Corrective Action Plans

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

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.