Corrective Action Plans

FINDING 2022-002: Over awarded Pell Grants A. Comments on Findings and Recommendations: In response to the under awarded Pell Grant, Brillare Beauty Institute agrees with the single audit finding 2022-001. B. Actions Taken or Planned: Brillare Beauty Institute has resolved the student under award Pell grant issue. The student was given a check by the Institute to rectify the under-awarded Pell Grant amount to be received. Brillare Beauty Institute has contracted with a new 3rd party Financial Aid Servicer as of December 2022 and as a part of this transition, both reviewed and strengthened our Pell grant policies and procedures. This revision took place after the student's 2021-2022 Pell grant disbursements.

A. Comments on Findings and Recommendations: 2022-001 - Missing Proof of Loan Entrance Counseling. It seems that the student may not have completed entrance counseling. When this student started, MCU was contracted with Weber as its Third- Party Servicer who used to check entrance counseling before processing our students. Since 2020, MCU has been contracted with Campus Ivy whose platform now requires the Financial Aid Department to upload the entrance counseling proof before processing can occur. B. Actions Taken or Planned: 2022-001 - Missing Proof of Loan Entrance Counseling. The student in question has now performed the required Entrance Counseling. Since May 2020, MCU's updated entrance counseling process with Campus Ivy has helped mitigate a risk of gaps with regard to the completion of entrance counseling. MCU will perform an internal review on current students enrolled before May 2020 to ensure entrance counselings are complete.

Finding 2022-001 ? Underawarded Pell Grants: During the audit, it was noted that two students were not awarded the full amount of their allowable Pell grants. It was recommended that the school credit the appropriate students? accounts $1,077. The Institution agrees with the finding. The school has made the appropriate corrections to the student accounts and both students have received their additional funding. The Institute recognized that our 3rd party Servicer was not disbursing the correct amount of Pell grant funds and requested that they complete a full audit of disbursements, the error on their end has been corrected and should not lead to additional findings moving forward.

2022-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Daniel Winokur, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions Proposed Completion Date: September 30, 2022

Finding 2022-001 ? Activities Allowed or Unallowed and Eligibility Information of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured and the COVID-19 Coverage Assistance Fund Federal Award Numbers: Various Federal Award Period of Performance: 09/01/2021?04/05/2022 Views of responsible officials and planned corrective actions: Management made the adjustments to the report script to ensure all uninsured COVID-19 patient accounts eligible for reimbursement by HRSA are captured for management review and includes accounts with a zero balance and/or have a closed status. The corrective action plan was implemented and in place by December 31, 2021 shortly after the 8/31/2020 Uniform Guidance audit was completed on November 29, 2021. The adjustments will ensure that claims completed after December 31, 2021 are captured. Responsible Official: Michael Mullen, Vice President Revenue Cycle Completion date: December 31, 2021.

2022-001 - Eligibility In our sample of 40 individuals tested for eligibility compliance, five individuals did not have original applications on file with applicant signatures to ensure the existence of the participant. The households for which these individuals applied were eligible for services and the original applications had been entered into an electronic data base for tracking, but the original applications were unable to be located. Corrective Action Plan: ? Provide additional outreach and training to staff in counties outside of Dickinson & Iron ? Conduct semi-annual onsite (or video-conference) reviews of other county client applications ? Review distribution attendance sheets monthly and confirm with other county staff that all CSFP recipients have a current application ? Increase communication with other county staff Person(s) Responsible: Christina Ureta, CSFP/TEFAP Director Timing for Implementation: Immediately

The Organization acknowledges the lack of an internal control process to assure all individuals claimed on federal grant activities met Temporary Assistance for Needy Families (TANF) eligibility requirements. To address this deficiency, we have developed internal controls to prevent ineligible individuals from being claimed: ? A second person, the Director of Quality & Process Improvement, reviews the data entered by the employee responsible for preparing program reports to verify TANF eligibility for each individual claimed on the grant ? Any errors discovered are corrected before the program report is approved ? After the employee?s work has been reviewed and any errors have been corrected, the Director of Quality & Process Improvement approves and submits the report The Organization will continue to implement an internal control system requiring that a second person reviews eligibility requirements before claiming individuals on the federal TANF grant.

Recommendation: Established procedures to either identify and track eligible loans deployed during the RRP grant performance period or establish a method in which to validate the analysis and data provided by Inclusiv. Action Taken: Management agrees with the finding and will ensure we are able to identify eligible loans deployed in the TM in the future.

2. Finding 2022-001 ? Major Federal Award Programs Audit: Federal Assistance Listing Number 14.182, Section 8 New Construction and Substantial Rehabilitation a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In connection with out lease file review, we noted the following deficiencies: The enterprise income verification form in the tenant?s file for 2 out of 15 tenants tested did not have documentation in their lease file that their income was verified. The procedures applied to a sample of 1 out of 2 tenants tested did not have move out inspections in their lease files. The procedures applied to a sample of 1 out of 15 tenants tested did not have a signed HUD Form 50059 in their lease files. b. Action(s) Taken or Planned on the Finding Management has engaged Onesite Realpage Compliance Monitoring to review all files going forward to ensure compliance with EIV. This is implemented effective 10/1/2023. Regards Management Agent

U.S. Department of Education 2022-003: Student Financial Aid Cluster ? Student Eligibility and Awarding ? Assistance Listing Number: Various Recommendation: We recommend that the College implements a process that will ensure all Title IV funds are awarded at proper amounts. Action taken in response to finding: This student was awarded an incorrect amount because a subsequent ISIR transaction was received but the Pell was not recalculated on the basis of the new information. After this discovery, we have taken the following actions in response: ? We examined our ISIR import process to make sure that our means of communicating locked transactions was functioning correctly. We found that our system for monitoring new transactions was deficient; if a set of conditions were aligned, a new transaction could slip by our notice. Implemented by August 2022. ? We added another layer of review wherein the output of both the messages we receive from our third-party verification partner and our internal reports associated with importing ISIRS are examined on a regular basis. New transactions on students with a current locked transaction are reported to staff members for further review. Implemented by August 2022. ? We wrote an ad hoc report that allows us to identify subsequent ISIR transactions and will run it regularly to reduce the likelihood of this issue occurring again. Implemented by August 2022. Name(s) of the contact person(s) responsible for corrective action: Alysa Borelli, Dean of Enrollment and Student Services. Planned completion date for corrective action plan: The corrective action plan was implemented by August of 2022.

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.