Corrective Action Plans

Finding 2022-003 Personnel Responsible For Corrective Action: Cheryl Vannoy, Deputy Superintendent, Accountability, Data & Technology Services Anticipated Completion Date: June 30, 2023 Corrective Action Plan: The Information Technology Department will revise the Technology Issue and Reclamation Plan to include two reconciliation periods, one after technology issuance in the summer/fall, and the other after technology reclamation in the spring/summer, to ensure that all contracts and documentation accounted for have the correct corresponding contract in the devices profile in the database where the documents are kept.

Finding 2022-001 ? Special Tests and Provisions ? Enrollment Reporting (Student Financial Assistance Cluster) Contact Person: Christina F. Villanueva, Registrar, Office of the Registrar Current Status: Corrected Anticipated Completion Date: October 17, 2022 Condition: For two of 40 students selected for testing, campus and program-level data did not agree between the University?s records and the information submitted to NSLDS with regards to the date of the withdrawal. The withdrawal date reported to NSLDS is obtained from the date the student?s enrollment status is changed in the ERP system. The University did not have effective procedures in place to ensure the student?s enrollment status date agreed to the date the student withdrew from courses. Corrective action: To ensure discrepancies between the actual course withdrawal date and the student?s enrollment status date are identified, the University has created an automated process that currently runs every 30 minutes. This process identifies students who are not actively enrolled but have an eligible enrolled status. It also compares the course withdrawal date to the enrollment status change date. If a discrepancy is identified, a notification is sent to the Registrar?s Office and School of Law notifying them of the need for further review and correction.

Corrective Action Plan For the year ended March 31, 2022 U.S. Department of Housing and Urban Development: The Housing Authority of the City of Paterson respectfully submits the following corrective action plan for the year ended March 31, 2022. Auditor: Novogradac and Company, LLP Certified Public Accountants 1144 Hooper Avenue Suite 203 Toms River, New Jersey 08753 The findings from the March 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Financial Statement Findings Reference 2022-001: Criteria: In accordance with N.J.S.A. 46:30B and the Uniform Unclaimed Property Act of the State of New Jersey, all property, including any income or increment derived there from, less any lawful charges, whether located in this state or another state, that is held, issued, owing in the ordinary course of a holder's business and has remained unclaimed by the owner for more than three years after it became payable or distributable is presumed abandoned, and is subject to custody of the state as unclaimed property. Additionally, HUD requires PHA?s to conform to state escheatment laws related to unclaimed tenant utility reimbursements. Condition: The Authority has unclaimed property in stale dated checks that meet that State?s definition. Reference 2022-001 (continued) Context: During our audit, we noted several checks that were either outstanding for greater than a three-year period or determined to be stale dated by management. These checks were made up of housing assistance payments and utility reimbursements, and were recorded as a liability in the Section 8 Housing Choice Vouchers Program. HUD?s regulations require the Authority to follow the State?s escheat laws, which would require the Authority to ultimately consider these checks as unclaimed property, and turn them over to the State Treasurer. Known Questioned Costs: N/A Cause: The Authority did not properly consider state and federal regulations related to unclaimed property. Effect: Due to the stale dated checks being outstanding for greater than a three-year period, they are to be considered unclaimed property in the State of New Jersey. The Authority did not properly identify these outstanding checks as unclaimed property, or follow the proper reporting requirements of the State of New Jersey. Additionally, no stale dated checks were escheated to the State. Recommendation: The Authority should draft and adopt a method of complying with reporting requirements related to unclaimed property in accordance with the State of New Jersey Statutes. Authority Response: The Authority accepts the recommendation of the auditor and has made arrangements to comply with the State of New Jersey Statutes. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor and has made arrangements to comply with the State of New Jersey Statutes. Irma Gorham is responsible to remedy the deficiency by March 31, 2023. Federal Award Findings and Questioned Costs Finding 2022-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Catalog Numbers: 14.871 Noncompliance ? E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). Finding 2022-002 (continued): Condition: Based upon inspection of the Authority?s files and on discussions with management there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of thirty-six (36) tenant files, the following information was unavailable for examination at the time of audit: ? Verification of income and assets was missing in one (1) file Our sample size is statistically valid. Known Questioned Costs: $11,054 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered and designed a system of internal controls that reasonably assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: We agree with the Auditor?s observations on the inspection of the tenant files and will implement internal control procedures that will assure tenant file compliance. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor on the inspection of tenant files and has made arrangements to comply with the Section 8 Housing Choice Vouchers Program. Irma Gorham is responsible to remedy the deficiency by March 31, 2023. Schedule of Prior Year Audit Findings Reference 2021-001: Observation: During our audit, we noted several checks that were either outstanding for greater than a three-year period or determined to be stale dated by management. These checks were made up of housing assistance payments and utility reimbursements, and were recorded as a liability in the Section 8 Housing Choice Vouchers Program. HUD?s regulations require the Authority to follow the State?s escheat laws, which would require the Authority to ultimately consider these checks as unclaimed property and turn them over to the State Treasurer. Reference 2021-001 (continued): Status: The finding remains open. See Finding 2022-001 above. Sincerely yours, Irma Gorham Executive Director

U.S Department of Housing and Urban Development 2022-003 Housing Choice Voucher Program ? Assistance Listing No. 14.871 Recommendation: We recommend the Authority review their process for maintaining 3rd party verification of income, for uploading data to PIC, and for generating HAP amendment letters. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Create a third party verification policy and procedure SOP. Name(s) of the contact person(s) responsible for corrective action: Doryan Campo Planned completion date for corrective action plan: April 2023

Corrective Action: We will be creating universal tick sheets for the elementary and secondary schools. The internal control will be more manageable when we make this change. The tick sheets will be on separate sheets for breakfast and lunch and there will be a signature line on each sheet in order to identify the employee that ticked during the meal. All Student Nutrition employees will be instructed to use the standardized tick sheet and will be advised not to make any change to the form. Due Date of Completion: December 31, 2022 Responsible Party: Director of Student Nutrition

We will contact DESE for guidance regarding this matter and implement proper controls over program expenditures. Misti Flowers, District Treasurer June 1, 2023 Action Started June 30, 2023 Action completed

Finding 2022-003 ? Lack of Data Available to Audit the Federal Compliance Requirements Applicable to the Section 8 Housing Choice Program (Material Weakness, Potential Material Noncompliance) Section 8 Housing Choice Voucher Program ? Assistance Listing No. 14.871; Grant period ? fiscal year ended March 31, 2022 Corrective Action The Commission will maintain, and make available for audit, data applicable to the Section 8 Housing Choice Voucher Program compliance requirements. Laurie Ingram, Executive Director, has assumed the responsibility of maintaining and making available for audit, data applicable to the Section 8 Housing Choice Voucher Program compliance requirements and expects the deficiencies which led to this Finding to be resolved by February 28, 2023.

Finding 2022-002 ? Lack of Data Available to Audit the Federal Compliance Requirements Applicable to the Public Housing Program (Material Weakness, Potential Material Noncompliance) Public Housing Program ? Assistance Listing No. 14.850a; Grant period ? fiscal year ended March 31, 2022 Corrective action The Commission will maintain, and make available for audit, data applicable to the Public Housing Program compliance requirements. Laurie Ingram, Executive Director, has assumed the responsibility of maintaining and making available for audit, data applicable to the Public Housing Program compliance requirements and expects the deficiencies which led to this Finding to be resolved by February 28, 2023.

U.S. Department of Treasury Pass-through Entity: N.C. Pandemic Recovery Office Program Name: Emergency Rental Assistance Federal Assistance Listing Number 21.023 Eligibility and Reporting Non-Material Non-Compliance Finding 2022-005 Corrective Action Plan: Mecklenburg County Finance has implemented a process in which all Federal Agency reports are reviewed and approved by the Deputy Finance Director prior to submission. Furthermore, documentation of the approval will be retained by the department. Person responsible: David Boyd, Chief Financial Officer Estimated date of completion: June 30, 2023

Department of Agriculture Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Supplemental Nutrition Assistance Program Federal Assistance Listing Number: 10.561 Non-Material Non-Compliance - Eligibility Finding 2022-004 Corrective Action Plan: I. Training a. The Quality and Training unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine SNAP eligibility and their supervisors and managers to address the specific errors identified during this audit, including but not limited to appropriate documentation of the completed and signed DSS-8207 or electronically generated ePASS application. This training will be delivered by the end of the third quarter of fiscal year 2023. b. NC FAST Certification for Core Functions and Level One FNS policy is required by NC DHHS and completed in the NC FAST Learning Gateway for all staff that determine SNAP eligibility. This is a staggered process initiated by NC DHHS. Mecklenburg County began this process in September 2021 with all new hires obtaining NC FAST Certification within 90 days of their hire. Existing staff that determine SNAP eligibility were enrolled in January 2022 and will complete this training within 18 months to meet all state requirements. c. In December 2022 Sr. Quality & Training Specialists were realigned to provide direct policy support to assigned teams. The assignment of specific Sr. Quality and Training Specialists to work directly with certain teams will enhance the relationship between Q&T, Eligibility staff and their Supervisors, with the goal of improving quality and timeliness of work. This realignment will more easily enable Sr. Quality & Training staff to correct errors identified through the second party review process and share those findings with the worker and their Supervisor for learning and accountability purposes. d. Managers will review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans. II. Process Improvement - A new Quality Assurance team will be created to validate the second party review process across all DSS divisions. This process will involve sampling records that have gone through the second party review process at the divisional level to ensure the review was accurate and that any errors were corrected. This team will also align second party review findings to audit findings to determine if training or process improvement strategies may improve quality. The team should be hired and standard operating procedures drafted during the 4th quarter of FY23. Person responsible: Jim Wright, Sr. Social Services Manager Ellese Massey, Social Services Manager Estimated date of completion: June 30, 2023

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal Assistance Listing Number: 93.778 Material Weakness and Non-Material Non-Compliance - Eligibility Finding 2022-002 Corrective Action Plan: I. Training a. The Quality and Training unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine Medicaid eligibility and their supervisors and managers to address the specific errors identified during this audit, including but not limited to completing exparte determinations for eligibility when SSA terminates SSI eligibility, sending the 5097 to verify self-attest wages, properly documenting and reacting to IV-D non-cooperation, correct verification and documentation, and performing the required electronic verifications to complete an application or review. This training will be delivered by the end of the third quarter of fiscal year 2023. b. NC FAST Certification for Core Functions and Level One Medicaid policy is required by NC DHHS and completed in the NC FAST Learning Gateway for all staff that determine Medicaid eligibility. This is a staggered process initiated by NC DHHS. Mecklenburg County began this process in September 2021 with all new hires obtaining NC FAST Certification within 90 days of their hire. Existing staff that determine Medicaid eligibility were enrolled in January 2022 and will complete this training within 18 months to meet all state requirements. II. Process Improvement Strategies a. The division is continuing to hire Eligibility Specialist positions that will manage Medicaid cases. These added resources will help alleviate current workload challenges faced by existing staff and allow for a more thorough review of work being completed. b. In December 2022 Sr. Quality & Training Specialists were realigned to provide direct policy support to assigned teams. The assignment of specific Sr. Quality and Training Specialists to work directly with certain teams will enhance the relationship between Q&T, Eligibility staff and their Supervisors, with the goal of improving quality and timeliness of work. This realignment will more easily enable Sr. Quality & Training staff to correct errors identified through the second party review process and share those findings with the worker and their supervisor for learning and accountability purposes. c. A new Quality Assurance team will be created to validate the second party review process across all DSS divisions. This process will involve sampling records that have gone through the second party review process at the divisional level to ensure the review was accurate and that any errors were corrected. This team will also align second party review findings to audit findings to determine if training or process improvement strategies may improve quality. The team should be hired and standard operating procedures drafted by the 4th quarter of FY23. Ill. Quality Sampling and Accountability a. The Quality and Training Unit will complete monthly quality sampling for Medicaid. Error trends will be shared with the managers and their supervisors, who will work collaboratively with Quality & Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward. b. Supervisors will review specific quality sampling results with their staff. The supervisor will, when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process. c. Managers will review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans. Person responsible: Jim Wright, Sr. Social Services Manager Ellese Massey, Social Services Manager Estimated date of completion: June 30, 2023

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Significant Deficiency - Eligibility Finding 2022-003 Corrective Action Plan: I. Quality Sampling and Accountability a. In December 2022 Sr. Quality & Training Specialists were realigned to provide direct policy support to assigned teams. The assignment of specific Sr. Quality and Training Specialists to work directly with certain teams will enhance the relationship between Q&T, Eligibility staff and their Supervisors, with the goal of improving quality and timeliness of work. This realignment will more easily enable Sr. Quality & Training staff to correct errors identified through the second party review process and share those findings with the worker and their Supervisor for learning and accountability purposes. b. The Quality and Training Unit will complete monthly quality sampling for TANF. Error trends will be shared with the managers and their supervisors, who will work collaboratively with Quality & Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward. c. Supervisors will review specific quality sampling results with their staff. The supervisor will, when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process. d. Managers will review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans II. Process Improvement - A new Quality Assurance team will be created to validate the second party review process across all DSS divisions. This process will involve sampling records that have gone through the second party review process at the divisional level to ensure the review was accurate and that any errors were corrected. This team will also align second party review findings to audit findings to determine if training or process improvement strategies may improve quality. The team should be hired and standard operating procedures drafted by 4th quarter of FY23. Person responsible: Jim Wright, Sr. Social Services Manager Ellese Massey, Social Services Manager Estimated date of completion: June 30, 2023

The Housing Authority's Executive Director will start randomly pulling files to double check the calculations and make sure EIV reports/Income match.

Finding 2022-001- Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Significant Deficiency Housing Choice Voucher Program CFDA #14.871 Corrective Action Plan: 1) SCCHA will arrange for a thorough tenant file audit of existing HCVP files to determine whether there is a significant Incident of incorrect income projections and/or tenant rent calculations. The Initial audit will entail 230 HCVP files randomly sampled (approximately 10% of the program.) The file audit process will continue to include more randomly selected files as Indicated by the results of the initial audit. 2) SCCHA will Increase monitoring and review of HCVP files to increase accuracy and ensure compliance with regulatory and statutory requirements related to income projection and rent determinations. 3) Any staff members with rent calculation certifications older than ten years will be required to attend HCVP rent calculation training and pass the corresponding certification exam. Anticipated Completion Date: 1) Within six months; 2) Initiated within 60 days and on-going thereafter; 3) Within twelve months depending on third-party trainer availability Persons Responsible: Larry McLean, Executive Director; Pam Jackson, HCV Program Director; and Shanae Golliday, Program Integrity & Compliance Coordinator

Finding 2022-003 Federal Agency Name: Department of Agriculture Passed through State of South Dakota Department of Education Program Name: Emergency Food Assistance Program (TEFAP) CFDA # 10.569 Finding Summary: One instance in which Emergency Food Assistance Program (TEFAP) food commodities were distributed to a non-approved TEFAP agency. There was no agency agreement signed on file at that time. Responsible Individuals: Matthew Burn, Chief Operations Officer Corrective Action Plan: Internal controls have been revised to include validation of agency as a TEFAP certified agency while orders are picked. As well as additional training and updated standard operating procedures.

Corrective Action Plan Finding: 2022-004 Contact Person: Stacey Elmes, DSS Director Proposed Completion Date: Immediately and ongoing Training was provided to the Adult Medicaid unit on December 15, 2022 regarding exparte reviews for SSI recipients. Income Maintenance case workers were instructed to go back in the case after a task is closed and make sure that the benefit history is pending closure and not on hold. The case workers complete a form on each exparte review and turn it into the supervisor at the end of the month to ensure reviews are complete.

Finding Number: 2201-002 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Michael Pooler, Human Services Director Corrective Action Planned: The County will implement additional TANF targeted case reviews to ensure verifications and case documentation are being recorded and filed correctly when determining eligibility. Anticipated Completion Date: December 31, 2023

November 23, 2022 U.S Department of Housing and Urban Development Office of Public Housing 400 West Bay Street, Suite 1015 Jacksonville, FL 32202 The Palatka Housing Authority respectfully submits the following corrective action plan for the year ended March 31, 2022. Berman Hopkins Wright & LaHam, CPAs and Associates, LLP 8035 Spyglass Hill Road Melbourne, Fl 32940 Audit period: April 1, 2021 - March 31, 2022 Findings - Federal Award Programs Audit 2022-001 Eligibility U.S Department of HUD - Public and Indian housing AL 14.850 Significant Deficiencies in Internal Controls Condition: Out of a total applicant population of approximately 420 tenant, 40 applicants were tested and the following deficiencies were noted: 1. 1 file has a late annual recertification 2. 2 files had missing or incorrect 214 declaration documents, 3. 1 file was missing a permanent historical document, 4. 1 file was missing a signed flat rent option sheet, 5. 2 files had missing or unsigned 9886 release of information forms, and 6. 1 file had incorrectly calculated tenant income. Auditor recommendations: The Authority should continue to train staff on the established procedures and controls in places to ensure fill compliance in regards to eligibility. The Authority needs to correct the deficiencies notes in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor's sample. Action Taken by PHA per deficiency: 1. Household transferred to different affordable housing unit and the new move-in date was assumed instead of maintaining the original move-in date. As a result, the recertification occurred within 14 calendar months instead of 12. The PHA will ensure that future transfers maintain their original recertification date. 2. In two instances, the HOH executed her name where the minor childrens's' names should have been written. The forms have been corrected to reflect the names of the minors and the HOH signed each form correctly. The corrected forms have been added to the tenant's file. 3. The PHA is working with the elderly resident in obtaining a copy of their birth certificate. We are also researching historical records in search of the document. The resident has resided in our affordable housing program for more than thirty years. 4. The flat rent option form has been presented to the HOH, executed, and placed in the tenant's file. 5. The release forms for the 2 resident files have been properly excited and placed in the resident's file. 6. Resident submitted VA Benefit documentation dated, December 9, 2021. The document listed benefits in the amount of $1,357.56; however, the resident recorded VA benefits as $1,437.66 within the recertification packet under total household income. The written figure was utilized for the rent calculation. Should the Department of Housing and Urban Development have any questions regarding this plan, please contract my office Sincerely Dr. Anthony E. Woods President/CEO

Finding ref number: 2022-001 Finding caption: The County had inadequate internal controls for ensuring compliance with federal reporting and ERA Funds Reallocation requirements. Name, address, and telephone of Pierce County?s contact person: Thomas Taylor 950 Fawcett Ave., Suite 100 Tacoma, WA 98402 253-798-7577 Corrective action the auditee plans to take in response to the finding: Pierce County has streamlined reporting procedures for 2023 so that documentation, related date, and reconciliations are retained in a dedicated file. As a result, County staff will be able to more readily provide information as requested and reporting accuracy will be improved. Anticipated date to complete the corrective action: September 1, 2023

Finding 2022-005 Name of Contact Person: Alice Wilson, Economic Program Administrator Corrective Action: The county will conduct refresher training on how and when to request information needed that includes when to request The Work Number, OVS,AVS, Property checks and Register of Deeds checks. The county will conduct a targeted second party of cases to check the effectiveness of the refresher training provided. This area will continue to be a part of the second party process conducted monthly by lead staff and supervision in the county. Proposed Completion Date: January 31, 2023.

Finding 2022-004 Name of Contact Person: Alice Wilson, Economic Program Administrator Corrective Action: The county will conduct refresher training to staff on the appropriate entry of resources on applications/recertifications. The county will complete a targeted second party of cases to check for the effectiveness of the refresher training. This area will continue to be a part of the second party checks conducted by lead staff and supervision in the county Proposed Completion Date: January 31, 2023.

Finding 2022-003 Name of Contact Person: Alice Wilson, Economic Program Administrator Corrective Action: The county will conduct refresher training for staff on how to correctly add/remove household members to a case. The county will conduct a targeted second party of cases to check for the effectivemness of the refresher training. This area will continue to be a part of the second party checks conducted by lead staff and supervision in the county. Proposed Completion Date: January 31, 2023.

Finding 2022-002 Name of Contact Person: Alice Wilson, Economic Services Program Administrator Corrective Action: County will conduct a refresher training to all staff on when/how to complete the IVD referral. The county has added a section for IVD referrals to the casenote template for all staff to complete when evaluating applications and recertifications for eligibility. The casenote template serves as a checklist for staff to ensure that all areas of eligibility as well as post eligibilty items are addressed. The county will complete a targeted second party to check for effectiveness of refresher training in the IVD referral area. This area will continue to be a part of the second party checks conducted by lead and supervision in the county. This is a repeat finding from previous year however the total number of findings for this review was lower than previous. Proposed Completion Date: January 31, 2023.

Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of the finding: Management did not retain evidence to support their review over the patient data submitted to Sponsor for the per diem billings from February 1, 2022 to December 31, 2022 was complete and accurate. Corrective action plan: The current attestation memo control will be replaced as follows: There are two categories of study activity that required review and approval by the appropriate individual (i.e., Principal Investigator, Clinical Research Manager (CRM) or a delegate): (1) at the time of enrollment to assure that the study participant met sponsor-defined eligibility requirements and (2) subsequent study activities that may include but are not limited to a study visit, data collection, follow-up phone call, questionnaire completion, laboratory testing, biospecimen collection, or some combination of these. Verification of eligibility at the time of enrollment will continue to be reviewed and approved by the study PI, CRM, or appropriate delegate per sponsor requirements. Documentation is maintained in study-specific binders, per FDA audit standards and internationally-accepted Good Clinical Practice principles to assure that only patients meeting the sponsor?s defined eligibility criteria are enrolled into the study. Review of study activities subsequent to the study participant enrollment will be conducted monthly by the CRM or their delegate. Sponsored Programs Administration (SPA) will prepare and send each CRM a Transaction Report downloaded from the institutional clinical trial management system for each federally funded study, at least quarterly, that includes a listing of study visits associated with enrolled study participants that occurred within the defined period of time. The CRM/delegate will review the report detail provided and, upon approval, sign, and date the report. To assure that the information in the report is consistent with what was submitted to third parties which generates reimbursement, the CRM/delegate will conduct an audit of a sample of patients from a random selection of studies included in the Transaction Report. Each sample will be verified against documentation maintained in the study binder. Audit results affirming document review will be recorded in an audit tracking log which will be retained with the study activity report in their Clinical Trial Office (CTO) file as evidence of their review of study activity for federally funded fixed fee/per patient studies. For those federally funded fixed fee/per patient studies that do not utilize the standard institutional clinical trial management system, a similar study activity report downloaded from the clinical trial management system utilized for the study will be used for review, signed and dated upon approval and kept in the CTO files as evidence of review. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: September 1, 2023 and going forward.

Finding 2022-103 - Improve Eligibility Screening and Documentation (Significant Deficiency) FAL Number: 10.557 Program Title: Special Supplemental Nutrition Program for Women, Infants, and Children Condition and Context: For two of 40 selected participants, the rights and obligations form was unsigned. Recommendation: The auditors recommended that Pinal County devote the necessary resources to the department to ensure all eligibility screenings are being performed and the rights and obligations form is signed prior to participants receiving benefits. Contact Name: Merissa Mendoza, Interim Director and Public Health Manager Corrective Action Planned: Each WIC staff member receives a minimum of 10 chart audits annually, resulting in roughly 160 chart audits completed by WIC management yearly. Additionally, each WIC staff member is observed with a minimum 6 certification appointments annually via their WIC Supervisor and/or Nutrition Specialist Senior. Staff will continue to follow AZ WIC Policy and Procedure when assessing clients for income eligibility. Any identified deficiencies in staff education or training will be identified and corrected by supervisory staff. Anticipated Completion Date: December 31, 2023