Corrective Action Plans

DHS management has implemented new procedures in SFY25 and anticipates this will not be a finding for the next Single Audit. Preparers of reports have been instructed to do a lookback for any additional entries from prior quarters not previously reported. Each report is now saved with the supporting documentation on a shared drive. Additionally, DHS will document the process of quarterly federal financial reporting. Regarding Federal Funding Accountability and Transparency Act (FFATA) reporting, DHS has started to track reporting by capturing contract execution dates to ensure timeliness. Anticipated Completion Date: June 30, 2025 Contact Person: Ben Quattrucci, Associate Director Financial Contract Management, Department of Human Services benjamin.a.quattrucci@dhs.ri.gov

System changes to modify the time schedule that RIBridges interfaces with SWICA for processing tasks has already been submitted (RIB-141767). Currently, the interface occurs twice yearly. This will increase the frequency to quarterly. Anticipated Completion Date: October 31, 2025 Contact Person: Donna Rook, Administrator, Family and Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov

DHS continues its prior actions of training addressing eligibility, standing agenda on meetings, and quarterly meetings. At this time, DHS has completed the solicitation to hire a contractor to identify problematic processes, through the Business Processing Excellence Reengineering project. (BPER). The scope of work includes evaluating the eligibility to determine the deficiencies and to propose solutions. Anticipated Completion Date: Ongoing Contact Person: Donna Rook, Administrator, Family and Adult Services, Department of Human Servicesdonna.m.rook@dhs.ri.gov

Finding: 1 of 60 individuals had a return-to-work date submitted by the employer, however, the claimant received three payments after that date. DLT did not investigate any potential overpayment. (Questioned costs - $2,139) We do not concur with this finding. Per ETA guidance, specifically UIPL 01-16, because this claim was in payment status, we have to continue to make timely weekly payments (after proper certification), and an overpayment cannot be deemed recoverable until an official ineligibility determination is rendered. Unemployment Insurance Program Letter 01-16 states “in order to be eligible to receive administrative grants, a state must do the following in context of identifying and establishing improper payments…continue to make timely UC payments (if due) and wait to commence recovery of overpayments until an official determination of ineligibility is made…” In addition to the above requirement, data that State Workforce Agencies gather from crossmatch sources such as IB4, wage record /benefit, SDNH and NDNH wage/benefit have to be verified prior to initiating a decision disqualifying benefits. The actual cross match itself simply produces possible cases to investigate. The investigation is then initiated when the department sends out a request for wages form (720). When the form is returned by the employer the department can then use the verified information to render a disqualifying decision. A crossmatch itself is not enough to render a working and collecting determination based on wage record data as the claimant may have had actual earning within the quarter. The date identified on a NDNH crossmatch also is not enough to render a disqualification. This information needs to be verified. From: Unemployment Insurance 401 Handbook ETA 227 – OVERPAYMENT DETECTION AND RECOVERY ACTIVITIES E. Definitions 4. Cases Investigated. The number of cases emanating from a state-initiated overpayment detection process for which an investigation regarding a potential overpayment has been concluded. Example: during a wage/benefit crossmatch process, a state agency produces a printout identifying all benefit payments matched against wages in the same quarter. After the printout is screened, requests are sent to employers to identify which weeks in the quarter were worked. When an employer reply indicates overlap with weeks for which benefits were paid, claims are investigated to determine if they were overpaid. This was a continued claim that was effective 8/13/23 and the claimant certified weekly through 2/17/24. The RTW date listen on the ledger was autogenerated on 2/27/24. At this time the claimant had exhausted their balance of credits, all benefits had been paid. The date listed as the return-to-work date from the NDNH crossmatch stated 1/30/24. Since this date had the potential to affect benefits the department initiated it’s investigation and did send a 720 form to the employer to obtain the proper wage information. Since the requested information was not returned by the employer, the department lacked the proper information necessary to render a disqualification based on ETA guidelines. Finding: 1 of 60 was not registered within EmployRI and staff were unable to locate any records of the claimant. (Questioned costs - $10,829) The agency concurs with the above finding that includes state UC questioned costs of $10,829. This exception was caused by a programming (IT system) error. A nightly job is run that is sent to Workforce Development (Geosol) which then registers claimant’s with EmployRI. An issue was discovered on claims where the effective date of the claim was 56 days prior to the first payment being issued. These claimants were not populated on the nightly transfer to Workforce. ETSS has confirmed that this programming error has been fixed. We acknowledge the Auditor’s recommendations and offer the following response. We feel the findings, while relevant, are de minimis in scope, when compared to the workload volumes processed. Our current unemployment systems (Tax and Benefits) are aged and distressed. Due to their age and technology constraints, any changes or modifications needed, cannot be easily or quickly implemented. As such a larger burden is placed on staff to handle manually. DLT ‘s limited technology resources combined with having limited staffing resources also hinder our efficiency. We have limited staff resources to manually address our workload volumes, as well as the sheer number of forms involved in making proper determinations. In addition to this, the law requires benefit payments to be made timely based on available information until verifiable evidence is found that justifies a disqualification. Therefore, until we can implement a more modernized tax and benefits system, we acknowledge that similar findings such as these may persist. We will continue to utilize the resources we currently have and strive to be more efficient. We hope that by providing additional staff training and by strengthening our relationship with Workforce Development, this improved efficiency will be realized. We are in the process of evaluating whether or not an amendment to our work search requirement, is needed. In doing so, we will evaluate whether any changes are necessary to either; our internal policy, the guidance provided on the claimant’s benefit rights, the guidance displayed on DLT’s website and to regulation 1.18 Filing of Claims for Unemployment Insurance Benefits. Any necessary modifications will be made. Anticipated Completion Date: December 31, 2025 Contact Person: Philip D’Ambra, Director of Income Support, Department of Labor and Training philip.l.dambra@dlt.ri.gov

RIDE is currently evaluating third-party consultants in order to have the following services performed: • A cybersecurity assessment performed of the overall agency using the NIST Framework • A cybersecurity assessment of our internal applications including CNP Connect & Accelegrants • An updated business continuity plan • A Vendor Risk Assessment Program Development Through the above deliverables from the selected consultant, RIDE will be able to have a better understanding of gaps in IT/ Cybersecurity throughout the agency, as well as the applications cited by the Auditor General. Anticipated Completion Date: December 31, 2025 Contact Person: Brandon Bohl, Finance Director, Department of Elementary and Secondary Educationbrandon.bohl@ride.ri.gov

The District will ensure that Additional or Compensatory Special Education or Related Services (ACSERS) funds are not used to fund Substitute Services due to the teacher shortage.

2024-002: Health Centers Cluster – ALN# 93.224 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), ALN# 93.527 Grants for New and Expanded Services under the Health Center Program, June 30, 2024 - Special Tests and Provisions Condition: The Organization did not retain documentation or other evidence that patients were eligible for adjustment (discount) that was received. Corrective Action Plan: Patient Service Representatives are responsible for ensuring sliding fee schedule docuemtns are current. We have implemented another layer of oversight to ensure moving forward, we will be able to identify any patients with expired documentation for the sliding fee scale application. The PSR Lead will run a monthly report in the EMR to capture any information that may have been inadvertently missed and will help us ensure updates are completed accurately and in a timely manner. A report was run initially for the current fiscal year and will be run monthly going forward to identify expired applications so we can update accordingly. Responsible Person for Corrective Action Plan: Director of Operations and PSR Leads Implmentation Date of Corrective Action Plan: April 16, 2025

Finding 2024-004: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 HQS Enforcement Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: In Progress Planned Corrective Action: • SMHO will provide additional staff training and testing of understanding through a thirdparty training platform for inspections and re-inspections procedures. Management will quarterly review each file that requires re-inspection to ensure all documents are present in the file.

Finding 2024-003: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Action: • SMHO will require managerial file review/approval for income used at new move-ins, port-ins and annual re-exams and the manager/lead will initial the new income line item added to the check sheet for each file to indicate the review/approval has been completed.

Finding 2024-002: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Action: • SMHO will require managerial file review/approval for all new move-ins, port-ins and annual re-exams and the manager/lead will sign the check sheet for each file to indicate the review/approval has been completed.

Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025

Ensure full compliance with HUD regulations and internal policies related to eligibility documentation, income verification, utility allowances, and rent reasonableness determinations in the Housing Choice Voucher (HCV) program. 1. Correct the Deficiencies in the Identified Files Issue Missing 214 Declaration Form Utility Allowance Calculation (2 files) Missing Third-Party Income Verification Missing Rent Reasonableness Determination Action Contact tenant to obtain and file the signed 214 declaration. Recalculate and document the utility allowance using the current approved utility schedule. Request and obtain third-party verification; if unavailable, follow up with tenant and document efforts per HUD guidelines. Conduct and document rent reasonableness review for the current unit. Responsible Party Housing Specialist Housing Specialist Housing Specialist HQS/Rent Reasonableness Officer Timeline Within 10 business days Within 10 business days Within 10 business days Within 10 business days 2. Expand Review to Broader File Population Action Details Responsible Party Timeline Risk-based Review of Additional Files Identify Systemic Issues Report Findings Identify a representative sample of 100-200 files from the broader tenant population to assess the prevalence of the noted deficiencies. Track and categorize findings to identify patterns of noncompliance. Present findings to leadership and recommend procedural changes if systemic issues are found. Quality Assurance (QA) Team QA Manager QA Manager Within 45 days Within 60 days Within 75 days 3. Strengthen Policies, Procedures, and Staff Training Update Procedures Revise Standard Operating Procedures (SOPs) for file documentation, utility allowances, and rent reasonableness. Include clear checklists. Program Manager Within 90 days Staff Training Conduct mandatory refresher training on eligibility documentation,income verification protocols, rent reasonableness, and utility allowance schedules. File Audit Checklist Implement a standardized checklist for file reviews before final approval. 4. Ongoing Monitoring and Compliance Quarterly File Audits Continue random quarterly audits of tenant files to ensure ongoing compliance. Compliance Reporting Include compliance metrics in monthly management reports. Corrective Action Tracking Maintain a tracking system for noted deficiencies and corrective actions taken.

DCH will review MO 598348 within the Gateway system to ensure the established interface process is functioning properly. DCH will draft additional guidance through a policy memo to revise DHS policy 2750 as it relates to the processing of Ex-Parte members. The DCH policy memo will clarify that upon the completion of the determination by DHS, Gateway will notify GAMMIS of A/R's approval or denial thorough daily interface files sent from Gateway to GAMMIS. The non-confirmation report will be reviewed to determine SOP and validate that the file has been received. Additionally, the DCH policy memo will require Gateway to complete the DMA-962 and submit to Gainwell for manual processing if the file has not been received. DCH is also reviewing current policy to determine if the infinity date established for Ex-Parte members can be revised to a time-limited date.

DCH will develop a reconciliation process between members denied within Georgia Gateway and members removed within GAMMIS. DHS will provide training as outlined within the current contract to address changes and updates to Medicaid policy and the Georgia Gateway system.

The student in question had a lengthy break in enrollment (2015-2024). When the student returned, CGTC’s Banner rules differed from his previous enrollment and his status was not accurately updated within the correct term. To correct the issue, CGTC has worked with colleagues at the Technical College System of Georgia to identify and correct any discrepancies in the Banner rules for the Satisfactory Academic Progress (SAP) process to prevent future occurrences of this issue. The College’s Financial Aid office has identified the “cutoff” year for changes in SAP rules and has developed a procedure to manually review any students with long breaks in enrollment whose last enrollment occurred prior to the identified cutoff. This review process will help to ensure that students’ SAP status is accurately updated in the correct term.

Georgia State University (GSU) will ensure all team members are appropriately trained related to the process for locking student financial aid records and completing verifications after the term ends. Additionally, GSU has enhanced monitoring procedures to identify changes to institutional student information records after term ends with a verification indicator to ensure these accounts are resolved in a timely manner.

Effective November 16, 2024, GDOL restructured the Benefit Accuracy Measurement (BAM) unit to strengthen internal controls by incorporating a secondary review process prior to the final review by the supervisor. This process allows the reconciliation of discrepancies and validates the accuracy of the case findings prior to the supervisory review. If the reviewer identifies questionable items during the review, the case is returned to the auditor for corrections and updates. Once completed, it is returned back to the reviewer for an additional review, sign-off, and then submission to the supervisor for review and closure. Beginning April 2025, an initiative will be implemented to train staff to perform quality checks. Staff will review a sample of cases completed by other auditors in the previous quarter and provide feedback. This plan is being established to posture staff to supplement gaps in resources if the need arises and address challenges, such as, attrition. This allows staff to effectively fulfill the responsibility of reviewing cases and preparing them for official signoff in a timely manner. Summary: GDOL greatly appreciates the feedback and recommendations and has and will continue to take appropriate measures to ensure the established BAM procedures are followed.

GDOL Response: GDOL acknowledges this is a repeated finding from previous years and is partially resolved, therefore the Department concurs with this finding and offers the following response. GDOL’s limited technology resources and funding will hinder our ability to update our current system to satisfy the state audit’s recommendation. Therefore, we acknowledge that this finding will persist until a system-wide resolution is implemented in the new modernized UI system. GDOL will include a self-certification and dual certification process for employer-filed claims in the new solution. GDOL will also secure data analytic tools to aid GDOL staff with the identification of potential improper or fraudulent Payments, which will include payments linked to employer filed claims.

GDOL Response: GDOL acknowledges this is a repeated finding from previous years and is partially resolved, therefore the Department concurs with this finding and offers the following response. GDOL’s current UI Information Technology (IT) system was developed in 1982 using mainframe “legacy’ technology. Due to the system’s age and other limitations, many automated processes and corrections cannot be fixed and/or easily implemented. As such, many processes must be handled manually by staff. This includes reviewing all the Pandemic Unemployment Assistance (PUA) proof documents submitted to determine the validity and eligibility for each PUA claim. Based on the volume of workload and staff limitations, GDOL has been unable to quickly complete this manual review to correct the finding. It is anticipated this manual review will continue throughout the FY25 audit review period. The modernized UI system will include controls over eligibility determination for current and future unemployment programs. Employer-Filed Claims (EFC) are submitted by employers on behalf of the claimant. The employer is responsible for attesting to the employment status and weekly earnings of the claimant for the EFC submitted. An affidavit certifying that the employer has obtained earnings from other employment as well as other requirements must be completed before EFCs can be entered or uploaded. Claimants for which EFCs submitted are considered to be still attached to the employer and are exempt from the requirement to register for employment services per Georgia Employment Security Law Rule 300-2-4-.02. Such individuals are not required to be nor certify on a weekly basis to be able, available and actively seeking work. We recognize the state auditor's recommendations to add the self-certification. However, the current unemployment system is aged and distressed. GDOL’s limited technology resources will hinder our ability to update our current system to satisfy the state audit’s recommendation. Therefore, we acknowledge that this finding will persist until a system-wide resolution is implemented in the new modernized UI system. GDOL will include a self-certification process for employer-filed claims in the new solution. GDOL has procured a vendor to build and implement a modernized UI system. We are also pursuing data analytics tools to expedite the identification and detection of fraudulent activities. These tools will also be incorporated into the modernized solution. Summary: GDOL greatly appreciates the feedback and recommendations and will ensure they are incorporated into the new UI modernized system which is planned to be implemented in Spring 2026.

Recommendation: We recommend that management implement a control to ensure complete documentation is maintained for all cases that require retainer agreement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: Our Deputy Director/General Counsel contacted the person who had failed to sign the retainer that was missing the staff signature to remind them of that requirement. She also held a training on LSC requirements in Q1 2025 in which she reminded staff of the retainer requirement. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: Already implemented

Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: In 2024, but after employees logged the two erroneous PAI entries, we implemented a new PAI time entry system in LegalServer. Employees must now choose the nature of the PAI involvement when they log the time, which would have avoided both of the two erroneous entries, had that been in place. Additionally, our Deputy Director/General Counsel provided an LSC regulations training in Q1 2025 to remind employees of LSC regulations, including the regulation governing PAI time. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: Already implemented

Management is currently conducting a comprehensive review of the process to ensure alignment with compliance requirements and identify areas for improvement.

Management is currently conducting a comprehensive review of the process to ensure alignment with compliance requirements and identify areas for improvement. Status of finding: Corrective Action

The following represents the Corrective Action Plan related to the audit finding listed in the Schedule of Findings and Questioned Costs included in the December 31, 2024 audited financial statements of Manchester Supportive Housing, Inc. d/b/a Page Place (the “Corporation”). Finding 2024-001: Incomplete Documentation of New Residents Condition and Criteria: The Corporation is required to obtain, confirm, and document income information for each resident in Form HUD-50059 upon move-in and recertification. The Corporation was found to have an error in the documented income information for one out of the three residents selected for testwork. Management Response and Corrective Action Plan: Management agrees with the finding. The Corporation is implementing an updated standard review process over the resident files to prevent and detect errors on a timely basis.

The following represents the Corrective Action Plan related to the audit finding listed in the Schedule of Findings and Questioned Costs included in the December 31, 2024 audited financial statements of Plum Presbyterian Senior Housing, Inc. d/b/a Plum Creek Acres (the “Corporation”). Finding 2024-001: Incomplete Documentation of New Residents Condition and Criteria: The Corporation is required to have all new residents sign a Form HUD-9887 and a Resident Rights and Responsibilities document upon move-in. The Corporation did not have these documents signed and maintained in the resident file for one out of four residents selected for testwork. Management Response and Corrective Action Plan: Management agrees with the finding. The Corporation is implementing an updated standard review process over the resident files to prevent and detect errors on a timely basis.