Corrective Action Plans

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: ABU started working on partnering with the National Clearing House in the fall 2023 for NSLDS reporting. Due to a system conversion at the time this process took longer than anticipated. However, the first error free report was uploaded 09/01/2024. ABU now has a schedule with set reminders from the clearinghouse to ensure timely and regular reporting. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Anticipated Date of Completion: Fall 2024

Contact Person Darin Scherr, Business and Operations Manager Corrective Action Plan The District agrees with the finding as presented. The child nutrition department will ensure both that the months are closed out in our software system so that data does not change after the fact and that original meal count reports ran from the system that match the claims filed with ND DPI are kept on file for the required time period. Corrective action has already taken place on a go forward basis starting when this was identified during audit testing. Completion Date Immediately

Name of Contact Person: Sheila Conley, IMS III Corrective Action: Significant Deficiency, non-material non-compliance Eligibility Macon County has updated all worksheets for all Medicaid programs; the worksheets are to verify information of the client before keying the verified information into NC Fast system. We have developed a short worksheet that will calculate earned income; this is to reduce error. All workers must complete a manual budget then compare to the system budget to insure calculations are correct. We continue to training from the Medicaid Manual sections 2250 Income, 2230 Financial Resources, 2260 Financial Eligibility Regulations-PLA. We will also continue second party reviewat least 10% of the workers cases, 100% of all new workers from three to six months. Proposed Completion Date: Immediately

As of June 30, 2024, RMHS has implemented procedures to ensure participants are receiving timely notifications for the need to recertify and has taken steps to ensure the client management software is functioning properly.

ederal Supplemental Educational Opportunity Grant - Assistance List No. 84.007 Federal Work Study Program- Assistance Listing No. 84.033 Federal Pell Grant Program - Assistance Listing No. 84.063 Federal Direct Student Loans - Assistance Listing No. 84.268 Recommendation: We recommend the University review internal controls related to Eligibility and ensure appropriate checks are in place to identify students who are not meeting the University's qualitative and quantitative criteria for maintaining SAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding . Action taken in response to finding: The Registrar's Office procedure will be to convert clock hours to credit hours to avoid this situation moving forward. Name(s) of the contact person(s) responsible for corrective action: Erin Moore and Dasha Smith Planned completion date for corrective action plan: December 15, 2024

Correction Action: Management determined that this recipient was ineligible during the program year and changed their status to inactive. However, new staff did not process reimbursement for the overpayment. To address this, management has improved its quality assurance procedures by having personnel run monthly eligibility reports to identify recipients whose ages fall outside acceptable ranges prior to submitting the monthly invoice. Any ineligible recipients who have not been terminated will be promptly removed from service and excluded from the monthly invoice. The quality assurance team will also evaluate any potential overpayments that may have occurred and, if necessary, will apply refunds as credits on the next invoice to the Division of Early Learning. In relation to the issue mentioned in this finding, management has recorded the amount of $1,947.06 as a credit on a Prior Year 23-24 Invoice in the 5045 report and has processed this amount for repayment to the Division of Early Learning as of September 13, 2024. Management conducted a thorough review of the identified eligibility issue and found only two cases among all enrolled participants. The total claims billed after the age-out date that remain unpaid amounted to $4,503.69 for both instances during the fiscal year. These amounts have been submitted to the Division of Early Learning for repayment.

FORCED ELIGIBILITY Supervisors/Lead Workers and staff will pull case management reports weekly to ensure all recertifications are actively being completed. Supervisors will disburse vacant caseload timely after employee leaves to ensure all recertifications are accounted for, distributed and worked. Supervisors for will ensure that staff run eligibility checks even if the recertification is rolled over by the system/state. In an effort to prevent the system from automatically rolling the case over, staff will process (recertify and terminate) all cases by the 8110 cutoff date and document on the case. Staff will implement these changes for January 2025 recertification period. Staff will be informed on changes and changes will be implemented on December 2, 2024.

Condition Found: The University has an adequate Satisfactory Academic Progress policy. Student GPAs and completion rates are reviewed at the end of each academic year. However, the University is not informing students when they are placed on financial aid suspension and how to appeal the decision. Corrective Action Plan: Management agrees with the auditors’ finding and their recommendation. The Business Office and the Director of Financial Aid is in the process of creating a Financial Aid Suspension Letter to notify students of the financial aid ramifications of being placed on financial aid suspension. Anticipated Completion Date: The corrective action will be completed by December 31, 2024. Contact Person: Tasha Young, CFO 816-425-6151

Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The District will obtain proper documentation to pay increases and online food service applications. 3. Official Responsible for Ensuring CAP: Megan Gracia, Business Manager, is the official responsible for ensuring corrective action for compliance. 4. Planned Completion Date for CAP: The planned completion date is June 30, 2025. 5. Plan to Monitor Completion of CAP: The School Board of ISD No. 508 will be monitoring this corrective action plan.

Finding 2024-001- Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster-ALNs 14.871 and 14.879 Corrective Action Plan: Finding: Somerville Housing Authority (SHA) received the authority's Single Audit for the year ended March 31, 2024, indicating that SHA received a finding of Significant Deficiencies. Auditors noted two files missing proper income verification, five containing miscalculation of income, and one missing deduction verification. Extrapolation of errors to the population found the potential misstatement to be immaterial to program HAP expense. Auditors recommend that SHA conduct a file audit to determine the extent of deficiencies. They also recommend that SHA implement a quality control review to monitor the maintenance of tenant files. PHA Response: The SHA has implemented a corrective action plan to address noted deficiencies. The SHA has had significant staffing turnover in the last year. While vacant positions were filled, the SHA contracted with Nan McKay Associates (NMA) to complete all Annual Recertifications. NMA assigned four full-time staff to complete all recertifications and assigned one additional full-time staff person to conduct a monthly Qualify Control Review of all recertifications completed by NMA. During NMA's contract, SHA focused hiring and training new staff. SHA has hired a new Director of Leased Housing, a new Leased Housing Supervisor, and three Leasing Coordinators. SHA is also in the process of promoting it's Tenant Selector to Leasing Coordinator and onboarding a new Tenant Selector. The Director and Supervisor have been providing one-on-one training and support. New staff have also been enrolled in training opportunities provided by outside vendors such as the Nan McKay Rent Calculation Class. As of 7/31/2024, SI-IA has resumed program management from NMA. SHA has also increased the agency's internal quality control audits. The Director of Leased Housing has increased monthly SEMAP review from 10 to 40 files. Monthly feedback is provided to staffers individually and systemic issues are addressed to the entire department. The Supervisor also conducts a monthly review of the Income Verification Tool, following up with staffers to assist them in addressing discrepancies with their client's records. Additionally, SHA has fully implemented an electronic file storage system, utilizing PHA Web's online system to better organize, track, and maintain client files. Since implementation of the corrective action plan, 100% of reviewed files were found to have appropriate Payment Standards, 99% have appropriate third party documentation, and 98% have appropriate adjusted income. 84% were found to have appropriate Utility Allowances. Corrective action has been taken on all errors, and guidance has been provided to staff. Staff are currently conducting a front to back audit of Utility Allowances. SHA will continue conducting file audits, as well as following up with staff. PHA Goal: Based on the SHA's monthly quality control sample of tenant files: (A) The SHA obtains third party verification of reported family annual income, the value of assets totaling more than $5,000, expenses related to deductions from annual income, and other factors that affect the determination of adjusted income, and uses the verified information in determining adjusted income, and/or documents tenant files to show why third party verification was not available; (B) The SHA properly attributes and calculates allowances for any medical, child K:are, and/or disability assistance expenses; and (C) The SHA uses the appropriate utility allowances to determine gross rent for the unit leased, (D) The SHA applies the appropriate payment standard in accordance with 24 CFR 982.505. PHA Strategies: 1) The SHA will review its current quality control tracking system to record the results of random sampling of files as required in 985.2. The SHA will revise this system of an ongoing basis if necessary. Targeted completion date: 3/31/2025. 2) Confirm that 90% or more files sampled contain proper third party written verification (or equivalent) of income and assets, proper calculation of appropriate deductions and allowances and that appropriate utility allowance were used in the calculation of tenant rent. Targeted completion date: 3/31/2025. Person Responsible: Matt Lincoln, Director of Leased Housing Daved Hospedales, Leased Housing Supervisor

Management will maintain tighter scrutiny over the waiting list intake process and only appropriately qualified individuals will enter the waitlist. Additionally, sufficient notations will be made on the waiting list to provide documentation of management decisions and an auditable record of changes and updates to information. The waiting list will be printed out every 30 days and will be maintained in our files.

Management's Response/Planned Corrective Action: The Organization’s Director overseeing these programs will engage with the Compliance Manager to review and establish policies to ensure documentation is retained. Additionally, staff will be trained on policies. This will be completed by February 2025.

Need Analysis and Estimated Financial Assistance Planned Corrective Action: The new student information system adopted this fall will help avoid this issue. In addition, students with high SAIs will be monitored more closely to ensure scholarships and need based aid are being applied appropriately. Person Responsible for Corrective Action Plan: Jean-Claude St Juste, Financial Aid Director Anticipated Date of Completion: December 31, 2024

Student Financial Assistance Cluster– Assistance Listing No. 84.007,84.033,84.063,84.268 Recommendation: We recommend that the college review the process packaging awards and adjusting awards after they are packaged to ensure that the student’s subsidized loan award is calculated correctly, and student is not under awarded. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student’s record has been updated to reflect proper Direct Subsidized Stafford Loan. School will create validation reports run regularly to find any records that may need further review. Name(s) of the contact person(s) responsible for corrective action: Avena Singh Planned completion date for corrective action plan: Incorrect student record fixed November 2024. Validation report shall be completed before February 2025.

Finding: 2024-002, Significant Deficiency over Eligibility Name of Contact Person: David Richmond, Director Corrective Action/Management’s Response: No financial costs are associated with findings. Refresher trainings on household member relationships verification will be held with all Family and Children Medicaid Workers. Ten Targeted second party reviews will be completed by Quality Assurance Team to monitor compliance with policy. Workers are held accountable for outcomes/actions for correct eligibility determination of cases. Proposed Completion Date: All training for corrective action refresher training will be completed by March 31, 2025. Targeted second parties will begin December 2024 and continue.

Corrective Action Plan: As of 5/1/2024, Community Health Partners merged with One Health, thus adopting the sliding fee scale policies and procedures. One Health employs Patient Financial Services Staff that support and review the sliding scale application process, in addition to front desk staff assisting with the initial application. Anticipated Completion Date: 12/31/2024 Contact Person Responsible for Corrective Action: Emily Faricy – Associate Vice President Finance

Identifying Number: 2024-0001 Finding: Eligibility – Determining Federal Direct Student Loan Awards Applicable Regulation: Per 34 CFR 685.203(b)(iii), in the case of a graduate or professional student for a period of enrollment beginning on or after July 1, 2012, the total amount the student may borrow for any academic year of study under the Unsubsidized Loan program may not exceed $8,500. Per 34 CFR 685.203(c)(2)(v), the additional amount that a student described in paragraph (c)(1)(i) of this section may borrow under the Direct Unsubsidized Loan Program for any academic year of student may not exceed the following: in the case of a graduate or professional student, $12,000. Finding: UWS improperly awarded 6 out of 6 students Unsubsidized Federal Direct Loans in excess of the maximum amount for one academic year of $20,500. Summary: During testing of eligibility, six out six students selected for testing within the Doctor of Naturopathic Program were overawarded Unsubsidized Federal Direct Loans. Eligibility testing was performed over 40 other students with no exceptions. We determined that UWS improperly awarded 6 out of 6 students Unsubsidized Federal Direct Loans in excess of the maximum amount for one academic year of $20,500. The total overawards accumulated to $119,443 in total loan funds. The students were awarded the higher annual Direct Unsubsidized Loan limits for certain graduate and professional health professions students. Schools may award the increased unsubsidized amounts to students who are enrolled at least half time in certain health professions programs. The programs must be accredited by specific accrediting agencies for students to qualify for additional unsubsidized loan amounts. The UWS Naturopathic Medicine Doctoral program has not yet achieved the required accreditation from The Council on Naturopathic Medical Education Corrective Action Planned or Taken: During the course of an internal audit of student awards in the Naturopathic Medicine Doctoral program it was determined that the required programmatic accreditation had not been achieved from the Council on Naturopathic Medical Education to qualify for the additional Health Professions unsubsidized loan eligibility. As a result of this finding a thorough audit was completed for all students that were enrolled in the program since the first class began in October of 2023. In total six students were identified, and awards were adjusted to the proper annual loan limit of $20,500. The Institution made students whole by forgiving any student balances that would have been paid by theover award amount. In addition, the software configuration was changed to ensure moving forward that students receive up to the proper maximum of $20,500 until proper accreditation is achieved. Contact Person: Michelle Miller, Senior Vice President of Enrollment Management mmiller10@tcsedsystem.edu Anticipated Completion Date: September 13, 2024

2024-001 ALN 14.195 – Section 8 Housing Assistance Payments Program – Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Cole Carroll, Executive Director Projected Completion Date: June 30, 2025

Finding 2024-001: Student Financial Assistance Cluster-Student Eligibility Criteria: In accordance with 34 CFR 668.165 (a), before an institution disburses title IV program funds for any award year, the institution must notify a student of the amount of funds that the student or his or her parent can expect to receive under each title IV program and how and when those funds will be disbursed. Additionally, when Direct Loans are being credit to a student's account, the institution must notify the student, or parent in writing of the date and amount of disbursement as well as the timing and process by which a parent may cancel the loan. The notification process is often completed by either an award letter or college financing plan. Controls were not in place to ensure that college financing plans were emailed to all required students and/or parents. Condition: The college notifies students of Title IV funding by emailing a college financing plan to the student and/or parent. The college's manual process to identify students who should be notified of the Title IV funding did not identify three students out of forty tested that should have received a college financing plan. Cause: The college process to notify students and/or parents, involves a manual process to idently those who should receive a college financing plan. College financing plans are distributed by email to the student/ and or parent. The college does not have a system in place to verify that everyone who received Title IV funding received a College Financing Plan. Effect: The college did not provide notification via a College Financing Plan of Title IV funding to three of its students as required and potentially could have additional student that did not receive proper notification. Repeat Finding: This is not a repeat finding Recommendation: We recommend that the college implement procedures to ensure all students receive notification of Title IV funding as required under 34 CFR 668.165 (a). Questioned Cost: None View of Responsible Officials and Planned Corrective Action Plan: Responsible Party: Executive Director of Finance and Financial Aid Corrective Action Plan: To ensure that alt students and their parents are adequately informed of the funds they can expect to receive under each Title IV program, as well as the timing and process for disbursement, the college will implement the following actions: 1. College Financing Plan Notification: The college will incorporate the College Financing Plan notification into the packaging checklist, ensuring that it is completed when a student's financial aid package is finalized. 2. Updated College Financing Plan: A new College Financing Plan will be provided to students whenever there is an addition or adjustment to their awards. 3. Loan Disbursement Notification: Loan notification letters will be sent to students each time a Direct Loan is disbursed to their account, informing them of their right to cancel the loan if desired. 4. Quarterly Review: The Assistant Director of Financial Aid will conduct a quarterly review to ensure compliance with these procedures and verify that all necessary notifications are being issued as required.

Finding No. 2024-004 Delay in Direct Loan Adjustment After Enrollment Cancellation Condition Found During our eligibility test, we identified a situation in which a student's enrollment was canceled after Pell and Direct Loan funds had already been credited to the student's account. Even though the Pell Grant adjustment and return to COD were completed promptly, the adjustment for the Direct Loan was only made after the auditor discovered that the loan had not been properly adjusted and returned to the Department of Education. Corrective Action Plan We will thoroughly explore system capabilities, and a targeted training session in the Ellucian software will be developed and scheduled to directly address the identified deficiency. All Student Financial Aid Officers will be required to complete this mandatory training. Additionally, comprehensive internal monitoring exercises will be conducted for all R2T4 events to ensure full compliance and process integrity. Name(s) of the Contact Person(s) Responsible for Corrective Action Doris Quero, Senior Financial Aid director Carmen Rivera Laboy, Title IV Compliance Coordinator Eliezer Rodriguez, Ellucian Specialist Anticipated Completion Date Will be completed on or before December 15, 2024.

2024-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: Equity Health, f/k/a San Francisco Medical Center Outpatient Improvement Programs, Inc. will: - Update the Sliding Fee Discount Program (SFDP) policies and procedures as well as forms for better clarity and tracking. - Continue to perform monthly internal audits of sliding fee transactions. - Retrain current staff quarterly based on the monthly internal audit results. - Train all new staff at new hire orientations. Proposed Completion Date: December 31, 2024

Recommendation: We recommend that at each NSLDS upload date, management review the NSLDS enrollment reporting upload to ensure student withdrawals during the period are appropriately reported in a timely manner. Corrective Action: The Clarendon College Registrar’s Office will establish a review process to ensure that all classes in which a student fully withdrawing from the institution was enrolled are dropped promptly, and that the student's enrollment status matches the status reported to NSLDS.

Finding 2024-003 Inadequate Request For Information Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs The County will make it a practice going forward of calculating the correct net present values recorded for all GASB 87 leases. The prior period adjustments from the previous year did not involve GASB 87 leases and have been remedied. Immediately. Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Robin Huneycutt, Family and Children's Medicaid Supervisor Unit training to discuss accuracy of income and HH size calculations, proper information is included in the case file and necessary procedures are taken when determining eligibility. This will include the importance of documentation of caseworker actions and results from actions. Robin Huneycutt held training with her staff on 10/24/2024 to discuss these deficiencies. Robin Huneycutt, Family and Children's Medicaid Supervisor, and Beth Efird, Adult Medicaid Supervisor Adult Medicaid: An email was sent to staff to remind them to run Work Number/TWN at application and recertification. The Adult Medicaid unit has all new staff since 2023. FC Medicaid: Robin Huneycutt held a training with staff to go over timely request of necessary information specifically income requirements.

Finding 2024-002 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 Inadequate Request For Information Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs The County will make it a practice going forward of calculating the correct net present values recorded for all GASB 87 leases. The prior period adjustments from the previous year did not involve GASB 87 leases and have been remedied. Immediately. Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Robin Huneycutt, Family and Children's Medicaid Supervisor Unit training to discuss accuracy of income and HH size calculations, proper information is included in the case file and necessary procedures are taken when determining eligibility. This will include the importance of documentation of caseworker actions and results from actions. Robin Huneycutt held training with her staff on 10/24/2024 to discuss these deficiencies.

The District will monitor vendors to ensure they are able to accept federal monies. The District will also review all invoices relating to bids to verify correct charges. This will be completed by Ashley Simmons, Accounts Payable Clerk by 6/30/2025.