Corrective Action Plans

2022-039 Department of Human Services Improve documentation of required income and benefit verifications 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: Special Tests and Provisions Type of Finding: Material Weakness Prior Year Finding: 2021-011 Questioned Costs: N/A Criteria: 45 CFR 205.55 Federal regulations require each state to participate in the Income Eligibility and Verification System (IEVS), which for Oregon, includes using income and benefit screens accessible through Oregon Employment Department, Internal Revenue Service, and Social Security Administration, when making Temporary Assistance for Needy Families (TANF) eligibility determinations. The department?s current procedure instructs caseworkers to narrate ?IEVS checked? in the case management system, Oregon Eligibility (ONE), after reviewing all appropriate IEVS screens at the time of eligibility determination. The department submitted change requests to the eligibility system?s service provider that would prohibit ONE from paying benefits until all IEVS screens are checked; however, the system change has not yet been completed. 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 in 16 cases, there was no narration of the IEVS check by caseworkers, in either ONE or the former narrative system. We verified these clients did meet the TANF eligibility criteria related to IEVS screens, however, by not providing assurance of verification of the use of IEVS screens, the department increases the risk of providing benefits to TANF ineligible applicants. We recommend department management ensure verification of income and benefits with IEVS screens is clearly documented in client case files when determining client eligibility. MANAGEMENT RESPONSE: We agree with this recommendation. The Department is implementing a new tool, Note Buddy, to assist workers with case notes when determining eligibility. Note Buddy will include a field that allows staff to select whether IEVS was checked. Staff will be encouraged, not mandated, to use Note Buddy. The Department will form a small workgroup to discuss options for revising and lowering the level of effort for the Change Request (CR) previously submitted. The Department will re-submit the CR for changes to ONE. Anticipated Completion Date: September 30, 2023 Contact: Annette Palmer, TANF Program Manager

2022-037 Department of Human Services Improve accuracy of cases reported as noncooperating with child support 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: Special Tests and Provisions Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 45 CFR 264.30-31 Federal regulations require the department to refer all appropriate individuals in the family of a child to the child support enforcement agency. If the department determines referred individuals are not cooperating, without good cause, in establishing, modifying, or enforcing a support order with respect to the child, then the department must reduce or deny assistance in the Temporary Assistance for Needy Families (TANF) program. The department faces reduced State family assistance grant payments for failure to enforce penalties against noncompliant individuals. In March 2020, the department established good cause exemptions due to Covid for all individuals. Noncooperation sanctions were reinstated in April 2021, by which time the department had moved its case management system to Oregon Eligibility (ONE). When a caseworker enters a child support noncooperation code in ONE, the system should automatically reduce TANF benefits. The population of cases identified in ONE as not cooperating with child support is obtained from the quarterly performance data reports compiled by a service provider. As stated in a separate finding, titled `Ensure performance data reports are complete and accurate,? we determined the data reports are not complete or accurate, therefore, the population of cases not cooperating with child support is also incomplete. However, we tested some cases in the reports to verify ONE was appropriately reducing benefits. The quarterly performance data reports for periods October 1, 2021, through June 30, 2022, consisted of 133 unique cases identified as not cooperating with child support. We randomly selected 14 cases and could not find support in ONE for noncooperation. The department identified one case entered in ONE incorrectly by a caseworker and the remaining cases had various nuances causing the performance data reports to retrieve the information incorrectly. All 14 cases were either cooperating with or not applicable to child support. The department also identified at least eight defects in child support data retrieval it reported to the service provider. We are unable to determine if ONE is correctly reducing TANF benefits when a case is not cooperating with child support. We recommend department management ensure noncooperative child support cases from ONE are completely and accurately reported in its performance data reports. MANAGEMENT RESPONSE: We agree with this recommendation. The Department has logged defects to correct Federal reporting requirements. The ONE system approving eligibility without a cooperation record was addressed through a defect and system build which corrected the issue on May 10, 2023. The Department has logged a defect to correct historic records where referrals were not sent; currently awaiting input from Division of Child Support. The system defect fix for issues identified related to incorrect values of child support cooperation status in ACF reports is currently in the development and testing cycle. Once the fix is deployed, future submissions will have correct data for this element. The reports will be resubmitted to ACF at the end of the current fiscal year (for months October 2022 ? Sept 2023) to correct previous data. Anticipated Completion Date: December 31, 2023 Contact: Annette Palmer, TANF Program Manager

2022-036 Department of Human Services Ensure performance data reports are complete and accurate 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: Reporting Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: 2021-009, 2020-013, 2019-008 Questioned Costs: N/A Criteria: 45 CFR 265.7(a) and (b) and (f) Federal regulations require the department to collect monthly and report quarterly certain financial and non-financial data elements for services paid with Temporary Assistance for Needy Families (TANF) federal funding in the ACF-199 TANF data report. Federal regulations also require the department to report data quarterly for TANF eligible clients whose benefits are paid with designated state funds called maintenance of effort (MOE) in the ACF-209 SSP-MOE data report. Both data reports should be supported by applicable performance records. During fiscal year 2021, the department transitioned key aspects of the TANF program to Oregon Eligibility (ONE) for case management, while TANF child welfare payments continued to be recorded in OR-Kids the child welfare system. The department contracts with a service provider to extract data from ONE and OR-Kids to populate the data reports. Program staff currently work with the service provider to obtain comprehensible data reports prior to submission to review them for errors and when found, each issue is logged as a defect for the service provider to correct. The department and the U.S. Administration for Children and Families identified data reports submitted for state fiscal year 2022 were incorrect. The federal quarterly report ended September 30, 2021, was revised and resubmitted but still had likely errors according to program staff. Quarterly reports ended December 31, 2021 (Q1), March 31, 2022 (Q2), and June 30, 2022 (Q3), were corrected and resubmitted in February 2023. Data reports are comprised of individual component reports identified by ?T? for ACF-199 TANF and ?M? for ACF-209 MOE. We reviewed the resubmitted Q1, Q2, and Q3 reports and found: The Q1 TANF T2 and MOE M2 reports corrected a prior known defect. The fields identifying work participation have populated associated fields with job type and hours. The Q3 T6 report showing number of applications, number and types of families, and amount of assistance, reported $4.5 million more than supported by accounting records. The April 2022 T1 report contained 4,035 case numbers not found in the underlying system records, and 1,081 from system records not reported in the T1 report. OR-Kids cases in the Q1, Q2, and Q3 T1 24 of 45 fields left blank. In 10 of 21,171 cases recorded as having surpassed the federal funding limit of 60 months in the Q1, Q2, and Q3 T2 reports, we found three where the T2 reports did not agree to support in ONE. As the performance data reports are known to be incomplete and inaccurate, we are unable to test them for compliance with federal reporting requirements. To date, the implementation of ONE has not resolved findings related to performance data reporting, which have been ongoing since fiscal year 2010. Though the department has yet to receive a Service Organization Control (SOC) report from the service organization administering ONE and compiling data reports the department is in the process of contracting for a SOC report. Without an annual SOC report, the department does not have assurance controls are functioning as intended at the service organization for the TANF program. We recommend department management continue to review ACF-199 and ACF-209 reports prior to submission and monitor known compilation defects to ensure performance data reports submitted are complete and accurate. We also recommend department management obtain an annual SOC report over the service organization?s internal controls for the ONE application. MANAGEMENT RESPONSE: We agree with this recommendation. The Department continues to review ACF-199 and ACF-209 reports prior to submission to identify and resolve defects. The Department continues to monitor defects, sync up reports design with federal instructions, and progress towards complete and accurate reporting. The ACF 199 report issue regarding OR-Kids cases with 24 of 45 fields left blank is currently under development; mapping has been identified to rectify the missing data and once fixed, the future submissions will be corrected. The reports will be resubmitted to ACF at the end of the current fiscal year (for months October 2022 ? Sept 2023) to correct previous data. The issue regarding discrepant case counts between ACF 199 report and OR Kids data extract is under analysis. Child Welfare, TANF, and our technical team will develop a plan for rectifying and reconciling case numbers. The Department?s, Oregon Eligibility Partnership, has contracted for a SOC Type 2 audit, through contract 178884. The first audit review will be utilized to make sure all the reporting requirements and functional areas are in place. This means, the first formal audit finding, based on recommendation from the vendors, will occur in FFY25. Additional internal and external audits are happening on the system. Anticipated Completion Date: December 31, 2023 Contact: Annette Palmer, TANF Program Manager

Finding Number: 2022-002 Planned Corrective Action: The Business office has endeavored to keep pace with the shifting and changing guidance that is promulgated by the Department of Education. This has been a challenge. The Chief Financial Officer continues to monitor any guidance updates and make the appropriate changes to the reports to ensure their accuracy. There was only one report posted that contained one typographical error, but it is the University?s responsibility to ensure the accuracy of the reports and these reports will be monitored more closely going forward. Anticipated Completion Date: Continuing Responsible Contact Person: Eugene L. Munin

Action Taken The Paterson Community Health Center, Inc. is committed to its mission to provide quality and respectful health care to the greater Paterson community and beyond, especially to the uninsured and underinsured. The center had a training session in May, 2023 and discussed the one error out of twenty-five audit samples with applicable staff and discussed how to assure they understand how to implement the annual updates of the sliding fee discount schedule and to review the sliding fee discount given to eligible patients as outlined in our Fiscal Policies and Procedures. The center will continue with periodic checks of patients records to see if the training is effective and will provide training to new staff as added and continue to provide ongoing support to existing staff and make sure the annual training takes place in the month with the annual update of the sliding fee discount schedule. Person Responsible: Debora Walcott, CFO

Name of Contact Person: Ginger Loscavo, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a top priority in the program?s operation. There are currently more than 1,475 applications processed through WOFB and 40 site locations for CSFP. During the auditing process, there were 6 participants who did not sign the signature sheet to receive their box. They had a proxy sign and received the box for them that was not listed on their application as being a proxy eligible to do this. It was discovered for four of the participants that the pantry site administrator, who distributes the boxes monthly, signed for the participant because of a misunderstanding they had assuming they were automatically considered a proxy for those receiving boxes from their location. The remaining two participant?s boxes were signed for by another program participant who received her monthly box along with boxes for 2 other participants who were unable to get their box on their own because of not having transportation. The site administrator made an error allowing this person to sign for the boxes as that person was not listed as a proxy. Additional testing discovered 2 participants out of 25 were not eligible at the time of the distribution based on an invalid or expired application on file. One of the applications had the client put his annual income in the income field of the application but marked he received this monthly instead of annually. The other participant had an application that was not dated properly but was processed allowing him to receive a box. Effective January 1, 2023, WOFB will conduct a refresher course for all program sites and site administrators reviewing eligibility and program requirements for CSFP. The Program Specialist will oversee these training sessions. Any new sites that may develop throughout the year will be trained on all rules, regulations, and eligibility for the program. All new site staff and/or volunteers will be trained annually. Every six months, the Program Specialist will audit signature sheets from all site locations and make any necessary adjustments. This will be an ongoing corrective action plan throughout the existence of CSFP at WOFB. The process will be overseen by the Chief Operations Officer. In addition, all applications will be reviewed thoroughly ensuring the correct income field is marked by the applicant that coordinates with their stated income and dates will be reviewed on each application ensuring the client is eligible and using the correct annual application. The Program Specialist will review at least 10% of the applications currently on file each month. These will also be reviewed by the Chief Operations Officer to check for accuracy. Proposed Completion Date: WOFB?s fiscal year begins July 1 each year. The Program Specialist will conduct training with all program sites by October 30th of the current year. As new sites, staff and/or volunteers distribute food boxes for CSFP, training will be conducted before their first distribution. This process will be ongoing. Beginning January 1, 2023, the Program Specialist will begin reviewing 10% of CSFP applications monthly with the Chief Operations Officer doing a 2nd check and periodically spot-checking applications for the program. This will be ongoing.

The Registrar?s Office will use the date the student confirms their intent to withdraw. If that isn?t available, then the last available date of attendance will be used. The College is not an attendance taking college according to its policy and procedures and that has been revised in the academic catalog. This process was implemented February 15, 2023, and the responsible college official is Tina Wiseman, Director of Financial Aid.

The Financial Aid Office has updated its internal procedures to ensure disbursements for first-time borrowers will not occur until after the 30 day delayed requirement. To ensure this procedure, the disbursement date has been calculated for 30 days after the first day of class for first-time borrowers on the Period of Enrollments (POE). This process was implemented October 1, 2022, and the responsible college official is Tina Wiseman, Director of Financial Aid.

FINDING 2022-013 Contact Person Responsible for Corrective Action: Tricia Malone Hudson, District Curriculum Specialist Contact Phone Number: 812-279-3521 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: The district will develop a system for reviewing the Real Time report to ensure accuracy. In addition, the district will maintain a copy of the participating nonpublic school?s summary data related to enrollment and poverty status. Anticipated Completion Date: North Lawrence Community Schools will implement this procedure by June 2023.

2022-02 Federal Award Findings and Questioned Costs Person Responsible for Implementing the Corrective Action; Brian Smart, Manager of Financial Operations Anticipated Completion Date for Corrective Action; June 30, 2023 Planned Corrective Action: The ERP system that was put into place in fiscal year 2022 had an override in the payables module that the City was unaware of. After discovering this, the City has put policies and procedures into place to prevent these errors in fiscal year 2023 and beyond. Also, reporting has been developed for a more thorough review of postings to the grants. Additionally, since the end of fiscal year 2022, we have hired a group that is responsible for grants and grants compliance.

Finding #2022-002: Grant Program: Department of Health and Human Services Health Centers Cluster ? Assistance Listing #93.224/93.527 Description of Finding: Two errors were noted in the sliding fee category. In one instance, a patient was improperly billed for a sliding fee level they were not eligible for based on support provided with their application. In the second instance, no supporting eligibility application and income verification were maintained by the Clinic to support the sliding fee scale adjustment the patient received. Corrective Action: CHP will provide re-training and support to staff to implement the appropriate procedures for sliding fee verification. CHP will develop an audit tool and engage Site Management in a quarterly audit process to assure compliance with CHP?s sliding fee application policy. Senior Management will address any findings from the quarterly audits and respond with a corrective action plan. Name of Contact Person: Jessica Wilson, CFO and Tey Silva, CCOO Projected Completion Date: The first quarterly audit will be completed during the first quarter of FY 2024 (7/1/23 ? 9/30/23) and will occur quarterly thereafter.

We are in receipt of the Federal Single Audit Report from our external auditors, R.S. Abrams & Company, LLP. I am pleased to report that they found no material weaknesses in our internal controls but have included the following recommendation under Federal Awards (Finding #2022-001). The response and implementation date to the finding is discussed below. In addition, the status of the prior year's findings are provided as well. Finding #2022-001 - According to 34 CFR Section 300.203, and the OMB Compliance Supplement, IDEA Part B funds received by a school district cannot be used, except under certain limited circumstances, to reduce the level of expenditures for the education of children with disabilities made by the school district from local funds, or a combination of state and local funds, below the level of those expenditures for the preceding fiscal year. To meet this requirement, school districts must meet (I) the eligibility standard using budgeted amounts and (2) the compliance standard using prior year's expenditures. Recommendation: We recommend the District develop a system of internal control to have the maintenance of effort calculator reviewed and approved with all supporting documentation by a responsible administrator prior to submitting it to the State. We also recommend the District officials contact the State to verify procedures to file a revised MOE calculation, if considered necessary. District Response: The Business office has made the revisions to the Maintenance of Effort calculator which was resubmitted and approved. Moving forward, the Maintenance of Effort calculator will be reviewed and approved by Beth Rella, the Assistant Superintendent for Business. In addition, the District has established templates to be used for the back-up needed for the Maintenance of Effort calculator. This recommendation is considered implemented as of March 3rd, 2023.

FINDING 2022-005? Pell Award Calculation AL# and Program Expenditures: 84.063 ($279,693) Award Number: P063P227533 Federal Award Year: July 1, 2021 to June 30, 2022 Questioned Costs: $-0- Condition Found: The amount of Pell grant awarded was calculated incorrectly for one of the fourteen students who received Pell in our sample. The student was awarded Pell grant funds as if the student was enrolled ? time when the student was enrolled full-time. Corrective Action Plan: An additional $318 of Federal Pell Grant funds was awarded to the student in question in August 2022. Communication between the offices will be improved to ensure that the financial aid office is made aware of enrollment status changes timely. Anticipated Completion Date: The corrective action was completed in August 2022. Contact Person: Stephanie Dickerson, Registrar/Financial Aid 910-323-5614

Finding Number: 2022-001 Condition: For a sample of tenants selected in conjunction with eligibility testing, the Commission did not perform reexaminations within the required 12-month timeline, did not correctly calculate family income composition, and did not retain required documentation supporting eligibility determinations. Planned Corrective Action: The commission?s plan is to audit 100% of the remaining tenant files in the next 90 days. This audit will involve a combination of the commission?s more experienced employees as well as the assistance of an outside consultant. All identified findings will be reviewed, and additional training will be provided to help facilitate better compliance timeliness and accuracy Contact person responsible for corrective action: Steve Raiche Anticipated Completion Date: 01/31/2023

Major Federal Program: 09.744050 ? Legal Services Corporation ? Basic Field Grant Compliance Requirements: Allowable Activities Response: The LANWT Board of Directors reviews and adopts case and matter priorities as guidance to LANWT staff for the delivery of legal services and advocacy to eligible applicants seeking assistance. LANWT?s current protocol regarding case and matter priorities, adopted in 2022, provides that the Case & Matter Priority Policy (Policy) is given to employees several different times during their onboarding with the firm and then again each year thereafter. Employees first receive a copy of the Policy from LANWT Human Resources (HR) during New Employee Orientation (NEO). The employee signs an acknowledgement confirming they have received the Policy and they will review it. HR retains the signed acknowledgement from each employee in the employee?s personnel file. Employees train on the Policy during the Branch NEO with their manager. The managers use the Branch NEO Checklist (Checklist) during their training to identify important policies and procedures. The branch NEO training consists of reviewing the Policy with the employee, ensuring they know the location of the Policy for future reference, what defines a priority case and matter, what an emergency is and the procedure for handling an emergency. Upon completing the training, employees sign the Branch NEO Checklist acknowledging they have received and reviewed the Policy. HR places the signed Checklist in each employee?s personnel file. During Onboard Training with employees, facilitated by the Directors of Litigation, the Policy is provided, reviewed and any questions answered. Any updated Case & Matter Priority Policy is published to employees for review and use. To ensure ongoing compliance with the regulation, LANWT supervising and managing attorneys attend case staffing and supervise the acceptance of cases pursuant to the Policy. Managers submit written confirmation to LANWT?s Chief Executive Officer (CEO) that their staff have complied with the Policy on a quarterly basis. LANWT will: 1. Review and revise the acknowledgement documentation for its Case & Matter Priority Policy within 30 days; 2. Provide guidance to managers and relevant administrative staff on completion and retention of the documentation during NEO process and during any other relevant times determined by LANWT; and 3. Provide the revised acknowledgement documentation to all intake staff, advocates and those staff having authority to make case selection decisions and have them sign within 60 days. Date of Completion: July 7, 2023 Person Responsible to Ensure Completion: Maria Thomas-Jones, CEO

FINDING # 2022-002 (REPEAT FINDING OF #2021-002, 2020-003, and 2019-004) U.S. Department of Education ? Passed-through the NYS Education Department Special Education - Grants to States (IDEA, Part B); ALN 84.027; Project #0032-22-0877; Grant Period ? Fiscal Year Ended June 30, 2022 Special Education - Grants to States (IDEA Preschool); ALN 84.173; Project #0033-22-0877; Grant Period ? Fiscal Year Ended June 30, 2022 Significant Deficiency Compliance Requirement: Level of Effort Criteria: According to the OMB Compliance Supplement, IDEA Part B funds received by a school district cannot be used, except under certain limited circumstances, to reduce the level of expenditures for the education of children with disabilities made by the school district from local funds, or a combination of State and local funds, below the level of those expenditures for the preceding fiscal year. To meet this requirement, school districts must meet (1) the eligibility standard and (2) the compliance standard. Condition: The District did not maintain supporting documentation for the maintenance of effort calculator for compliance for actual amounts for the 2020/2021 fiscal year and thus, the District was unable to substantiate various amounts reported within the calculator. Cause: Due to turnover of multiple positions at the District, the District did not maintain the supporting documentation used to substantiate the amounts reported in the maintenance of effort calculator for compliance. Effect: The District did not maintain the supporting documentation used to substantiate the amounts reported in the maintenance of effort calculator for compliance. Questioned Costs: None. Recommendation: We recommend the District develop a system of internal controls to maintain support for the maintenance of effort calculator for compliance. District?s Response: Implementation Plan of Action: The District agrees with these findings; had recognized this matter prior to the start of this audit and took corrective action for maintenance of effort calculator?s. Going forward the business official will file the maintenance of effort reports which will reconcile with the ST-3. Implementation Date: March 30, 2023 Person Responsible for the Implementation: Richard Snyder, the School Business Official is responsible for the implementation of this policy and procedure.

Finding Number 2022-001: Significant deficiency in internal controls over applicability and determination of eligibility requirements. Contact Person(s): Cobie Sparks-Howard, Director of Housing Services; Calli Clevinger, Housing Program Manager Corrective Action Plan: Wellspring has a long tradition of beginning work prior to having a signed contract in hand for ongoing programs. Wellspring recognizes the urgency of its clients? needs and wishes to help. However, beginning work prior to having a signed contract for a new program meant that systems and training were completed before Wellspring knew the terms of the contract. Beginning in 2023, Wellspring will no longer begin work prior to receiving a signed contract for a new program. Second, contracts often contain provisions that impact several areas within the agency, such as systems, finance, human resources, and programs. However, prior to 2023, contracts were generally reviewed by a limited number of individuals prior to being signed and were circulated among the broader team inconsistently. As a result, there was no centralized control over whether the terms of the contract were reviewed by the responsible party or implemented appropriately. Wellspring identified this as an issue in 2021 and instituted monthly contract meetings. However, it soon became evident that we needed a central tracking system and approval process in order to ensure compliance. Wellspring is currently in the process of building a contract management system that will manage both the approval process and the compliance aspects of our contracts. We expect this system to be fully implemented by September 30, 2023. Finally, in 2022, Wellspring hired a new and experienced housing director who has established new internal controls at the program level, including quarterly internal audit review procedures. Anticipated completion date: June 30, 2023.

INTECARE, INC. CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 United States Department of Veterans Affairs InteCare, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 01, 2021 - June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Veterans Affairs 2022-001 Supportive Services for Veteran Families ? Assistance Listing No. 64.033 Recommendation: We recommend that the control process be reviewed to ensure consistency in obtaining, approving, and retaining required documentation for eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Name(s) of the contact person(s) responsible for corrective action: Eleni Clark Planned completion date for corrective action plan: January 2023 for all monthly procedures, quarterly refreshers starting at end of December 2022. If the United States Department of Veteran Affairs has questions regarding this plan, please call Eleni Clark, SSVF Program Manager at 317-504-9815.

Emphasize adherence to established policies to ensure procurement is performed according to the procurement policy, and that proper procurement documentation is maintained. We also recommend enhancement of the procurement policy to ensure the policy addresses specific requirements outlined in the Uniform Guidance.

2022-001 Sliding Fee Discount Determination Name of Contact Person: Liz McMullen, CFO Corrective Action: West Oakland Health Council will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Perform periodic audits of sliding fee transactions Proposed Completion Date: June 30, 2023

2022-003 Medical Assistance ? Assistance Listing No. 93.778 Recommendation: We recommend the County reviews its procedures to ensure all casefile reviews are documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will incorporate procedures and controls to ensure all casefile reviews are documented. Name of the contact person responsible for corrective action: Kari Ouimette (Economic Assistance Director) Planned completion date for corrective action plan: December 31, 2023.

FINDING 2022-001 ?Public Housing Tenant Files ? Eligibility ? Internal Control Over Tenant Files Non-Compliance and Significant Deficiency? SHA RESPONSE The Springfield Housing Authority acknowledges the eleven (11) errors as delineated in the full 2022 FYE audit report. In 2022, the Springfield Housing Authority Public Housing program employed three (3) Asset Managers, three (3) Occupancy Specialists and one (1) Program Integrity Specialist. Due to post COVID-19 turnover and unqualified workers in the local workforce, the SHA has experienced a higher than usual turnover rate in the positions that conduct rent calculations. The primary function of the Program Integrity Specialist position is to audit and quality control tenant files and rent calculations conducted by Occupancy Specialists. The Asset Managers are responsible for reviewing 3% of recertifications audited by the Program Integrity Specialist position as an additional quality control measure. Further, during the auditor?s closeout meeting with the SHA Management team, the auditors stated that they observed that the SHA team conducted necessary file audits and identified deficiencies, however they did not observe corrections to the identified deficiencies upon staff notification. This error rate was directly attributable to the high turnover rate of Occupancy Specialists during the 2022 fiscal year. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: ? The Program Integrity Specialist will conduct reviews of 100% of annual and interim recertifications for public housing tenants by December 31, 2023. ? The Program Integrity Specialist will ensure 100% audited file corrections are completed by the Occupancy Specialists, monthly. ? The Asset Manager(s) will review 10% of the recertifications audited by the Program Integrity Specialist as an additional quality control measure by December 31, 2023. ? The Asset Managers, Occupancy Specialists and Program Integrity Specialist will be provided with additional internal and external training opportunities in low rent public housing rent calculations and program integrity by December 31, 2023. ? The Asset Managers will re-review the files identified with errors during the independent audit and resolve the errors in accordance with the SHA Admissions and Continued Occupancy Plan and HUD rules and regulations by September 30, 2023. PERSON RESPONSIBLE Melissa Huffstedtler ANTICIPATED COMPLETION DATE December 31, 2023

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Montgomery County, operating as Council House, respectfully submits the following corrective action plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: October 1, 2021 through September 30, 2022 The findings from the September 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number in the schedule. FINDING No. 2022-001: Section 8 Housing Assistance Payments Program, CFDA 14.195 Recommendation: The Project should implement procedures to ensure all documentation related to applicants and tenants are properly executed and maintained, and that the manager verifies eligibility by obtaining all required documents for potential tenants while verifying and maintaining support for tenant income eligibility through the EIV system in a timely manner. Action Taken: Individual and group training will be conducted with managers in following the proper procedures when taking applications and moving in a new tenant. Going forward Compliance has arranged to review the move-in files for Council House to ensure all required forms are signed and dated. Alerts have been activated in One Site to remind managers when it is time to pull the initial EIV Income Report. If the audit Oversight Agency has questions regarding these plans, please call Christine Harris at 954-835-9200. Sincerely yours, Christine Harris Accounting Manager

FINDING 2022-002 Subject: Medicaid ? Eligibility, Other Matters Federal Agency: US Department of Health and Human Services Federal Program: Medicaid Assistance Listing Number: 93.778 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Findings: Material Weakness, Noncompliance Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirements that are performed by the Special Education Cooperative on behalf of the School Corporation. Context: The School Corporation participates in a Special Education Co-op. In 2015, the Co-op provided an avenue, through a third-party company, for the member school districts to obtain reimbursement for Medicaid services. It was discovered in 2021 that the annual parental disclosure statements had not been completed for Medicaid eligibility compliance. Due to this oversight, each member school had to void transactions through the third-party company and pay back the amount of these transactions for the period August 9, 2015 through April 23, 2021. The School Corporation?s amount owed was $82,291 for the period identified during 2015-2021. The School Corporation completed a Voluntary Self-Disclosure of Provider of Overpayments Packet through the Indiana Family & Social Services Administration?s Office of Medicaid Policy and Planning Office to reimburse the amounts owed. The amount related to this period July 1, 2020 through June 30, 2022 was indeterminable. The full amount was paid back prior to June 30, 2021. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation completed a Voluntary Self-Disclosure of Provider of Overpayments Packet through the Indiana Family & Social Services Administration?s Office of Medicaid Policy and Planning Office to reimburse the amounts owed. Responsible Party and Timeline for Completion: The School Corporation completed a Voluntary Self-Disclosure of Provider of Overpayments Packet through the Indiana Family & Social Services Administration?s Office of Medicaid Policy and Planning Office to reimburse the amounts owed. There were two checks issued in response to this corrective action plan. Check number 22425 in the amount of $13,642.04 on May 27, 2021, and check number 22469 in the amount of $68,648.67 on June 15, 2021. The two payments totaled $82,290.71, and fulfilled our requirement per the corrective action plan.

2022-001 Name of Contact Person: Sharon Barlow Corrective Action: Training and monitoring will place an increased emphasis on documentation. Proposed Completion Date: Training and monitoring are ongoing.