Corrective Action Plans

Housing Voucher Cluster – Assistance Listing No. 14.871 / 14.879 Recommendation: We recommend the Commission implement processes to ensure that all proper documentation is being maintained during the recertification process for every tenant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective September 2024, the HOC compliance team significantly enhanced the quality control review process to proactively identify SEMAP findings and eligibility discrepancies before the end of each fiscal year. Staff anticipates that this proactive approach will facilitate early identification of training needs on a more frequent basis, ensuring compliance standards are met while also improving overall program effectiveness. Additionally, HRD staff will identify and address systemic findings during monthly staff meetings. To further support these efforts, HOC enlisted a third-party consulting firm to provide training to new and existing staff in October 2024. Staff were trained on eligibility, portability and SEMAP requirements. Additional HOTMA training is scheduled on 11/6/24 - 11/7/24. Moreover, HOC will continue to procure recurring training based on systemic quality control findings prior to the end of the fiscal year. This comprehensive approach will ensure that staff are well-equipped to address any challenges and enhance overall compliance and effectiveness. Name(s) of the contact person(s) responsible for corrective action: Lynn Hayes, Vice President of Housing Resources Division and Darcel Cox, Vice President of Compliance. Planned completion date for corrective action plan: Staff training commenced October 2024 and will continue throughout the fiscal year.

November 18, 2024 Response to Finding 2024-002 Special Tests and Provisions - Enrollment Reporting Significant Deficiency in Internal Control over Compliance Otis College of Art and Design agrees with the finding. Responsible Office and Individual The Executive Director of Financial Aid and The One Stop, Michaela Matsumoto (mmatsumoto@otis.edu) and Registrar Nicole Raef (nraef@otis.edu) are the responsible individuals for implementation of the corrective action plan. Corrective Action Plan Upon review of the finding, Financial Aid administration met with the Registrar's staff to create a new procedure whereby immediate reporting of withdrawals are made directly to NSLDS in addition to the regularly scheduled monthly reports to NSLDS through the National Student Clearinghouse (NSC). This immediate reporting should elimnate any timing issues with the monthly reports through NSC. In addition, a joint effort to streamline the routing of withdrawal forms to the appropriate departments for faster processing is underway. This is reprocessing of the withdrawal forms will be implemented in the next 120 days.

Finding 2024-001, Significant Deficiency and Non-Material Non-Compliance - Eligibility: During the Medicaid control testing, eleven cases were identified that required subsequent corrections in NCFAST; however, these corrections were not completed within the 20-day requirement following the case worker’s audit, as mandated by DHHS policy. Corrective Action Plan: Case Corrections Goal: To ensure Medicaid error findings identified by internal and external audits are timely and accurately corrected for compliance, oversight will be provided by Medicaid Leadership and applicable staff. Plan: The county’s Medicaid Audit Submission tool has been revised to include a case correction due date for eligibility, procedural, and internal control findings. The revision ensures compliance with timely and accurate case corrections. Case corrections must be initiated within five business days of the case audit date. When policy allows, case corrections should be completed within 20 days of the case audit. Performance Improvement Strategies: 1. Program managers, supervisors, applicable lead staff, and trainers, will be provided access and training on the audit tool to monitor the compliance of timely and accurate case corrections. 2. Audit reports will be stored on the county’s OneDrive in the Medicaid Division folder. 3. Supervisors will begin to follow up no later than the 6th business day from the date of audit to ensure case corrections have been completed or initiated, at minimum, by the eligibility specialist. Supervisors will follow up throughout the case correction process to ensure corrections are complete and accurate. 4. Each month, for the prior month, each program manager will select a total of ten audit findings from the Medicaid Audit Finding spreadsheet to ensure their assigned supervisors are compliant with the case correction procedure. These compliance reviews will be conducted and saved to the Medicaid Division folder by the last day of the month. Program managers will take further corrective measures if noncompliance is discovered, by first reporting the continued deficiencies to the Medicaid Division Director. Responsible Parties: Medicaid Program Mangers, Jennifer Hurdle and Alison Westbrook Timeframes: A Medicaid Division meeting will be held no later than November 30, 2024, with all program managers, supervisors, lead staff, and trainers to discuss roles and responsibilities, receive the required training, and the state’s requirement of compliance with monthly audits, case corrections, and corrective actions to mitigate risks from recurring. Agenda and sign-in sheet are required and due to D. Hill no later than December 5, 2024. Finding 2024-001, Significant Deficiency and Non-Material Non-Compliance - Eligibility: During the eligibility compliance testing, it was identified that a Register of Deeds (ROD) check had not been performed at the time of recertification for one case. Although this was an oversight, it did not impact the eligibility determination for the case. The ROD results were subsequently reviewed during the audit process, confirming that the beneficiary was appropriately eligible to receive benefits. This error was classified as a procedural and documentation issue related to the completion of the ROD check. Corrective Action Plan: Register of Deeds Goal: To ensure Register of Deeds (ROD) is inquired and the results are uploaded to the County’s document imaging system when policy requires. Plan: Medicaid programs that have a resource limit require inquiries to be made to the local ROD in the applicant's county of residence to assist with identifying countable and non-countable assets such as real property when determining Medicaid eligibility at application and redetermination. Performance Improvement Strategies: 1. Adult Medicaid - program manager, supervisors, applicable lead staff, and trainers, will develop a required documentation template for all Adult Medicaid staff to use when completing applications and recertifications. The template will be used for all programs under the Adult Medicaid umbrella without exception. The template will include a subsection for resources, highlighting the date ROD checks were conducted and uploaded into NC FAST, if applicable. ROD verification of real property and verification of no real property should be uploaded to the attachments folder within the administrative tab on the Income Support Case. 2. The documentation template will be included in the note section on the beneficiary’s person page or the head of household’s (HOH) person page, if the applicant is not the HOH. 3. The required template will be added to the audit tool to ensurecompliance. 4. Supervisors are required to provide compliance when conducting monthly second party reviews by ensuring the required template, documentation, and uploaded ROD verification is present and correct. 5. Supervisors will take further corrective measures if noncompliance is discovered by first reporting the continued deficiencies to the Medicaid Division Director and Adult Medicaid Program Manager. Responsible Parties: Adult Medicaid Program Manager, Supervisors, Lead Staff, and Trainers Timeframes: A Medicaid Division meeting will be held no later than November 30, 2024, with the Adult Medicaid program managers, supervisors, lead staff, trainers, and other applicable staff to introduce and provide training on the mandatory template. The template will be effective December 1, 2024, with supervisor compliance beginning January 1, 2025, for dates of applications beginning December 1, 2024, and redeterminations initiated beginning December 1, 2024. Agenda and sign-in sheet are required and due to D. Hill no later than December 5, 2024.

Beginning in Spring 2025, the Financial Aid Office will now run the ARGOs Report (Financial Aid Awards by Student) weekly prior to disbursements to find students who applied late in the academic year and need aid to disburse for the previous semester. The financial aid office will no longer need to rely on the processor to notify them when they are packaging aid.

After consulting with other Texas higher education institutions, we have identified that the initial setup of our NSC reports should have included a set of rules. We have submitted an Actionline request to Ellucian Colleague requesting their assistance. We are doing everything to ensure the Fall 2024 report, and subsequent reports, accurately report enrollment statuses.

Views of the responsible official and planned corrective actions: Cisco College has updated the import process to include a review of data by the Financial Aid Office when it is imported into the COD system.

Views of the responsible official and planned corrective actions: Cisco College has updated the process for the NSLDS reporting. The Director of Institutional Effectiveness & Planning will be the reporting official and the Dean of Enrollment Services will be the back-up person for the NSLDS reporting. Both positions have been trained and will ensure that the reporting will continue if there is ever another gap in replacing an open position.

2024-005: Enrollment Reporting Unofficially withdrawn students (students who failed to earn credit during the term) are reviewed after the end of the semester, and R2T4 is calculated, where required. However, there was not a process in place for the Registrar to update the Enrollment Reporting as a result of the review process. Corrective Action: As part of the process of reviewing these students and performing the R2T4 calculation, the Financial Aid Office will send a report of unofficially withdrawn students to the Registrar to ensure that enrollment reporting is appropriately updated. Anticipated Date of Correction: Immediately Contact People: Shanna Vargas, Director of Financial Aid, and Kayla Miller, Registrar

Below you will find our corrective action plan to address the one finding in our FY 2024 Federal Single Audit, which received an unmodified opinion from our auditor Audit Finding #: 2024-1 Eligibility Determination Grantor: Department of Health and Human Services Federal Program Name: Low Income Home Energy Assistance (LIHEAP) Federal Assistance Listing (CFDA#): 93.568 Description: During the audited year July 2023 – June 2024, Access paid benefits for one individual whose income was over the threshold of 60% of the CT state median income. The income was documented, but incorrectly calculated. Statement of Concurrence: Access management concurs with the audit finding: Corrective Action: Access has put in place written procedures as follows: ○ Access will review and revise its training orientation for the next fiscal year. and will provide additional training support and resources to staff to ensure that all LIHEAP applications are certified in an accurate manner. ○ Access will review and improve its file audit process to create a master log of all files reviewed and also note any major findings so a timely response can be made.

Identifying Number: 2024‐003 ‐ U.S. Department of Education Student Financial Assistance Cluster – Special Tests and Provisions: Return of Title IV Funds Finding: The College failed to return title IV funds to the student within the 45‐day time frame for 1 student out of 3 students tested. Contact Person Responsible for Corrective Action Plan: Director of Financial Aid Corrective Action Plan: The Vice President of Academic Life (VPAL) has been informing the Director of Financial Aid ofeach student who has withdrawn, been administratively withdrawn, or been suspended from the College so as to be able to accurately calculate the return of Title IV funds in a timely manner. Anticipated Completion Date: Immediately

2024-002: Missing Exit Counseling Documentation - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing, we noted two students out of 40 did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be an instance of non-compliance with the Eligibility Compliance Requirement. Corrective Action Plan We have updated our Loan Procedures to include running an internal report on all loan students on the 1st and 15th of every month, or the next work day following those dates if they land on a day the campus is closed. If a student with loans has withdrawn completely and stopped attending, we will send an exit letter within 7 business days of discovering that the student has ceased attending. Responsible Person for Corrective Action Plan Isamar Taylor - Director of Financial Aid and Jill Wohrley - Financial Aid Reconciliation and Compliance Specialist Implementation Date of Corrective Action Plan 10/16/2024

For ALN 93.959, a Financial Assessment Form was not properly signed for 1 of the 60 clients tested. Additionally, 2 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form completion date. Obtaining a client's signature on the form has been challenging, particularly during recent years as use of telehealth services has expanded. As a corrective action, team members will be trained in how to properly document receipt of verbal approval. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 89% of the time. As a corrective action plan, SMA will include the completion of the Financial Assessment Form both at admission and annually to be reviewed monthly by the programs. In addition, an action plan will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.

For ALN 93.958, the discount fee that was shown on their Financial Assessment Form was not used for 7 of the 60 clients tested. Additionally, 8 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 89% of the time. As acorrective action, the Client Service Specialist will be trained to ensure data is entered accurately. SMA will also include the completion of the Financial Assessment Form both at admission and annually to be reviewed monthly by the programs. In addition, an action plan will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.

2024-001 - Nonmaterial Noncompliance - Eligibility Program: Child Nutrition Cluster (ALN 10.553 and 10.555) - United States Department of Agriculture; Federal Award Year: 2024 Responsible Officials: John Wack, Chief Financial Officer, Henrico County Public Schools Planned Corrective Action: School Nutrition Services Leadership has put a new process in place, to run a report from the point-of-sale system weekly, that will catch any "Manual" updates to lunch statuses. This report will be run weekly and verified by either the Dietitian or Controller. The report will be initialized and kept on file. Expected Completion Date: 12/31/24

Corrective Action Plan: The District established written procedures to ensure that we are using current eligibility verification through our Skyward Food Service Program. Anticipated Corrective Action Plan Completion Date: June 27, 2024 Contact Information: For additional information regarding this finding please contact Bill Trewyn, Business Manager, at 262-741-9143.

Finding 2024-001 – Tenant Files Auditee’s Response and Planned Corrective Action HHA will take measures establish and utilize a check list as an internal control to be used by Housing Assistants to use during the recertification process to ensure all compliance requirements are met. The checklist will be signed or initialed by the Housing Assistant, reviewed and signed by a member of management, and maintained in the tenants file. This checklist will serve as documentation that all compliance requirements are met. Planned Implementation Date of Corrective Action: December 5, 2023 Person Responsible for Corrective Action: Shereen Goodson, Executive Director Village of Hempstead Housing Authority Shereen Goodson, Executive Director

To Whom It May Concern, Please accept this letter as a formal Corrective Action Plan for the district regarding the audit finding 2024-003, as listed in the FY 2024 Audit. During the 2024-2025 school year either a free and reduced application was misplaced/lost or the district incorrectly qualified the household children of a foster residence to be automatically qualified for free meals as is done with homeless households. Regardless, the district will take the following corrective actions to address the issue in the future: 1. The district has already begun using an electronic lunch application process through the new Student Information System, which should address the issue moving forward. This started with enrollment in the Fall of 2024. AND 2. The superintendent will review the qualification requirements with all staff members that are involved with the free and reduced lunch application process, as well as the district foster care liaison. The person responsible to provide this training will be the superintendent and the training will be completed by December 21, 2024. Sincerely, John French Superintendent of Schools Lewis County C-1 School District

Disbursements to Ineligible Students Planned Corrective Action: The new SIS has been additional filters added that will have two data points to confirm student enrollment before processing disbursements. New packaging and disbursement rules are being added to ensure that this data is captured earlier in the disbursement process. This will be used when packaging for 2025-2026 academic year. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Anticipated Date of Completion: Fall 2025

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

Internal Control over Compliance and Other Matters Recommendation: The organization should design and implement controls to ensure an adequate review process is in place to review compliance with LSC Regulation 45 C.R.F. Part 1611 Eligibility as it relates to obtaining and maintaining signed retainer agreements and eligibility forms for cases requiring such documentation. There is no disagreement with the audit finding. Action taken in response to finding: NNJLS created a Case File Checklist Form and implemented a procedure in which all supervising attorneys must complete the form weekly by reviewing cases to ensure that required signed retainer agreements and eligibility documentation are obtained by the client and uploaded to the case management system. The supervising attorney must report their findings of the review weekly to the Executive Director, obtain any necessary signatures and/or documents, and upload the Case File Checklist Form and documents to the case management system. The supervising attorneys receive a weekly-generated report of cases from the case management system. Name of the contact person responsible for corrective action: Leah Ashe, Executive Director Planned completion date for corrective action plan: As of September 30, 2024, this procedure became effective for all supervising attorneys and will remain in effect with no anticipated expiration.

Planned Corrective Action: DHNP will create a checklist for all staff, to ensure all documents are maintained in the file. DHNP has an effective Quality Control review process that was implemented February 2024. The audit findings were based on files completed in FY 23/24. All files go through the QC process and if errors are found, they must be corrected before payments are approved to be released. Anticipated Completion Date: March 31, 2025 Responsible Contact Person: Ruth Hill, Director

2024-003 – Student Financial Assistance Cluster – (a) Federal Supplemental Educational Opportunity Grants (b) Federal Work-Study Program (c) Federal Perkins Loan (d) Federal Pell Grant Program (e) Federal Direct Student Loans (f) Teacher Education Assistance for College and Higher Education Grants (TEACH Grants) (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 (f) 84.379 – Year Ended June 30, 2024 Criteria: 34 CFR 685.203 states, "A first (second) (third) year student can receive up to $3,500 ($4,500) ($5,500) in subsidized loans in one academic year (34 CFR 685.203).” Condition: We tested 40 files, 37 of which were Federal Direct Loan recipients, and 1 student did not receive the full amount of her Federal Direct Subsidized Loans. Questioned Costs: $1,375 Cause and Effect: The result is a student received unsubsidized loans prior to receiving full subsidized loans. Recommendation: We recommend the College evaluate policies and procedures to ensure students receive the proper amount of Title IV aid. Views of Responsible Officials: Management agrees with this Single Audit Finding. All members of the Financial Aid Office staff will complete the loan learning track on the FSA training site. There will also be a refresher on steps to take prior to awarding a student to ensure the right credit hours are being used for Direct Loan recipients.

Recommendation: The College should update its procedures and related calculations to factor in the current semester enrollment status when a student is close to the Lifetime Eligibility Usage max in order to ensure proper disbursement amounts. Action Taken: The Financial Aid office at SCC is in the process of developing a comprehensive policy and set of procedures that will provide detailed, step-by-step instructions for managing cases involving students who are approaching or have reached their Pell Lifetime Eligibility Used (LEU). The identified error has been thoroughly reviewed with the relevant employee. We expect the updated policy and procedures to be in place by March 2025. Upon completion and approval of the policy and procedures, the office will conduct in-house training to ensure all staff members are well-informed and equipped to implement these guidelines effectively.

Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 09/30/24

Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 09/30/24 2024