Corrective Action Plans

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Assistance Listing Numbers: 14.850 Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness 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). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Finding 2023-004 (continued): Context: There are approximately 460 units. Of a sample size of seventeen (17) tenant files, the following was noted: • HUD 50058 annual recertification was not filed timely in 2 files • Original Application was missing in 1 file • Verification of income was missing in 3 files • Verification of assets was missing in 2 files Our sample size is statistically valid. Known Questioned Costs: $28,961 Cause: There is a material weakness 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, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Public and Indian Housing Program is in material 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 assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Public and Indian Housing Program and will implement internal control procedures that will ensure compliance with federal regulations. Elizabeth Campbell, Interim Deputy Director, will be responsible to implement this corrective action by December 31, 2024.

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871 Noncompliance - N. Special Tests and Provisions - Selection from the Waiting List Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: Selections from the Waiting List. The PHA must have written policies in its Section 8 Administrative Plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203 (Special admission (non-waiting list), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that certain new move-ins to the Section 8 Housing Choice Vouchers Program were selected from the wait list in an order that is in accordance with the Authority’s Section 8 Administrative Plan. Context: Of a sample size of thirteen (13) new move-ins, seven (7) could not be determined to be housed in proper order from the Authority's waiting list. Our sample size is statistically valid. Known Questioned Costs: $181,533 Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to selection from the waiting list. The Authority has not properly housed applicants in compliance with program requirements. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the eligibility type of compliance related to selection from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Finding 2023-006 (continued): Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Voucher Program to ensure that established internal control policies are being followed on a timely basis. Kim Dolan, Chief Financial officer, will be responsible to implement this corrective action by December 31, 2024.

Finding 2023-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster - Section 8 Housing Choice Vouchers - Mainstream Vouchers - Emergency Housing Vouchers Assistance Listing Numbers: 14.871, 14.879, 14.EHV Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Housing Voucher Cluster - Section 8 Housing Choice Vouchers - Yes - Mainstream Vouchers - Yes - Emergency Housing Vouchers - No Finding 2023-001 (continued): Material Weakness and 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). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 2,434 units. Of a sample size of fifty-six (56) tenant files, the following was noted: • HUD form 9886 was unable to be provided in 4 files • Verification of income was unable to be provided in 5 files • Verification of assets was unable to be provided in 4 files • HUD 50058 annual recertification was not filed timely in 8 files • Original Application was unable to be provided in 12 files • Citizen Declaration Section 214 form was unable to be provided in 2 files • Lead based paint form was unable to be provided in 16 files • Signed lease was unable to be provided in 6 files • Our sample size is statistically valid. Known Questioned Costs: • 14.871 - Section 8 Housing Choice Vouchers - $65,025 • 14.879 - Mainstream Vouchers - $31,974 • 14.EHV - Emergency Housing Vouchers - $14,095 Cause: There is a material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and a significant deficiency in the Emergency Housing Vouchers program 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, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers and Mainstream Vouchers programs are in material non-compliance, and the Emergency Housing 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 assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Kathleen Wyatt, Director of Housing Operations, will be responsible to implement this corrective action by December 31, 2024.

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected during the final quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the final quarter of 2024.

Finding 2023-002 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). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of twenty-two (22) tenant files, the following information was unavailable for examination at the time of audit: • Biennial inspection reports were missing in two (2) files Our sample size is statistically valid. Known Questioned Costs: $21,520 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, designed, implemented, maintained, and monitored 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. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. Adam Bovilsky, Executive Director, is responsible for implementing this corrective action by March 31, 2024.

93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Eligibility 2023-024 Strengthen Controls to Ensure Compliance with Eligibility Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response: Use of Tax Return Resources Seven MAGI beneficiaries - DOM did not verify self-employment income reported on tax return DOM Does Not Concur. OSA compared eligibility data to state income tax returns. DOM is prohibited from accessing state income tax records per Mississippi Code Annotated §27-3-73 and currently, is not allowed to have access to federal income tax records. DOM maintains that for determining eligibility, it has complied with the CMS-approved state plan. Using the approved CMS MAGI Based Verification plan in effect during the audit time period, the state sought to verify the reported income to the standard of reasonable compatibility, as defined by CMS, through all available electronic data sources. Further, DOM is required to accept the information provided by the applicant and utilize the available verification methods as detailed in the CMS-approved state plan to evaluate the accuracy of the information provided. If an applicant does not report self-employment income, and the tools available to DOM do not reveal such, DOM has performed its due diligence in the eligibility process and complied with the requirements of CMS, DOM's federal regulatory and oversight agency. Additionally, tax return information is outdated and not deemed applicable to DOM. Four of the 180 MAGI beneficiaries - Income was not verified through Mississippi Department of Employment Security DOM Concurs. This oversight was reviewed with the employees. Additionally, DOM Eligibility staff will be reminded of the MOES response time to ensure that when a MOES request is generated the adequate response time is waited prior to processing an application. Two of the 300 beneficiaries - The beneficiary's case file did not contain a completed application. DOM Concurs. This file could not be located. One of the 300 beneficiaries - DOM could not provide a case file. DOM Concurs. This file could not be located. Fifteen ABD beneficiaries - Resources were not verified through A VS at the time of redetermination. DOM Concurs. This was a previous finding that DOM concurred with. In June 2022, the eligibility system change request list was updated to include asset checks within the system processing workflow to eliminate the manual request process and facilitate asset verification through A VS. This process was implemented June of 2022 for redetermination contacts. Application contacts are a manual process. DOM did not perform resource verification through A VS for the beneficiaries in question prior to this implementation. However, after being notified DOM ran A VS for all applicants, which resulted in no change in the eligibility determination. One hundred ninety-five beneficiaries were not included on all of the required quarterly Public Assistance Reporting Information System (PARIS) me transmissions for fiscal year 2023. Of the 195 beneficiaries, one beneficiary was not included on any quarterly PARIS me transmissions during fiscal year 2023. DOM Does not Concur. PARIS jobs run on February 1, May 1, August 1, and November 1. PARIS will not be pulled on a beneficiary if the case is closed at the time the file is generated or if there is no SSN on file. Additionally, while the records are sent, not all the cases return a match. Our vendor confirmed that a PARIS request was sent for the open cases with SSN numbers on file with one exception. One case was in COE 29-Family Planning. The omission was identified in a previous audit and was corrected in late 2023. DOM Corrective Action Plan: a. All issues identified will be reviewed with regional office staff. Examples of these issues will be included in annual training sessions performed by Eligibility staff. Further, DOM is implementing an electronic storage system to house all documents associated with applicants/beneficiary files. b. Cindy Bradshaw c. December 31, 2024

2023-025 Response: Strengthen Controls to Ensure Compliance with Eligibility Requirements for the Emergency Rental Assistance Program (ERA). ALN# 21.023 We acknowledge the finding. The Mississippi Department of Finance and Administration was not appropriated funds for this program nor was the agency given any authority for the administration for the program. As such, DFA was not in a position to assess eligibility determinations or perform monitoring. DFA drew down funds on behalf of Mississippi Home Corp in light of an impending federal deadline. Mississippi Home Corporation had eligibility and fraud prevention policies in place for the ARPA programs. These policies included, but are not limited to, contracting with a third-party law firm to review all applications with a three-tier review system, monitoring with random sample selections for every 10% completed, employing an internal, qualitycontrol auditor, and reviewing any applications submitted that were greater than $10,000. As a result of their monitoring, MHC was able to identify suspicious applications and report them to the Mississippi Attorney General for investigation. MHC continues to report all expenditures directly to U.S. Treasury on a quarterly basis. It is also worth noting that the program stopped taking applications in September of 2022 which was prior to the issuance of the 2022 Single Audit Report that was released on July 31, 2023. Thus, policies and controls in place could not be changed for this. DFA is taking the position that corrective action is no longer necessary for these funds. Corrective Action: A. The Mississippi Department of Finance and Administration is taking the position that corrective action is no longer necessary. The program stopped taking applications in September of 2022, which is prior to the current 2023 single audit report dated November 21, 2024. Policies and controls in place could not be changed for this. B . N/A C. N/A D. The Emergency Rental Assistance program stopped taking applications September of 2022.

Reference Number: 2023-003 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Agency: Mississippi Department of Employment Security Federal Program: WIOA Cluster Assistance Listing Number: 17.258, 17.259, 17.278 Award Number and Year: 7/1/22 – 6/30/23 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: Compliance – Per 20 CFR parts 680, 681, 682, and 683, state workforce agencies must ensure that individuals are eligible to participate in the program. Control – Per 2 CFR section 200.303(a), a non-Federal entity must: Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The Mississippi Department of Employment Security (MDES) was unable to provide documentation that the eligibility determination for a participant had been reviewed and approved. Context: Documentation for one of forty participants selected for testing did not contain a supervisor’s signature indicating that it had been reviewed and approved. Questioned costs: Undetermined. Cause: Internal controls were not sufficient to ensure that documentation supporting participant eligibility was reviewed and approved by a supervisor. Effect: Failure to ensure that all eligibility documentation is properly reviewed and approved could result in ineligible individuals participating in the program. Recommendation: MDES should review and enhance internal controls and procedures to ensure that participant eligibility documentation is properly reviewed and approved by a supervisor. Views of responsible officials: MDES Response MDES concurs with this finding and recommendation. These incidents were isolated and non-reoccurring. MDES will implement procedures to require a review of all eligibility documents for completeness. Corrective Action Plan: a. MDES Action Plan: MDES will require, as a compensating control for each file to contain a checklist of required documentation that will be reviewed and approved by the supervisor responsible for the respective job center. MDES will verify internal compliance with these procedures over the next quarter. b. Contact Person Responsible: Director of Grant Management. c. Anticipated Corrective Action Plan Completion Date: MDES will complete this corrective action on or before September 30, 2024.

Views of Responsible Officials: Prior to receiving this finding, HIPS was not in the practice of saving documentation of financial or programmatic reporting submission. Staff responsible for submissions are now documenting submission of reports as of 2024. Incorrect application of the de minimis rate was due to an error in the funder-provided spreadsheet. HIPS Finance Manager has been tasked with checking all spreadsheet calculations prior to submissions of financial reporting.

Brockwood Community Association 801 W. Washington Street Greenville, South Carolina 29601 CORRECTIVE ACTION PLAN March 20, 2024 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Brockwood Community Association respectively submits the following Corrective Action Plan for the year ended December 31, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The finding from the year ended December 31, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - Federal Award Program Audit Finding 2023-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Projects (Section 223(f)/207) Recommendation: We recommend that the management ensure the required household members sign the HUD-50059 prior to submitting to HUD. Action Taken: We agree with Finding 2023-001 and the recommendation described in the accompanying schedule of findings and questioned costs. Management obtained the required signature on the HUD-50059. Management will ensure that all required signatures are obtained on all Form HUD-50059's prior to submitting to HUD going forward. If HUD has questions regarding this corrective action plan, please call (704) 771-1696. Sincerely yours, Claudia A Keene, CPA Controller Multifamily Select, Inc. Managing Agent

2023-004 Tenant File Documentation The Housing Authority of Okanogan County recognizes we had several oversights in our tenant file documentation. We will continue to review our tenant file documentation procedures to ensure compliance with HUD program requirements in the future. Subsequent to year-end, during April 2024, the Housing Authority of Okanogan County underwent a Section 8 Management Assessment Program review by the U.S. Department of Housing and Urban Development and received a final score of Standard. We have made several process and procedure improvements and anticipate full compliance during our subsequent audit.

Financial Reporting and Review Process Description of the Finding: BSEDC did not have a secondary review process over the required financial reporting to Federal EDA. The lack of a secondary review process allowed for errors and omissions to go undetected, thus resulting in omission of $3,614 of loan origination fee income and interest income from federal program income calculations. Planned Corrective Actions: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director have implemented processes for the Senior Director of Finance to perform a secondary review of the required reporting to Federal EDA before it is submitted. Timeline for Completion: BSEDC implemented the secondary review process in October 2024 with the completion and submission of the FY24 annual report to Federal EDA. Responsible Person or Party: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director are both responsible for ensuring that the secondary review is complete before submitting reporting to Federal EDA.

Finding No. 2023-001: Compliance with Single Audit Requirements Description of the Finding: Big Sky Economic Development Corporation, Inc. (BSEDC) did not engage to conduct a single audit for FY23 despite meeting the expenditure threshold, and the required audit report was not submitted within the prescribed due dates. This oversight necessitated the reissuance of the FY23 financial statement audit to complete and issue a single audit. Planned Corrective Actions: BSEDC’s Senior Director of Finance engaged with an independent auditor to complete the single audit for FY23 and re-issue the financial statement audit which was missed during the performance of the FY23 financial statement audit due to the Senior Director of Finance and the parties they engaged to perform the audit not having a clear understanding of the calculation for federal expenditures for the federal revolving loan fund. The Senior Director of Finance now has a clear understanding of the requirements for the calculation and reporting of federal expenditures in the Schedule Expenditures of Federal Awards as it relates to the federal revolving laon fund. Timeline for Completion: BSEDC engaged with an independent auditor to complete the single audit for FY23 and reissue the FY23 financial statement audit in June 2024. Expected completion is November 2024. Responsible Person or Party: BSEDC’s Senior Director of Finance is responsible for implementing the corrective action.

Finding 2023-004 Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs (continued) Supervisors, will ensure staff complete all required trainings provided by the Division of Health Benefits. Supervisors will provide additional training, when needed to ensure staff have a good understanding of all current and new policy as policy continuously changes. Records will be reviewed internally to ensure cases provide proper documentation. Corrective Action (continued): Proposed completion date: Corrective Actions for Finding 2023-002, 2023-003, and 2023-004 also apply to State Award Findings. Section IV - State Award Findings and Question Costs Training will be provided the week of November 20, 2023 to review findings and corrective action items. Trainings will continue every week to review policy changes, NCFAST updates as well as common errors that may be found during second party reviews. Workers will be trained on the importance of ensuring files include, online verifications, documentation of resources and ensuring, documented resources and income match information entered in NCFAST. Documentation in files should provide clear steps taken by caseworkers to determine eligibility. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications, As policy changes and new recommendations are provided by the state, checklists are updated to ensure staff are aware of the most recent policy and procedures.

Finding 2023-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2023-004 Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs (continued) Supervisors, will ensure staff complete all required trainings provided by the Division of Health Benefits. Supervisors will provide additional training, when needed to ensure staff have a good understanding of all current and new policy as policy continuously changes. Records will be reviewed internally to ensure cases provide proper documentation. Amy Spring, Income Maintenance Administrator Training will be provided the week of November 20, 2023 to review findings and corrective action items. Trainings will continue every week, to review policy changes, NCFAST updates as well as common errors that may be found during second party reviews. Amy Spring, Income Maintenance Administrator Training will be provided the week of November 20, 2023 to review findings and corrective action items. Trainings will continue every week to review policy changes, NCFAST updates as well as common errors that may be found during second party reviews. Supervisors, will ensure staff complete all required trainings provided by the Division of Health Benefits. Supervisors will provide additional training, when needed to ensure staff have a good understanding of all current and new policy as policy continuously changes. Records will be reviewed internally to ensure cases provide proper documentation. Workers will be trained on the importance of ensuring files include, online verifications, documentation of resources and ensuring, documented resources and income match information entered in NCFAST. Documentation in files should provide clear steps taken by caseworkers to determine eligibility. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications, As policy changes and new recommendations are provided by the state, checklists are updated to ensure staff are aware of the most recent policy and procedures.

Finding 2023-002 Name of contact person: Corrective Action: Training will be provided the week of September 5, 2023 to review findigns of corrective action items. Trainings will continue every week to review policy changes, NCFAST updates, as well as common errors that may be found during second party reviews. Two applications cited in error were processed by temporary staff hired to assist with the volume of Crisis Intervention applications as well as the Low-Income Energy Assistance applications. Two applications cited in error were processed by an employee who has retired. Training will be provided to all temporary staff when hired to ensure applications are processed accurately and all necessary information is requested. Supervisor will be reviewing records internally to ensure accuracy of cases. Applications will be revieiwed and monitored on a rotation basis. Findings from second party reviews will be reviwed with the worker to monitor a pattern for errors and will review policy guidelines to ensure worker is knowledgeable of policy requirements. Training will also be provided to ensure all files include online verifications. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibilty decisions. Checklists have been established to include errors cited during the audit. Checklists are to be completed at all applications. Amy Spring, Income Maintenance Administrator Supervisors, will ensure staff complete all required trainings provided by the Division of Health Benefits. Supervisors will provide additional training, when needed to ensure staff have a good understanding of all current and new policy as policy continuously changes. Records will be reviewed internally to ensure cases provide proper documentation. Workers will be trained on the importance of ensuring files include, online verifications, documentation of resources and ensuring, documented resources and income match information entered in NCFAST. Documentation in files should provide clear steps taken by caseworkers to determine eligibility. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications, As policy changes and new recommendations are provided by the state, checklists are updated to ensure staff are aware of the most recent policy and procedures.

Finding No.: 2023-004 Federal Agency: U.S. Department of Agriculture AL Program: 10.555 Child Nutrition Cluster Federal Award No.: 7GU300GUB Area: Eligibility Questioned Costs: $0 Views of Auditee and Corrective Actions: GDOE agrees with the finding. GDOE did not published School Year 2022-2023 eligibility notifications for the community eligibility provision to the GDOE website by May 1, 2023 as required by the National School Lunch Act (NSLA). GDOE Child Nutrition Program (CNP) division is aware of the requirement and has publicly posted eligibility notifications to ensure compliance to NSLA. GDOE does not anticipate this will be an audit finding moving forward. Plan of action and completion date: The CNP Office has incorporated a calendar reminder within the CNP Office and updated the internal calendar of report due dates to facilitate the timely upload of the required information to the GDOE CNP website. Plan to monitor and responsible officials: The CNP State Administrator, Franklin Cruz, will ensure that CEP eligibility notifications are posted to the GDOE website by May 1 of every year to be in compliance with the reporting requirements of the NSLA.

CAMcare has made significant changes to the patient payment collection process. Updates were made to the Patient Payments, Refusal to Pay, Waiver/Reduction of Charges Policy, Sliding Fee Scale Policy, and Patient Payments Policy, and a Patient Payments Policy was introduced. The new EMR system allows for individual Patient Service Representatives (front desk personnel) to monitor management's adherence to collection efforts.

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will be reuqiqred to complete training courses in 2024. Property clerks and leasing specialists will be required to complete Rent Calculation courses that coorelate to their program type. HACFM is actively working on creating operation procedures and process manuals. the Procedure manaul will include the following reuqirements: Annual recertificaton packets will be sent to the resident 120 days from the houshold's annual effective date. Submission of reuqired documentation from resident will be enforced according to the lease agreements. A certification review checklist to support staff in ensuring all documnetation is in the file and all requried signatures are present. The Checklist will ensure that the submitter is verifying the file, the property manager has certified the file prior to finalizing the review in the tenant software program and uploading the file to the records. The property manager is reuqired to conduct 5% audit of the files monthly and correct any deficiencies found. An audit checklist will be created to support this required task. The management analyst position is required to audit 5 random files from each site on a quarterly basis. Ans audit checklist will be createdto support this required task.

The following procedure is put in place to prevent the conditins found during a recent audit review of the LIPH and HCV files: All staff will read HUD requirements for reexamining income and family composition for families in the Public Housing and Housing Voucher Programs. Property managers will be reuqiqred to complete training courses in 2024. Property clerks and leasing specialists will be required to complete Rent Calculation courses that coorelate to their program type. HACFM is actively working on creating operation procedures and process manuals. the Procedure manaul will include the following reuqirements: Annual recertificaton packets will be sent to the resident 120 days from the houshold's annual effective date. Submission of reuqired documentation from resident will be enforced according to the lease agreements. A certification review checklist to support staff in ensuring all documnetation is in the file and all requried signatures are present. The Checklist will ensure that the submitter is verifying the file, the property manager has certified the file prior to finalizing the review in the tenant software program and uploading the file to the records. The property manager is reuqired to conduct 5% audit of the files monthly and correct any deficiencies found. An audit checklist will be created to support this required task. The management analyst position is required to audit 5 random files from each site on a quarterly basis. Ans audit checklist will be createdto support this required task.

All Nations Health Center has switched EHR systems that allows for intake coordinators to suspend/pause eligibility status until all proper documentation has been obtain from the client, scanned into the system, and filed appropriately.

Management Response #2023-008: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. The Corporation also failed to provide sufficient support to verify that the applicant signed the Rights and Obligations statement. Corrective Action Plan: • All eligibility verification data, including screenshots and signed Rights and Obligations statements, will be stored in a centralized, secure shared drive maintained and managed by the WIC Director to ensure it is protected with limited access and password protection. The drive will be organized using a de-identified naming convention to ensure privacy while maintaining ease of access for authorized staff. • To maintain a robust system of checks and balances, tasks related to eligibility verification and documentation will be divided among different team members. This separation will prevent any one individual from having full control over the process, reducing the risk of oversight or potential errors. • The WIC Department’s policy and procedure manuals will be revised and updated to include the new eligibility verification process. • To ensure adherence to the new protocols, periodic audits and review sessions will be conducted by the WIC Director or designated compliance staff to verify that documentation is being properly maintained and that all procedures are followed. Staff will be required to undergo refresher training sessions as needed to reinforce the updated protocols and best practices. Responsible Party: Tracy Harrison, COO

Cluster Name: Student Financial Assistance Cluster Assistance listing numbers and names: Northern Arizona University 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins Loan Program—Federal Capital Contributions 84.063 Federal Pell Grant Programs 84.268 Federal Direct Student Loans 84.379 Teacher Education Assistance for College and Higher Education Grants (TEACH Grants) 93.364 Nursing Student Loans 93.925 Scholarships for Health Professions Students from Disadvantaged Backgrounds—Scholarships for Disadvantaged Students (SDS) Agency: Northern Arizona University (NAU) Name of contract person and title: Bradley Miner, NAU Associate Vice President and Comptroller Anticipated Completion Date June 30, 2024 Agency’s Response: Concur The University agrees with this finding and although it relies on the Federal agencies for valid identity verification, the University has already taken significant corrective action to proactively monitor and detect fraudulent student identities. The University has various internal controls, system fraud controls, and integrity measures in place as required or identified as industry best-practice to mitigate and prevent the increasing sophistication of fraudulent activity. In academic year 2023 the University had 282 online students selected for Verification by the Department of Education (ED). The 8 isolated fraud instances were the only identified fraud cases. The University receives valid identity verification checks from the Department of Education (ED) as an input for creating student profiles. Additionally, the University works with administrative agencies and leverages FAFSA checks conducted by Social Security Administration (SSA), Department of Veteran Affairs (VA), Department of Homeland Security (DHS), National Student Loan Data System (NSLDS), Department of Defense (DOD), Department of Justice (DOJ). Financial Aid does not disburse until enrollment verification is complete. 1. The University has reviewed prior fiscal years to determine if additional fraudulently enrolled students received student financial assistance, and if fraudulent loans and awards were awarded. The University conducted an in-depth analysis of multiple qualitative attributes of students receiving financial assistance. This analysis identified high risk students receiving loans and awards. Students in this population were required to complete V4 verification. 2. The University implemented anti-fraud measures as an alternative to automated student Internet Protocol (IP) verification. During the analysis to identify fraudulently enrolled students, the University identified programs at high-risk for fraudulent activity. As a proactive fraudulent activity identification measure, the University will require all students in high-risk programs, with active FAFSAs to submit and complete V4 identity verification. This anti-fraud measure will identify fraudulently enrolled students prior to the disbursement of student financial assistance including loans and awards. 3. The University has put in to place a number of additional verification measures and detective controls to validate online student identities and check for repetitive information and trends. The University is conducting feasibility studies to determine if the suggested guidance for Internet Protocol student verification abides by certain security and privacy standards and policies. Additionally, the University has concern with fraudsters ability to mask Internet Protocols by deploying Virtual Private Networks (VPNs). This renders the advanced protocols ineffective. As a compensating control, the University will begin selecting 5% of online students for V4 verification. Random sampling of online students for identity verification provides enhanced detective measures to combat the risk of identity theft for use in financial aid fraud. Additionally, the University put in place several upfront measures to detect repetitive information and trends to identify potentially fraudulent activity. Detective monitoring reporting identifies duplicate deposit information, redundant student email information, and duplicate student address information. The Department will continue to utilize these successful anti-fraud measures to proactively identify fraudulent student identities. 4. The University will continue its efforts working with law enforcement agencies to recover improper payments for fraudulent claims it paid due to identity theft, to the extent practicable. The University worked with law enforcement agencies to investigate the fraud. At the conclusion of the investigation $138,135 has been repaid. The University will continue to partner with federal, state, and local law enforcement agencies and financial institutions across the country to recover losses and aggressively pursue legal action against perpetrators of fraud.