, Executive Management is committed to improve processes across business lines. In mid-2022, HACLA contracted with Guidehouse, Inc., a consulting firm that works with housing authorities across the country such as the largest--the New York City Housing Authority, to identify and implement process improvements to simplify operations, meet regulatory requirements more efficiently and provide better customer services to applicants, participants and landlords. Guidehouse is in the process of that analysis and it is HACLA?s expectation that there will be an improvement and associated training in the annual reexamination completion process through better monitoring reports and dashboards to be provided in a shift to a better housing program platform as they have recommended. Person Responsible: Director of Section 8

CORRECTIVE ACTION PLAN Audit Finding Reference Number: 2022-002 Contact Information: Pam Barnes Chief Financial Officer Health Services of North Texas, Inc. Plan of Corrective Action: HSNT is committed to addressing this condition promptly, thoroughly and will continue to monitor for policy and procedure adherence. The case manager will ensure overall compliance with eligibility determination every six (6) months by collecting proof of income, including assessing income within 500% federal poverty level (FPL), proof of residence, and obtaining documentation of HIV diagnosis from testing agency. The eligibility process will be conducted annually and at 6-month eligibility recertification. The manager of programs will monitor case managers? new clients enrolled into Ryan White daily to verify eligibility documents are complete. Additionally for existing patients, appointment calendars are monitored and cross-referenced for documents in the patient?s Electronic Medical Record. Ryan White standards of care eligibility is verified every six months. In the interim a process to standardize the naming convention of eligibility documents has been completed to allow further auditing and oversight of the collection of eligibility documents. In consultation with our Ryan White program Monitor (Dallas County) we have received technical assistance and guidance related to eligibility. All items above have been completed on March 31st, 2023 Anticipated Completion Date: March 31, 2023

CORRECTIVE ACTION PLAN Audit Finding Reference Number: 2022-001 Contact Information: Pam Barnes Chief Financial Officer Health Services of North Texas, Inc. Plan of Corrective Action: HSNT is committed to addressing this condition promptly, thoroughly and will continue to monitor for policy and procedure adherence. The case manager will ensure overall compliance with eligibility determination every six (6) months by collecting proof of income, including assessing income within 500% federal poverty level (FPL), proof of residence, and obtaining documentation of HIV diagnosis from testing agency. The eligibility process will be conducted annually and at 6-month eligibility recertification. The manager of programs will monitor case managers? new clients enrolled into Ryan White daily to verify eligibility documents are complete. Additionally for existing patients, appointment calendars are monitored and cross-referenced for documents in the patient?s Electronic Medical Record. Ryan White standards of care eligibility is verified every six months. In the interim a process to standardize the naming convention of eligibility documents has been completed to allow further auditing and oversight of the collection of eligibility documents. In consultation with our Ryan White program Monitor (Dallas County) we have received technical assistance and guidance related to eligibility. All items above have been completed on March 31st, 2023 Anticipated Completion Date: March 31, 2023

2022-003 Waiver of Asset Ceilings Legal Services Corporation ALN#09.233100 Finding: Per LSC Reg.# 1611.3.d Financial eligibility policies, (1) As part of its financial eligibility policies, every recipient shall establish reasonable asset ceilings for individuals and households. In establishing asset ceilings, the recipient may exclude consideration of a household?s principal residence, vehicles used for transportation, assets used in producing income, and other assets which are exempt from attachment under State or Federal law. (2) The recipient?s policies may provide authority for waiver of its asset ceilings for specific applicants under unusual circumstances and when approved by the recipient?s Executive Director, Project Director, or his/her designee. When the asset ceiling is waived, the recipient shall record the reasons for such waiver and shall keep such records as are necessary to inform the Corporation of the reasons for such waiver. Per Legal Services NYC policy, asset ceiling is $25,000. Out of sixty (60) LSC cases selected for testing, a waiver approval of asset ceilings for two (2) cases was not obtained. Corrective Action Taken or Planned: The paralegal who closed the case has been instructed to review for this kind of error before closing. The Compliance Officer is working with IT to see if there is a way to make the ?continue? button be required so it cannot be bypassed by clicking to page back. Upcoming trainings on closing cases will stress the importance of verifying accuracy and consistency in eligibility information before closing. The intake paralegal has been instructed not to use the Asset Override Note field to enter basic case notes, and both she and the paralegal who closed the case has been instructed to verify eligibility information against other data in the case before closing. Financial eligibility training will emphasize that the Asset Override Note field should only be used for relevant information, and continue to emphasize that Asset Waivers require written supervisor approval that must be uploaded into the case file.

2022-002 Financial Eligibility ? Assets Definition Legal Services Corporation ALN#09.233100 Finding: Per LSC Reg.# 1611.2(d) Definition of Assets, ?Assets? means cash or other resources of the applicant or members of the applicant?s household that are readily convertible to cash, which are currently and actually available to the applicant. Out of sixty (60) LSC cases selected for testing, three (3) cases were reported as having an asset above ceiling ($25,000). However, the reported assets did not meet the asset the definition of assets as per LSC Reg.# 1611.2(d). These program clients were indeed financially eligible but the asset classification in Legal Server was not accurate and did not support the eligibility conclusion. Corrective Action Taken or Planned: All financial eligibility trainings and compliance trainings describe what does and doesn?t constitute an includable asset and instruct employees to click on the ?Exclude? button where appropriate. We will continue to emphasize that this is necessary in trainings throughout the year.

2022-001 Retainer Agreements Legal Services Corporation ALN#09.233100 Finding: Legal Services Corporation (LSC) Reg. #1611.9.a Financial Eligibility section 9 Retainer agreements requires that when an LSC grant recipient provides extended service to a client, the recipient shall execute a written retainer agreement with the client when representation commences or as soon thereafter as is practicable. Out of sixty (60) LSC cases selected for eligibility testing, a retainer was not executed for one (1) extensive service case and a retainer agreement for one (1) case could not be located. However, there is a case note written by the former employee who handled the case documented that the retainer agreement was obtained. Corrective Action Taken or Planned: The paralegal was admonished and provided with additional training stressing the need to have an executed retainer uploaded to each case file where needed. All compliance trainings for staff emphasize that retainers must be executed and uploaded to Legal Server prior to commencement of legal representation. We will continue to emphasize the need for this at trainings throughout the year.