Corrective Action Plans

Corrective Action Plan: The following actions will be taken: ? Work with the Ohio Department of Rehabilitation and Correction to obtain more accurate incarceration dates. Currently we are not receiving the dates the claimant is incarcerated in a facility. We are currently receiving their expected release date which does not meet the needs of the office. ? We do not believe there is a need to work with the Department of Health as there has been no discrepancy with the accuracy of the data provided. ? We will create a process to create a weekly review file and save those results for review and evaluation purposes for both death and incarceration records. ? We will create a procedure to investigate the results of the death and incarceration files consistent with our existing procedures to investigate similar situations. Anticipated Completion Date for Corrective Action: January 2024 Contact Person Responsible for Corrective Action: Carl Prideau, Section Chief-BPC, Ohio Department of Job and Family Services 30 East Broad Street, 38th floor, Columbus OH 43215 Phone Number: 614-644-5164, E-Mail Address: Carl.Prideau@jfs.ohio.gov

Corrective Action Plan: ? Office of Unemployment Insurance Operations (OUIO) will develop a schedule of cross matches to ensure the matches are being performed timely and as intended. If the information necessary to complete the cross-matches is obtained from an outside party, the Department will work with the entity to ensure the information is obtained timely. Additionally, the Department will continue to prioritize issues based on the aging of issues created by the cross-matches, monitor the issue backlog, ensure issues are being addressed timely, and the Notices of Determination are issued in a timely manner. ? OUIO will develop quality reviews focusing on the timing of the fact-finding questionnaires generated by the OJI and/or uFACTS systems once an issue has been created. ? OUIO will develop periodic management reviews over the certification of OJI and uFACTS overpayments to the Ohio Attorney General and subsequent collections. ? OUIO will develop system enhancements within OJI to ensure the monetary fraud overpayment penalty amounts are being applied to each applicable overpayment. Management should monitor the system enhancements to ensure they are being captured, properly applied, and appropriately collected. Anticipated Completion Date for Corrective Action: June 2024 Contact Person Responsible for Corrective Action: Carl Prideau, Section Chief-BPC, Ohio Department of Job and Family Services 30 East Broad Street, 38th floor, Columbus OH 43215 Phone Number: 614-644-5164, E-Mail Address: Carl.Prideau@jfs.ohio.gov

Corrective Action Plan: The Office of Community Development (OCD) is in the process of implementing a new timeline for ESGP funding to be compliant with federal regulations. The following steps of the corrective action have already been completed. 1. Since the OHTF account balance is now in the position to allow OCD to commit funds earlier within the program year, the HCRP timelines can be adjusted to meet HUD?s 60-day requirement. 2. OCD must handle this change cautiously as HCRP serves Ohio?s most vulnerable population, the homeless, and our most vulnerable grantees, non-profit organizations. Interruptions in services and operating support would be detrimental to both. Both are dependent upon the continuity of OCD?s programs? timing. Therefore, a series of meetings have been scheduled with grantees to strategize about the most seamless way to implement this change with the least disruption in services and support. The first meeting was held on February 24, 2023. The second one is scheduled for March 31, 2023. 3. OCD will discuss this topic with the Supportive Housing Advisory Group in the fall of 2023. This meeting is part of Ohio?s Consolidated Planning Process to gather stakeholders input to create Ohio?s Annual Action Plan to submit to HUD for approval. A public comment period is built into the process as well, so additional feedback may be gathered to consider. Finally, the new timeline will be approved by HUD within the Annual Action Plan. 4. While OCD is having meetings and gathering feedback, staff will be working on the internal impact this change may create. System requirement changes and delays they may cause; report deadline shifts and alignment with other homeless reporting systems; and staff workload balance in coordination with other programs are a few we are aware of at this point. Also, the program planning begins far in advance to the grantee application submission. Therefore, timelines get set and approved early on. There are times when our allocation amounts are released from HUD late which delays our application process. There are times when HUD issues our grant agreement late which will require OCD to hold all grantees? agreements until ours is executed. Either one will cause a disruption in services after the program period is changed to an earlier start date. All these factors must be carefully considered prior to making this transition, so that surprises and delays are kept to a minimum. In some cases, a back-up plan will be required. Anticipated Completion Date for Corrective Action: September 2024 Contact Person Responsible for Corrective Action: Talia D. Givens-Gore, Program Operations Manager, Ohio Department of Development 77 South High Street, 26th floor, Columbus, Ohio 43215 Phone Number: 614-728-8140, E-Mail Address: Talia.Givens-Gore@development.ohio.gov

2022-001 Sliding Fee Discount Determination Name of Contact Person: Brent Copen, CFO Corrective Action: LifeLong Medical Care will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions Proposed Completion Date: January 31, 2023

Corrective Action Plan: The Ohio Department of Job and Family Services (ODJFS), in coordination with the Ohio Department of Medicaid (ODM), the Department of Administrative Services (DAS), and our vendor teams will continue to work to address system design weaknesses by identifying and prioritizing system changes and updates that impact eligibility determinations and benefit amounts as well as alert volume and processing improvements. Weekly problem review meetings will continue to be held to identify reported system issues and track any needed updates through the normal prioritization and slotting process. These changes will be delivered according to the agreed upon release cadence based on business priority and impact. Upon delivery of such system changes, the team will monitor production to determine if the desired outcome was achieved. ODM and ODJFS continue to meet to analyze the alerts in Ohio Benefits and the group presents recommendations to our vendor team for overall system alert improvements; these recommendations were prioritized and corrected in our normal release cadence through calendar year 2022, with the most recent release occurring in February 2022. The next alert centered release is scheduled for April 2023. Comprehensive alert reduction efforts thus far have reduced the overall ~29 million backlog alerts and drove a ~22 million annual reduction in new arrival of alerts. A system release specific to IEVSs enhancements is planned for R4.6.1 (April 2023) which will streamline the process for county staff to process IEVS matches from the IRS Unearned Income interface. There will be both E-Verify enhancements and a change in the match logic which will result in a reduction in the volume of IRS records that are flagged as IEVS matches. Caseworker time spent on processing IRS IEVS matches is expected to reduce; remaining time spent on IRS IEVS matches is expected to have more value by allowing caseworkers to focus time on matches with an eligibility impact or potential for benefit recovery. Periodic and timely review of IEVS will be completed as follows: ? Each state Fraud Control Specialist is assigned designated county agencies to provide technical assistance and training, as well as to monitor certain reports to ensure compliance with state and federal regulations. The counties will be monitored monthly and those not showing improvement will be offered training and technical assistance as appropriate. When a Fraud Control Specialist notices a county agency falling short of a required threshold, contact is made with county officials and the offer of assistance will be made. Once the number of alerts becomes manageable by the county agency, a Continuous Improvement Plan (CIP) may be required of the county agency if the issue continues over a four-month period of continuous contact and assistance. This type of CIP may be initiated outside the scope of Fraud Control Triad Review. ? The Fraud Control Section will conduct follow-up on Continuous Improvement Plans (CIPs) as part of the Triad Review process. When the county agency responds with a CIP, it is reviewed for clarity, action, and desired outcomes. Once approved, the Fraud Control Section will issue a closure letter for the Triad Review; however, a CIP may remain open for a longer period of time if warranted. We are in the process of creating a procedure and a closure letter for CIPs alone. This procedure will be implemented by June 30, 2023. ? Supervisory Reviews are monitored as part of the Triad Review process. Currently, the question is posed to the county supervisor about conducting random supervisory reviews. We are in the process of creating a procedure within the Triad Review process to be provided a list of IEVS matches that were reviewed by the supervisor. This procedure will be communicated statewide through the Fraud Control Training Program and enforced and verified during the Triad Review process.To continue to support the county caseworker staff, the Ohio Benefits Program provides training materials and promotes ongoing learning about related business processes without requiring in-person training. For each major system release or system enhancement that impacts the end user, updated training materials are produced and disseminated. These materials may take the form of job aids that are posted to the project website, train-the-trainer sessions, and video conferences where system users can ask live questions about the system. In addition to system support and training, the Ohio Department of Job and Family Services (ODJFS) in coordination with the Ohio Department of Medicaid (ODM) continue to provide the following methods by which training and system guidance is provided to CDJFS employees: 1. New Worker Training (NWT): A 12-week, comprehensive Policy and Systems training for new users (or refresher training for existing users) in the Ohio Benefits Worker Portal (OBWP) has been developed. The courses cover Policy and Systems overview, TANF, SNAP, Cash and Case Maintenance, along with the primary Medicaid programs (MAGI & ABD). The training is comprised of multiple, self-guided, Web Based Training (WBT) modules and virtual Instructor Led Training (vILT) sessions that provides `hands on? instruction. 2. Monthly Statewide County Conference: Monthly statewide webinars to cover general OFA updates for SNAP and Cash. These meetings include OFA?s Policy and TA staff, Outcomes and Analysis, Data Reporting, Quality Control, Automated Systems Training and the OB-IMS Help Desk. All areas share information on both refresher topics and emerging policy as well as systems issues where additional training is needed. The meetings are facilitated by the Program & Policy Services area within the Policy section of OFA and provides input on issues needing additional training and guidance. AST provides copies of job aids and other training documents during these support meetings. Recording of statewide training sessions are made available for counties to access on demand. 3. Operational Support Webinars: Bi-weekly webinars are delivered jointly by ODJFS and ODM, to counties for systems-based information and instruction on emerging topics and training related issues. Topics for the webinar are identified through a coordinated effort with the OB-IMS Help Desk, the weekly PBI/Defect Closure meetings and On Demand System Inquiries (received via email), to review any issues or concerns discovered by the Help Desk during the previous week. Counties are also able to submit questions and request topics in advance of the webinars to be reviewed and covered as part of the webinar agenda. 4. Ohio Benefits System Release Webinars: These are delivered jointly by ODJFS and ODM to inform counties about updates and enhancements made in each Ohio Benefits system release. During these webinars, counties are provided information regarding proper systems operation based on the items included in the release and target items that no longer require a workaround by the county worker. 5. Job Aids Available on the Innerweb: Automated Systems Training (AST) routinely provides systems-related job aids for county use that target specific topics and pain points for the counties. On the average, one to two new job aids are either created or updated each week and the Innerweb training pages are routinely referenced during New Worker Training, Operational Support, and Ohio Benefits system release webinars. 6. Quarterly Regional County Operational Support Meetings: Both the Automated Systems Training (AST) and the OB-IMS Help Desk participate in these regionally based, quarterly meetings, along with ODM Operations, Systems, and Policy staff. They provide guidance and system instruction on emerging systems issues and/or where additional training is needed. The meetings are facilitated by the Program & Policy Services area within the Policy section of OFA and provides input on issues needing additional training and guidance. AST provides copies of job aids and other training documents during these support meetings. 7. Quarterly Work Activity Round Table Meetings: Automated Systems Training (AST) and the OB-IMS Help Desk participate in these regionally based, quarterly meetings to provide guidance and system instruction related to TANF Work Activities. The meetings are facilitated by the Outcomes & Analysis area within the Policy section of OFA and provides input on issues needing additional training and guidance. 8. On Demand Systems Inquiries: Automated Systems Training (AST) maintains an email box where counties can submit inquiries about correct data entry and system functionality within the OBWP. Timely responses are provided to these inquiries frequently providing Help Desk confirmed instructions in a timely manner. Many of these inquiries are shared at the meetings and communications channels listed above. 9. System Support for Targeted Policy Training: Automated Systems Training (AST) provides system related content to support targeted Policy training topics to provide a holistic view of the application of policies within OBWP. The targeted training is delivered via virtual meetings and/or WBT modules. Some topic examples include `Expedited SNAP,? `Delayed Processing? and `Early Denial.? Recording of statewide trainings are made available for counties to access later.Interagency Agreement An Interagency Agreement is entered into by the Ohio Department of Job and Family Services (ODJFS) and the Ohio Department of Administrative Services (DAS). This Agreement is entered into for the purpose of setting forth the roles and responsibilities, budget methodology and payment terms, data sharing restrictions, security protocols, and compliance requirements for the Ohio Benefits Program. DAS and ODJFS has completed extensive policy, program, and legal reviews and the final Agreement is in circulation to secure DAS and ODJFS Director?s signatures.

Corrective Action Plan: Each state Fraud Control Specialist is assigned designated county agencies to provide technical assistance and training, as well as to monitor certain reports to ensure compliance with state and federal regulations. The counties will be monitored monthly and those not showing improvement will be offered training and technical assistance as appropriate. When a Fraud Control Specialist notices a county agency falling short of a required threshold, contact is made with county officials and the offer of assistance will be made. Once the number of alerts becomes manageable by the county agency, a Continuous Improvement Plan (CIP) may be required of the county agency if the issue continues over a four-month period of continuous contact and assistance. This type of CIP may be initiated outside the scope of Fraud Control Triad Review. The Fraud Control Section will conduct follow-up on CIPs as part of the Triad Review process. When the county agency responds with a CIP, it is reviewed for clarity, action, and desired outcomes. Once approved, the Fraud Control Section will issue a closure letter for the Triad Review; however, a CIP may remain open for a longer period of time if warranted. We are in the process of creating a procedure and a closure letter for CIPs alone. This procedure will be implemented by June 30, 2023. Supervisory Reviews are monitored as part of the Triad Review process. Currently, the question is posed to the county supervisor about conducting random supervisory reviews. We are in the process of creating a procedure within the Triad Review process to be provided a list of IEVS matches that were reviewed by the supervisor. This procedure will be communicated statewide through the Fraud Control Training Program and enforced and verified during the Triad Review process. Anticipated Completion Date for Corrective Action: ? The Ohio Benefits system improvement work and IEVS alert training ? Completed and continuing in fiscal year 2023 ? IEVS enhancement system release - April 2023 ? Triad Review closure letter procedures ? June 2023 Contact Person Responsible for Corrective Action Chris Dickens, Fraud Control Section Chief, Ohio Department of Job and Family Services 30 E. Broad Street, 37th Floor, Columbus, OH 43215 Phone Number: 614-387-5499, E-Mail Address: Chris.Dickens@jfs.ohio.gov

Corrective Action Plan: ? The program office will reach out to the county to advise of the error and ensure it has been corrected. ? The county will be reminded of the proper income entry and explain their plan to ensure it doesn?t happen again. ? The county will need to confirm they have started the overpayment process for any benefit overissued. Anticipated Completion Date for Corrective Action: February 2023 Contact Person Responsible for Corrective Action: Betsy Suver, Bureau Chief, Ohio Department of Job and Family Services 30 East Broad Street, Columbus OH 43215 Phone Number: 614-387-8302, E-Mail Address: Betsy.Suver@jfs.ohio.gov

Corrective Action Plan: Alerts - The Ohio Department of Administrative Services (DAS) in coordination with the Ohio Department of Medicaid (ODM), the Ohio Department Job and Family Services (ODJFS), and our vendor partners will continue to work to address system design weaknesses by identifying and prioritizing system changes and updates that impact eligibility determinations and benefit amounts as well as alert volume and processing improvements. Weekly problem review meetings will continue to be held to identify reported system issues and track any needed updates through the normal prioritization and slotting process. These changes will be delivered according to the agreed upon release cadence based on business priority and impact. Upon delivery of such system changes, the Ohio Benefits Program Team will monitor production to determine if the desired outcome was achieved. The Ohio Benefits Program Team continued to analyze system alerts during FY2021 and FY2022 and presented recommendations to the vendor partners for overall system alert improvements; these recommendations were prioritized, and strategic modifications were implemented in our normal release cadence through calendar year 2022, with the most recent release occurring in February 2022. Comprehensive alert reduction efforts thus far have reduced by approximately 29 million the overall number of backlog alerts and have resulted in approximately 22 million fewer new alert generations. The next alert-centered release, R4.6.1, is scheduled for April 2023. This release, specific to IRS IEVS enhancements will streamline the work for County Caseworkers to process IRS IEVS matches from the IRS Unearned Income interface. There will be both E-Verify enhancements and a change in the match logic which will result in a reduction in the volume of IRS records that are flagged as IRS IEVS matches. County Caseworker time spent processing IRS IEVS matches is expected to reduce; remaining time spent on IRS IEVS matches is expected to have more value by allowing County Caseworkers to focus time on matches with an eligibility impact or potential for benefit recovery. Interagency Agreements - An Interagency Agreement is entered into by the Ohio Department of Job and Family Services (ODJFS) and the Ohio Department of Administrative Services (DAS). A second Interagency Agreement is entered into by the Ohio Department of Medicaid (ODM) and the Ohio Department of Administrative Services (DAS). Each of these Agreements are entered into for the purpose of setting forth the roles and responsibilities, budget methodology and payment terms, data sharing restrictions, security protocols, and compliance requirements for the Ohio Benefits Program. DAS, ODM, and ODJFS have completed extensive policy, program, and legal reviews and the final Agreement is in circulation to secure DAS, ODM, and ODJFS Director?s signatures. Data Governance - A well-designed, mature, data governance program typically includes a governance team, a steering committee that acts as the governing body, and a group of data stewards. They work together to create the standards and policies for governing data, as well as implementation and enforcement procedures that are primarily carried out by the data stewards. The Ohio Benefits Program Data Governance Team meets monthly since September 2022. The team, led by ODJFS as one of the primary data owners, is working to complete its initial objectives which include: ? Address and Remediate Concerns about Reporting Cleanliness. o Develop an improved process for report intake, development, and delivery. ? Enhance Automatic Reporting and Monitoring. o Develop oversight reports to examine key areas of the business that are used to monitor for compliance. ? Evaluate EDMS? Audit Accessibility. o Understand the audit process and make recommendations on how to organize and display data to assist with future audits. ? Address Additional Priorities as determined by the data governance committee (in conjunction with the steering committee and other stakeholders). o The team will continue to establish key objectives to monitor and improve. DAS follows DAS Policy 2100-04 for Data Classification. The Ohio Benefits Program systems store data in a consistent manner, with shared data understanding for making program eligibility determinations based on quality data. As a collector and processor of the data, DAS acts as a DATA STEWARD for the agency DATA OWNERS. Per state data classification policy (2100-04, point 5.4), "? a data owner is responsible for establishing data use guidelines. An information owner shall not be a data or system administrator, but rather the head of a business or program area?? DAS customers are responsible for classifying their data and for informing DAS as to its levels of confidentiality and criticality." Since the DAS Ohio Benefits Program team has not been given data ownership and data classification information, the DAS Ohio Benefits Program team treats all data as "Confidential Personal Information". Some data may be further classified as Federal Tax Information (FTI) or Health Insurance Portability and Accountability Act (HIPAA) information, with the corresponding data access restrictions, monitoring and reporting requirements. As a Data Steward, the DAS Ohio Benefits Program team is responsible for carrying out data usage and security policies and meeting state and federal regulations for data contained on the Ohio Benefits Program systems and storage. Anticipated Completion Date for Corrective Action: ? Alerts ? April 2023 ? Interagency Agreements ? Completed ? Data Governance - Completed Contact Person Responsible for Corrective Action: Kristina Hagberg, Deputy State Chief Information Officer, Ohio Department of Administrative Services 30 East Broad Street, Columbus, Ohio 43215 Phone: 614-644-9245, E-mail Address: Kristina.Hagberg@das.ohio.gov

FINDING 2022-003 Contact Person Responsible for Corrective Action: Janet McCreary, Director of Curriculum, Instruction, & Assessments Contact Phone Number: 812-274-8001 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Data Management Specialist will save all reports submitted to the DOE. This will ensure that supporting documentation is kept that will be used determine Eligibility for Title I. The Title I Compliance Specialist/Grants & Compliance Specialist will verify the information for accuracy and keep documentation of the review. Anticipated Completion Date: 2/13/2023

Community Housing Services ? Ashley Valley Shadows, Inc. Corrective Action Plan December 31, 2022 2022-001 Finding Phil Carroll, President of Community Housing Services, has implemented steps to correct the issue. The onsite manager has been replaced. The Organization will review tenant file procedures to ensure that required documentation is obtained and maintained in accordance with HUD regulations. The anticipated completion date is December 31, 2023.

Finding Ref. No. 2022-002 Finding: The Uniform Guidance, 2 CFR 200.303, requires non-Federal entities receiving Federal Awards (i.e., auditee management) to establish and maintain effective internal controls over the Federal Award that provide reasonable assurance that the non-Federal entity is managing the Federal Award in compliance with Federal statutes, regulations, and terms and conditions of the Federal Award. 20 CFR 604.3(a) requires a State to only pay an individual who is able to work and available for work for the week which Unemployment Compensation (UC) is claimed. Based on work performed on unemployment compensation payments at the Alabama Department of Labor, for the period of October 1, 2021, through September 30, 2022, we identified 243 payments, totaling $58,809.00, which were made to 22 deceased claimants. We also identified an additional 186 payments, totaling $42,276.00, which were made to 27 incarcerated claimants. The combined improper payments to deceased or incarcerated claimants total $101,085.00 for the Unemployment Insurance Program. The Alabama Department of Labor did not have internal controls in place which were adequately designed to identify deceased or incarcerated claimants in a timely manner, in order to help prevent and/or detect improper payments. The lack of a well-designed system of internal controls, to identify deceased or incarcerated claimants, could cause the Alabama Department of Labor to continue to pay benefits to claimants who are deceased or incarcerated. Recommendation: The Alabama Department of Labor should establish and maintain effective internal controls to help ensure payments are not made to deceased or incarcerated claimants. Response/Views: We agree with the finding. Corrective Action Planned: ADOL now utilizes IDV through the Integrity Data Hub (IDH) for death crossmatch, giving ADOL the capability to crossmatch all claimants through the IDV. However, the review process is manual at this time. ADOL continues to pursue a fully automated process with the system vendor. ADOL is also working with the Interstate Connection Network (ICON) through the National Association of State Workforce Agencies (NASWA) to implement a match of SSN?s with the Social Security Administration?s Prisoner Update Processing System (PUPS). This will allow records to be checked in a nationwide database not just the State of Alabama. Reason for the Recurrence: The cause of this was due to the workload of pandemic claims and the lack of requirements to provide proof of income and employment. Prior to the pandemic a person had to have wages in order to qualify for benefits, eliminating a deceased person of more than 2 years from being monetarily eligible for benefits. Any remaining claimants that had died would be reported by the employer or through returned mail or a surviving of family member. Any notice of deceased person would be reviewed. With no way to verify whether a person was deceased or not, some did pay benefits. Anticipated Completion Date: ADOL implemented checking claims through IDH June 2022. Netacent, the vendor who maintains ADOL?s unemployment system, anticipates the PUPs project to be fully functioning by December 31,2023. Contact Person(s): Brent Langley, Assistant Unemployment Administrator

2022-004 Title I Grants to Educational Agencies Recommendation: School Corporation management should implement procedures and controls to ensure the required Title I templates are used and properly reviewed and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation will review the homelessness provisions of Title I and ensure documentation is retained to support the allocation. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

Eligibility, Nonmaterial Noncompliance, Significant Deficiency Per Title 24 of the Code of Federal Regulations parts 880 through 883, only eligible individuals should participate and the program and there should be evidence of eligibility determinations. The Authority has established a move-in and re-examination checklist to be used during the eligibility determination process to ensure that all required documents are maintained in the tenant?s file. Of the forty (40) tenants selected for testing, we noted the following: Seventeen (17) tenants were missing the re-examination checklist. Three (3) tenants were missing documentation that they were selected from the waiting list. Two (2) tenants were missing documentation of inspections and tenant certifications. The Authority has had a significant amount of turnover in their staffing who complete eligibility determinations, and the staff who were completing the eligibility determinations did not properly include the completed checklists in the file to evidence their review that all required documents were included in the file. The Authority did not have documentation of compliance with the eligibility requirement for one (1) tenant for the year ended June 30, 2022. Response: Within the next thirty days the Housing Program Compliance Analyst will complete a random audit at each complex of new admissions to confirm all HUD required forms have been completed, and will review random files to confirm the re-examination checklists have been completed. A report will be provided to the Director of Housing once the analyst has completed the review. Target Date: April 2023 Responsible Party: Director of Housing

Eligibility, Nonmaterial Noncompliance, Significant Deficiency Per Title 24 of the Code of Federal Regulations parts 5, 902, 960, 966, and 990, only eligible individuals should participate and the program and there should be evidence of eligibility determinations. The Authority has established an application and re-examination checklist to be used during the eligibility determination process to ensure that all required documents are maintained in the tenant?s file. Of the forty (40) tenants selected for testing, we noted the following: One (1) tenant where the Authority was unable to locate the tenant file to document their eligibility to participate in the program. Twelve (12) tenants were missing the re-examination checklist. Five (5) tenants were missing documentation that their income was accurately calculated and verified. For the one tenant whose file was unable to be located moved out of the program during fiscal year 2022, the Authority believes the file was moved to storage but was unable to locate it. For the missing checklists and other documentation, the Authority has had a significant amount of turnover in their staffing who complete eligibility determinations, and the staff who were completing the eligibility determinations did not properly include the completed checklists and other supporting documentation of eligibility in the file to evidence their review that all required documents were included in the file. Response: The Authority will have the Housing Program Compliance Analyst audit a sample of tenant files based on the latest re-examinations to ensure that the calculated income agrees with the supporting documentation, the checklist is completed in its entirety and is maintained in the tenant files. Target Date: April 2023 Responsible Party: Director of Housing

The Program Coordinator will complete the Volunteer File Master Checklist for each new volunteer including the income verification and background checks as well as other required steps. The Program Coordinator will sign and date the form. The Program Supervisor will review the checklist for completeness and sign and date the form. The completed form will be filed in the volunteer?s file. This practice is being implemented currently.

Finding: 2022-003 Name of contact person: Amy Seay - Director of Social Services Corrective Action: The Department will continue to provide more in-depth training to ensure cases requiring IV-D Cooperation are meeting policy guidelines. Proposed Completion Date: As soon as possible

Identifying Number: 2022-005 - USDOE Student Financial Assistance Cluster - Special Tests and Provisions: Students' Satisfactory Academic Progress Ineligibility Finding: The College disbursed funds within 30 days of the first day of class for 12 first year students out of 40 students tested. Name of Contact Person: Karen Overton, Director of Financial AidCorrective Action Plan: The College will create, follow, maintain, and monitor an appropriate satisfactory academic progress (SAP) policy that meets USDOE requirements. The USDOE requires all institutions to sustain an SAP policy that requires students to maintain a 2.0 GPA and successfully complete 67% of their educational program in order to be eligible for financial aid. Anticipated Completion Date: Beginning August 2022

Corrective Action Plan Section III. Findings and Questioned Costs for Federal Awards Material Weakness in Internal Control Over Compliance ? Medicaid Cluster Finding 2022-001 and 2022-002 "See Corrective Action Plan for Chart/Table"

Finding 2022-001 ? Moving to Work Tenant Files ? Eligibility ? Annual Recertifications ? Noncompliance & Significant Deficiency ? CFDA #14.881 Corrective Action Plan: The Auburn Housing Authority (AHA) has implemented and/or will implement the following by FYE 2023: a. PBV case management is now administered in-house b. HCV has developed an action plan to ensure that all PBV files are HUD-compliant c. PBV calendar-year 2022 (January 2022-December 2022) re-exams are substantially complete. All files will be HUD-compliance by FYE2023. d. During FYE2023, the HCV Manager will perform quality controls by randomly selecting departmental files. e. Other internal control measures will be implemented to eliminate future audit findings. Person Responsible: Sharon Tolbert, CEO Anticipated Completion Date: June 30, 2023

U.S. DEPARTMENT OF TREASURY 2022-002 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: The Health Board should ensure that program managers are aware of the significant compliance requirements of an award and implement a system of internal control that supports compliance and documentation of compliance. Explanation of disagreement with audit finding: We respectfully disagree with the characterization of the finding as a material weakness in internal control. The sample size of 28 selections called for 3 specific source documents to be provided in association with each sample. Thus, 10 out of a total of 84 source documents requested were not immediately available. The eligibility forms in question are part of the process which initiates the determination of the validity of the request for assistance. Due to the sensitive nature of this program, these documents are not readily available electronically (in order to protect the privacy of the recipients). The Health Board?s Community Services Team, which includes Rapid Rehousing, Gender-Based Violence, and Emergency Housing, experienced significant turnover due to the pandemic. We have informed the auditor about the turnover challenges faced by this specific department and the difficulties in securing physical documentation. Action taken in response to finding: In September 2022, the Community Service Team began reporting to the Health Board?s Behavioral Health Officer. Under her direction, processes have been updated and documented along with the creation of a stronger review process. The health board remains committed to further strengthening our controls and processes where necessary. We will ensure that program managers are aware of the compliance requirements associated with the award and implement a robust system of internal control that supports compliance and proper documentation. Name(s) of the contact person(s) responsible for corrective action: Linda Zhang, CFO Planned completion date for corrective action plan: September 30, 2023 If the U.S. Department of Treasury has questions regarding this plan, please call Linda Zhang, CFO at (206) 324-9360.

Item 2022-002 ? Eligibility Contact person: Chellye Stump, Dean of Administrative Services Finding ? During a dual purpose tests of controls and compliance there were 3 participants who were identified that did not certify to the fact that they were a citizen, national, or permanent resident of the United States, a requirement for eligibility of the TRIO program. Management Response ? The College will implement additional controls to ensure there is evidence of review of certifying statement from participant prior to services being rendered. TRIO Services Director will be responsible for the corrective action and anticipates completion of corrective action will be taken before 9/30/23. Effective date of completion: within the fiscal ending September 30, 2023

The Organization agrees with the recommendation. An internal review is currently in process to review and update policies as needed to address the use of federal funds.

2022-057 Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2105OR5MAP, 2021; 2105OR5ADM, 2021; 2205OR5MAP, 2022; 2205OR5ADM, 2022 Compliance Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency Prior Year Finding: 2021-020 Questioned Costs: N/A Criteria: 42 CFR 455.436; 42 CFR 455.102 to 455.107; 42 CFR 455.414 Provider eligibility requirements for the Medicaid program differ depending upon the type of services provided; however, all providers are subject to specified database checks and are required to sign an adherence to federal regulations agreement (agreement). Typically, the agreement includes disclosures specifically required by federal regulations. Additionally, the federal regulations require that the Oregon Health Authority (authority) and Department of Human Services (department) determine eligibility for Medicaid providers and revalidate providers at least every five years by performing database checks to ensure providers are still eligible to participate in the Medicaid program. We selected a random sample of 62 providers in the Medicaid program with 32 providers enrolled by the authority and 30 enrolled by the department. For 4 providers we found the issues described below. I-9 form for 1 department provider could not be located. This provider is not currently a provider with the State and an updated I-9 will not be obtained. Based on our review of other available support we were able to determine this to be an eligible provider during the fiscal year. I-9 form for 1 department provider could not be located. The department has since obtained a completed I-9 form. I-9 forms for 2 department providers did not include a review of minimum acceptable documents to verify identity and employment authorization. The department is actively working to obtain missing documentation and based on our review of other available support we were able to determine these to be eligible providers during the fiscal year. The above issues occurred due to human error and inadequate record maintenance which could lead to ineligible providers receiving Medicaid funding. We recommend department management strengthen controls to ensure documentation supporting a provider?s eligibility determination and revalidation is complete. MANAGEMENT RESPONSE: We agree with this recommendation. ODDS Response: The department is committed to having completed I-9 forms on file for all Personal Support Workers through our Fiscal Intermediary. The Provider Enrollment Unit now has a quality assurance staff who will conduct spot checks of the FI work. This is in process now and reviews will continue. APD Response: The department is committed to having completed I-9 forms on file for all employees and homecare workers. This expectation, as it relates to homecare workers, was reinforced by the department at the Client Employment Program Annual Summit held on 3/28/23 and 3/29/23. This Summit was attended by approximately 160 local office staff. Local office staff were instructed on how to properly fill out the I-9 form and retention requirements. Staff were also reminded of resources available to answer questions, including central office points of contact. The department is also exploring short- and long-term solutions to mitigate this risk, including creating a peer review process on business procedures across the state intended to assist in not only accuracy, but knowledge transfer, developmental growth and mentoring opportunities. The department may also explore system changes that would automatically validate the completion of tasks related to provider enrollment and renewals, including the presence of required documentation. Anticipated Completion Date: June 1, 2023 Contact: Vanessa Richkind, ODDS Provider Administration Manager or Diana Nott, APD Provider Relations Unit Manager

2022-058 Department of Human Services Perform timely reconciliations of refinanced OR-Kids transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.667 Social Services Block Grant Federal Award Numbers and Years: 2101ORSOSR, 2021; 2201ORSOSR, 2022 Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: $1,308,457 (likely) Criteria: 42 USC 1397a(c); 45 CFR 75.386a(2); 45 CFR 96.30b(2) According to federal requirements, to be eligible for federal funding, expenditures must be expended in the fiscal year allotted or in the succeeding fiscal year (period of performance). Additionally, federal post-closeout requirements stipulate the return of any funds due because of later refunds, corrections, or other transactions. As part of the grant closeout process, block grants also require the grantees to report the total funds expended and the date of the last expenditure. Grant closeout is the process by which the federal awarding agency determines that all applicable administrative actions and all required work have been completed. Social Services Block Grant (SSBG) has expenditures originating from the child welfare system, OR-Kids. OR-Kids is used to manage placements, eligibility, payments, and other case information. When various corrections are initiated, OR-Kids can re-process transactions as far back as January 1, 2008. For some placement corrections, OR-Kids processed the recovery of the funds in a state grant (Miscellaneous Other Fund grant), instead of the federal grant. To date, the department has not completed permanent fixes to the OR-Kids system to prevent these re-processing errors from occurring. During fiscal year 2022, the department was reconciling the Miscellaneous Other Fund grant and identified refunds related to SSBG. The refinanced expenditures reduced the amount of SSBG expenditures originally reported in closed grant awards. Instead of submitting a refund, the department identified expenditures recorded in subsequent grants that could have been used to backfill the reduction of expenditures. Allowable expenditures, that met the period of performance, were subsequently moved. To illustrate, a total of $1.3 million of expenditures were moved in the accounting system from grant award 21 (federal fiscal year 2021) to grant award 20. The department then moved expenditures totaling $1.2 million from grant award 20 to grant award 19. This process continued for all grant awards going back to grant award 11 (federal fiscal year 2011). The table below illustrates the movement of expenditures between grant awards. ?See Corrective Action Plan for Table? Although the department only moved expenditures that qualified for each respective period of performance, we question whether the federal awarding agency would allow the department to backfill the $1.3 million of expenditures in question after grant closeout had been completed. We recommend department management conduct more timely reconciliations of OR-Kids refinancing adjustments to ensure adjustments are made during the related periods of performance. We further recommend management work with its federal awarding agency to determine if it is appropriate to backfill program expenditures between grants to account for the reduction in expenditures created by the reconciliation process. If not appropriate, the questioned costs should be repaid to the federal awarding agency. MANAGEMENT RESPONSE: The agency disagrees with this finding. SFMA grant phase is an internal tracking mechanism only and is not mandated by ACF. None of the expenditures observed were moved into or out of the period of performance for which they originally qualified for. SSBG awards have a two-year period of performance for claiming. As a result, there is an overlap between internal phases where expenditures qualify for two at any given time. Assignment of phase in SFMA is based on internal balancing needs to ensure claiming is not over or under the award for that period. Prior period adjustments occur periodically and are debited or credited to the phase they were originally recorded under. Should those adjustments cause a phase to become under or over reported, the assigned phase in SFMA is adjusted to maintain consistency between SFMA expenditures and the SF-425 report provided to ACF. If a prior period increasing expenditure is outside the period of performance, it is moved to non-reportable and state only funding. Anticipated Completion Date: N/A Contact: Fariborz Pakseresht, Oregon Department of Human Services Director

2022-040 Department of Human Services Improve controls to ensure eligibility criteria are met Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $9,569 (known); $931,750 (likely) Criteria: 45 CFR 264.1; Oregon TANF State Plan The State of Oregon Temporary Assistance for Needy Families (TANF) State Plan (Plan) defines financial neediness criteria with its adjusted income limit tables. Federal regulations establish 60 cumulative months as the length of time a client may receive federal TANF assistance. The department uses its case management system, Oregon Eligibility (ONE), to count federal-eligible benefit months, and when 60 months is reached, an indicator is sent to the financial subsystem to change federal funding to state funding. From a population of 105,267 TANF benefit payments recorded in ONE, we randomly selected a sample of 40 and two additional individually significant payments for testing. We found: One sample?s financial eligibility information included a disaster relief benefit without details showing the date of payment and the covered time period. As a result, auditors and the department are unable to determine if this case met financial eligibility criteria, resulting in questioned costs of $1,311. One individually significant case?s child support and spousal support were entered incorrectly into ONE. The countable income at time of certification did not meet the adjusted income limit, making the client ineligible for TANF benefits. Questioned costs for this case total $8,258. We recommend department management ensure federally-funded client benefits are paid on behalf of eligible individuals, and documentation is retained to support eligibility decisions. We also recommend department management correct the identified error cases and reimburse the federal agency for questioned costs. MANAGEMENT RESPONSE: We agree with this recommendation. The Department will communicate to eligibility staff the importance of reviewing information reported by the applicant compared to information received from a third-party and direct staff to case note in the ONE system how the discrepancy was reconciled. The Department will also communicate the requirement to maintain eligibility records in both case notes and electronic file when applicable. The Department will review the cases cited and make an appropriate referral to the Overpayment Recovery Unit. Overpayments recouped can then be adjusted by Office of Financial Services to credit the TANF federal grant rather than reimbursing, per instructions outlined in TANF-ACF-PI-2006-03. Anticipated Completion Date: October 31, 2023 Contact: Annette Palmer, TANF Program Manager