Corrective Action Plans

Finding 2022-021 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with potential duplicate records for local office staff to review. In addition, CHAMPS is currently designed to reject potential duplicate records to prevent duplicate payments for the same individuals that already exist in CHAMPS and places these records on a CHAMPS report for review. These two reports could potentially contain the same duplicate records identified by both CHAMPS and Bridges. MDHHS central office will develop a process to reconcile the rejected records identified on the CHAMPS and Bridges reports and ensure that MDHHS is appropriately reviewing those records and making any necessary corrections. Anticipated Completion Date December 2023 Responsible Individual(s) Jamy Hengesbach, MDHHS Mariah Schaefer, MDHHS

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. MDHHS conducts mandated training for local office caseworkers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end of the PHE, as allowed by the Centers for Medicare and Medicaid Services. Anticipated Completion Date MDHHS continues to pursue other data sources for income verification and other system enhancements, in addition to determining where training is needed, on an ongoing basis. MDHHS expects to have all existing cases updated by June 2024. Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

Finding 2022-009 CHAMPS General Controls Management Views Although MDHHS and DTMB had not fully documented all database specific configuration standards until after the audit period, DTMB disagrees that during the audit period the system contained potentially vulnerable database configurations and disagrees that DTMB cannot ensure the security of the data. DTMB has been and continues to implement the manufacturer?s recommendations regarding security configurations. In addition, the databases reside in restricted trusted internal security zones, protected by firewalls, which are specific to each application and database, in conjunction with intrusion protection, antivirus software, and SOM standard security safeguards. Planned Corrective Action DTMB developed an organization-wide framework for database security configuration management. Anticipated Completion Date DTMB anticipates having compliance documentation by September 30, 2023. Responsible Individual(s) Nathan Buckwalter, DTMB

Finding 2022-045 CCDF Cluster, ALN 93.575 and 93.596 - Child Care Stabilization Grants Management Views MDE agrees with the finding. MDE?s written procedures for the fall 2021 grant round required manual verification of the number of subsidy eligible children, increasing the risk for human error in documenting the appropriate number of subsidy eligible children on the provider?s application. The exceptions noted by the auditors were found in the fall 2021 grant round before procedures were modified in the spring of 2022. Planned Corrective Action MDE revised procedures in March 2022 for the spring 2022 grant round to prepopulate applications based on the number of subsidy eligible children directly from Bridges for specified pay periods, also allowing the providers to dispute the number of subsidy eligible children included in the prepopulated application. Anticipated Completion Date Completed Responsible Individual(s) Lisa Brewer-Walraven, MDE

Finding 2022-041 Homeowner Assistance Fund, ALN 21.026 - Eligibility Determinations Management Views MSHDA agrees with the finding. Planned Corrective Action For parts a. and b., MSHDA will implement further training of both Case Managers and Case Manager Assistants to address the cited items. This will include additional training on documentation of the homeowner?s hardship and detailing calculations in the case notes. For part c., MSHDA will provide additional training to staff making sure that all fields on the checklist are answered correctly. The checklist now has a system failsafe that all fields must have an answer prior to allowing the file to be conditionally approved in the online application portal. Anticipated Completion Date Completed Responsible Individual(s) Dawn Hengesbach, MSHDA Glenn Ross, MSHDA Raul Escobedo, MSHDA Krysta Smith, MSHDA

Finding 2022-062 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency, Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2022, Corrective Action Plan, Finding 2022-001.

2022-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-001 from September 30, 2021 (Other Matter and Significant Deficiency in Internal Control over Compliance). Originally reported as finding 2019-001 from September 30, 2019 (Material Weakness in Internal Control and Material Noncompliance) Statement of Condition: Out of a total tenant population of approximately 1,114 vouchers, 25 files were selected for testing. Exceptions were noted as follows: ? 1 tenant file had the following errors: o The tenant?s annual recertification application is missing. o The tenant?s signed 9886 form is missing. o The wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting this error would cause the HAP rent to increase by $9. o The tenant?s signed HAP contract is missing. ? 1 tenant file had the following errors: o The name and social security number for one of the tenant?s dependents was reported incorrectly on the 50058 form. o The tenant?s utility allowance was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would cause the HAP rent to increase by $56. ? 1 tenant file had the following errors: o The lease agreement was not signed by the tenant. o The tenant?s assets was reported in error. Correcting this error would cause the rent to increase by $8. ? 2 tenant files where the tenants? income was miscalculated. Correcting the errors would cause the HAP rent for one of tenant files to decrease by $12 and the other to increase by $181. ? 2 tenant files where the wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting these errors would cause the HAP rent for one of the tenant files to decrease by $13 and the other to increase by $14. ? 1 tenant file where the family?s assets was reported in error. Correcting the errors had no effect on the HAP rent. ? 1 tenant file where a member of the household moved but was reported on the 50058 form. ? 1 tenant file where the tenant?s signed HAP contract is missing. ? 1 tenant file where the EIV report was never generated or was misplaced. In addition to the above, we noted the following during our new admissions testing (out of a total of 118 new admission, 18 files were selected for testing.): ? 1 tenant file where the member of the household did not checkmark the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen or permanent resident. However, the member?s birth certificate confirms that the member is a U.S. Citizen. ? 1 tenant file where the tenant?s signed 214-affidavit is missing. However, the member?s birth certificate confirms that the member is a U.S. Citizen. 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. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested will have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an Other Adult packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant?s file. The Counselor?s caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors? strength and weaknesses, and to determine if additional training and/or monitoring is needed. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor?s processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV staff will attend Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training. Effective Date: June 20, 2023 Contact Information Gwendolyn B. Dawson, CEO Ocala Housing Authority 1629 NW 4th Street Ocala, Florida 34475 (352) 369-2636

2022-003 Eligibility ? Internal Control Over Eligibility City?s Corrective Action Plan: For the cases identified, the auditors focused on a feature of the Intake System (Yardi) that allowed a reviewer to make modifications to the reported income. As part of the review process, conducted by a separate entity (El Concilio - Contractor) a number of documents (including income verification) were reviewed to ensure that the household was eligible for funding under the program. In all instances, the income was reviewed and determined to be under the eligibility threshold; however, the ?Monthly Income Correction? feature in the Intake System was utilized to make an income determination of $0. The ?Monthly Income Correction? feature being utilized does not mean that the income was not accurately verified for any of the cases. In none of the cases sampled did the households have income that was over the established income limits. Funding for this program has been fully disbursed as of December 2022. Responsible Person: Jordan Peterson (Program Admin), Raquel Chavarria (Fiscal) Expected Implementation Date: May 2023

Finding: 2022-005 Name of Contact Person: Tammy Mixon, Medicaid Supervisor Corrective Action: There were two errors related to this finding. Of the two, one of the errors was related to a case that was processed and paid in December 2021 by the State, but was for a claim with a date of service of January 2019. The eligibility decision related to this particular claim was completed in 2018 prior to our previous corrective actions. We consider the error related to this case already corrected. For the other case error training was completed FY 2020-2021, also findings were reviewed during a Medicaid meeting on September 1, 2022. Proposed Completion Date: This training has been completed during FY 2020-2021. Reinforcement of the training continued during monthly Medicaid meeting on September 1, 2022.

Finding: 2022-004 Name of Contact Person: Tammy Mixon, Medicaid Supervisor Corrective Action: "Of the nine cases found as errors during this audit, 100% of the errors were found prior to the agency having an opportunity to train based on the findings from previous fiscal year audit. The findings occurred during the timeframe prior to training from previous period findings. This has been discussed in our monthly Medicaid meeting on August 24, 2021. As a result of that meeting and discussions of the findings, a line was added to the agency's second party review form to look for errors regarding the worker's check of all electronic sources, as well as the documentation on the file of such checks. " Proposed Completion Date: This was discussed in monthly Medicaid meeting held on August 24, 2021. The second party review form was changed and implemented for use September 1, 2021.

Finding: 2022-003 Name of Contact Person: Tammy Mixon, Medicaid Supervisor Corrective Action: "Of the eleven cases found the agency consents these are repeat findings, however two of the eleven cases during this timeframe would be correct, due to changes in COVID rules as it relates to eligibility. During COVID the agency was under constant changes in policy and procedure from DHB, therefore making workers more vulnerable to oversights. The majority of the findings have been discussed in our September 2022 Monthly Medicaid Meeting. The additional findings will be discussed in the next monthly Medicaid meeting. A training will occur in the month of November, 2022 to fully insure the issues are addressed. These items will be reinforced during monthly Medicaid Staff meetings. " Proposed Completion Date: This will be discussed in next monthly Medicaid meeting in October 2022. Training will occur in November 2022 or sooner.

Finding: 2022-002 Name of Contact Person: Tammy Mixon, Medicaid Supervisor Corrective Action: "Of the eight errors found during this audit, only four were repeat findings from previous audit year. Those four findings occurred prior to the training from August 24, 2021, which was as a result of the previous year findings. Therefore, the workers had not been trained on the proper procedures at the time in which these errors occurred, as they were in the previous timeframe. Further, two of the four cases mentioned were correct later in the file due to COVID 19 waivers, but the audit did not cover the timeframe in which the corrections were found. Of the four findings that were not repeat, the agency has obtained training materials from the Operation Support Team for the State of NC for training to correct. The agency rebuts that this is a repeat finding. as the findings occurred during the timeframe prior to training from previous period findings. Further, only half of the findings were the same as the previous period. The agency denies this is a Significant Deficiency, as there were eight findings out of sixty cases pulled, and half of those findings fell within a timeframe prior to training to correct the issue. These findings were discussed in the monthly Medicaid meeting September 2022. OST training materials have been obtained and will be used for training to prevent future errors. Second party review form was also updated to capture in-kind income for prevention of future errors. " Proposed Completion Date: The training occurred on August 30, 2022 and September 7, 2022. Second party review form was made available for use October 1, 2022.

Finding 2022-001 Federal Agency Name: U.S. Department of State Program Name: Refugee Admissions - Reception and Placement CFDA # 19.510 Finding Summary: In connection with the audit procedures performed over the Refugee Admission - Reception and Placement program, we noted instances when indirect cost calculations included an insignificant amount of ineligible costs. Responsible Individuals: Rose Olivas, Contract Compliance Director and Dawn Miera, Finance Director Corrective Action Plan: Contract Compliance and Finance will meet every time we receive a new type of grant. The two teams will go over allowable costs and which costs are allowed to be applied to the de minimis rate. All applicable spreadsheets will be updated separately for each new contract and training for billing preparers and reviewers will be ongoing. Anticipated Completion Date: Ongoing

2022-003: Supporting Documentation Recommendation: We recommend the organization design controls to ensure an adequate review process is in place to review costs charged to grants are properly supported by documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will better enforce a policy that expenses must be sufficiently supported by documentation before payment is made. Name(s) of the contact person(s) responsible for corrective action: Joseph Ferlo, President & CEO Planned completion date for corrective action plan: June 30, 2023

Compliance requirement - Special tests and provisions ? Enrollment Reporting Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding in that there was one (1) case where the information of enrollment of this student was not available for examination. After multiples student search, the institution was unable to locate through the NSLDS the reported status update for said student. (b) The institution also agrees with the auditor in that there were (6) six cases where he noted that institution failed to report the student's status before the thirty (30) day deadline for the NSLDS web reporting. (c) The institution also agrees with the auditor in that there was one (1) instance where the institution submitted one (1) of its's enrollment report updates after the 15 days required timeline. Actions Taken or Planned: The institution would continue to submit its Enrollment Reports monthly in order to notify changes of student status to the Department of Education on a timely basis and to maintain the information of student's enrollment status more effectively.

Compliance requirement ? Special test and provisions - Return of Title IV Funds Institutional Comments on Findings and Recommendations: I. Compliance Requirements ? Applicable After a Student Begins Attendance: a. The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the students withdrew within 14 days after the student's last day of attendance. II. Compliance Requirements ? Applicable for a student who does not begin attendance: b. The Institution agrees with the auditors on this finding in which there was one (1) case were the student did not comply with the Incomplete course requirement and an unofficial withdrawal was not performed. Before the audit process was completed, the institution performed a R2T4 calculation and returned to the US Department of Education, the $439.00 associated with this finding. This process was evidenced to the auditors for their records. c. The Institution agrees with the auditors on this finding in which there was one (1) case were the student had stopped attending the enrolled courses without completing at least 60% of the payment period. Before the audit process was completed, the institution had returned to the US Department of Education, the $581.00 associated with this finding. This process was evidenced to the auditors for their records. d. The institution agrees with the auditors that in the cases mentioned in item b and c in that it failed to determine that the students withdrew within 14 days after the student's last day of attendance. e. The institution agrees with the auditors that in the cases mentioned in item b and c in that it failed to return Title IV funds after the 45 days' time frame. Actions Taken or Planned: The institution is aware of the importance to comply with Return of Title IV funds (R2T4) reporting requirements and deadlines. Also, the relation to students last day of attendance (date of withdrawal) vs date of school's determination that the students withdrew and the date of the return of any Title IV funds resulting from an R2T4 calculation. The issues as related to these findings were identified as ones being an oversight and lack in compliance with some of the academic processes as required by R2T4 and has already been discussed with the Academic Dean of the institution who in turn has revisited these matters with Faculty and administrative staff under her supervision including the Registrar. The already instituted task force that meets every Friday of each week to identify and review cases that could affect the R2T4 procedure and requirement has continued to review and evaluate information received from the faculty through the Academic Dean and from information the Registrar's office receives of students that are not attending classes in order to process all applicable withdrawals to assure that the return of Title IV funds procedures and the return of funds if any, are processed timely within the 14 days requirement of the student's last day of attendance and within the 45 days from the date that the institution determined that the student withdrew. Before the audit process was completed, the institution had returned to the US Department of Education, the $439.00 and $581.00 associated with this finding. This process was evidenced to the auditors for their records.

Compliance requirement ? Other ? Policies and Procedures requirements. Institutional Comments on Findings and Recommendations: 1 The institution agrees with the auditors on this finding in which the current University Catalog containing the updated general disclosures for enrolled or prospective students were not updated on time for the fiscal year. 2 The institution agrees with the auditors on this finding in which the Drug and Alcohol Abuse Prevention Program did not fully comply with the distribution requirement in writing for each student. It also agrees that the institution did not perform a recent biennial review of its Drug and Alcohol Abuse Prevention Program. Actions Taken or Planned: The institution has already updated, published, and distributed its Catalog to accurately represent the vision and goals, our academic offerings and administrative policies and procedures of our operation. As related to the institutions Drug and Alcohol Abuse Prevention Program, the same was also updated, revised, published, and distributed to all active students and staff. The updated Drug and Alcohol Abuse Prevention Program is also available for distribution for all prospective students and any potential employees through the Admissions and Human Resources offices respectively. The same would also be posted on the Web page of the institution. Evidence of both issues were submitted to the auditors.

2022?001 Direct Loan Awarding Federal Direct Student Loans ? Assistance Listing No. 84.268 Auditors? Recommendation: We recommend that the University ensures they have appropriate policies and procedures, as well as safeguards in place to ensure loan eligibility is correctly determined. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Point has completed the following: 1. Extensive training delivered by external vendor, Enrollment Fuel, in October 2022 focusing on financial aid awarding and cost of attendance. 2. Point University has contracted with Financial Aid Services, Inc. (FAS), whose services begin in April 2023. As an approved third-party financial servicing vendor, FAS will conduct student packaging and review to determine appropriate loan amounts are awarded for all degree-seeking students. 3. The institution will be is changing from BBAY to SAY packaging beginning in Fall 2023 for all students. Uniform packaging procedures for all students which will improve accuracy. 4. The institution is transitioning student information system to Ellucian Colleague, which is being configured for more automated packaging, which will reduce manual errors. Name(s) of the contact person(s) responsible for corrective action: Rusty Hassell, Chief Enrollment Officer; Rachal Wortham, Director of Financial Aid Quality and Compliance; Holly Hardnett, Director of Financial Aid Planned completion date for corrective action plan: 1. October 2022 ? training complete 2. April 2023 ? FAS implementation complete 3. August 2023 4. August 2023

Finding 2022-014 U.S. Department of Health and Human Services AL No. 93.568 Total Low-Income Home Energy Assistance Significant Deficiency over Eligibility Repeat Finding: No Auditee?s Corrective Action Plan: The Office of Home and Energy Programs (OHEP) bureau of The Mayors Office of Children and Family Success (MOCFS) agency has implemented a plan to locate needed files from previous and current fiscal years. The agency has implemented a scanning and uploading Standard Operating Procedure (SOP) that requires each case file to be digitally attached to its application and supporting documents. This will remedy this finding in its totality. Contact Person: OHEP Director ? Rigel Moore Completion Date: March 10, 2023

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: The Authority should review their policies to ensure all required documentation is maintained for all individuals who are on the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: NOHA has reviewed its policies regarding documentation maintenance for all individuals on the waiting list. Quality control review of waiting list data entry was put in place after October 2020. The oldest application on the current waiting list is dated 2018. NOHA anticipates this finding will continue until the waiting list application dates reach 10/2020. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 3/31/2023

2022-001 Housing Voucher Cluster ? Assistance Listing No. 14.871 Recommendation: The Authority should review their processes for eligibility determination and documentation to ensure all information is properly documented and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Northwest Oregon Housing Authority has reviewed eligibility determination and documentation processes. Staff have received training regarding proper documentation. NOHA has conducted quality control file reviews on approximately 10% of transactions between July 1, 2022, to January 31, 2023, to review and ensure file quality. QC reviews will continue on an ongoing basis. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 1/31/2023

Finding 2022-008 U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Significant Deficiency and Internal Control Deficiency over Eligibility Repeat Finding: No Auditee?s Corrective Action Plan: MOHS does have a written process in place for review of participant eligibility. The Housing Coordinator performs quality assurance reviews of participant eligibility and verifies documentation is maintained in the records. During the review period, the Housing Coordinator position was vacant. MOHS has started the process to fill the position. MOHS anticipates the Housing Coordinator position will be filled by Summer 2023. Contact Person: Compliance Supervisor ? Donata Patrick Completion Date: July 2023

Finding 2022-036 Crime Victim Assistance, ALN 16.575 - Subrecipient Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS Division of Victim Services (DVS) has distributed a comprehensive checklist to all Victims of Crime Act (VOCA) grant applicants that will require certification of eligibility for funding by the applicant and DVS prior to awarding funds. This checklist has been incorporated into the rollover application for fiscal year 2024. Anticipated Completion Date The checklist will be certified by all grant applicants and DVS by October 1, 2023, for the fiscal year 2024 award period. Responsible Individual(s) Twanisha Glass, MDHHS Patsy Baker, MDHHS

Finding 2022-031 Pandemic EBT Food Benefits, ALN 10.542 - Overpayment of Benefits Management Views MDHHS agrees with the finding. Planned Corrective Action During the school year, the two students in the identified case were enrolled in GSRP and issued benefits on January 28, 2022, based on the school file. These students enrolled in early childhood before the end of the school year, so they were also identified in the childcare group and were subsequently issued duplicate benefits as part of the Summer Pandemic EBT issuance on August 24, 2022. A technical solution is currently being evaluated to identify additional steps that may be implemented that cross references students across eligibility groups to ensure that duplicate payments are not issued. Anticipated Completion Date MDHHS expects to determine additional steps for a technical solution by September 30, 2023. Responsible Individual(s) Kathy Cornell, MDHHS

Finding 2022-028 SNAP Cluster, ALN 10.551 and 10.561 - EBT Reconciliations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working with the vendor and DTMB data warehouse technical staff to update and correct the Benefit Issuer Food Stamp Report (BT-90) so that it includes recipients who received Supplemental Nutrition Assistance Program (SNAP) benefits under the expanded COVID-19 eligibility requirements. The BT-90 is used to help ensure the client information in Bridges is accurate and does not have an impact on the federal draw. Anticipated Completion Date December 31, 2023 Responsible Individual(s) Sara Gross, MDHHS