Corrective Action Plans

Finding 2023-051 – Corrective Action Plan Management agrees with the finding. DHS completed the scope of work in order to hire an outside contractor to evaluate the work and redefine the workflow distribution to improve timeliness and performance. At this time an outside contractor has not been identified. An additional staff has been added to the RIW policy unit and assigned as the liaison with CSDL to ensure written instructions are clear and accurate. Another meeting between the RIW policy unit and operations has been added as another avenue to address concerns and make corrections. The system vendor is sampling cases to identify missing components. Anticipated Completion Date: October 1, 2024 Contact Person: Donna M. Rook, Ph.D, MSW, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov

Finding 2023-046 – Corrective Action Plan As a result of the USDOE review, RIDE has made the necessary changes to the redistribution of unspent funds. Anticipated Completion Date: The corrected process for redistributing unspent funds from prior years was communicated to the field during the FY24 Perkins Launch Webinar on June 8, 2023. The, corrected calculation redistribution was calculated and implemented on November 27, 2023, when the FY23 funds were redistributed. Contact Person: Mark Dunham, Chief Financial Officer, Department of Elementary & Secondary Education mark.dunham@ride.ri.gov

Finding 2023-045 – Corrective Action Plan This error was identified with the USDOE as part of the monitoring in May 2023. All prior years were correct – this was a one-time error in the calculation spreadsheet. As a result, the USDOE did not believe this occurrence rose to the level of a finding – but rather a procedural suggestion to have the calculation spreadsheet reviewed as part of an internal control procedure. Although the issue was discovered in May 2023, the USDOE did not feel the corrections was necessary to be implemented prior to June 30, 2023, as suggested by RIDE. The rationale was due to a projection of a large amount of unexpended FY23 funding - prior to redistributing the unexpended funds, the correct allocation calculation would be applied which would correct most of the previous allocations. Anticipated Completion Date: The correct allocation calculation was applied to the FY2023 Perkins Secondary funds on June 6, 2023. Contact Person: Mark Dunham, Chief Financial Officer, Department of Elementary & Secondary Education mark.dunham@ride.ri.gov

Finding 2023-034 – Corrective Action Plan The auditee does concur with the few exceptions found; however, the auditee feels that these exceptions are not the result of a lack in compensating controls. These exceptions are de minimis in the full scope of the UI program. Nonetheless, future enhancement and modernization of technical systems will reduce instances of these exceptions even further. Furthermore, under the UI PERFORMS Core Measures, the acceptable level of performance for improper payments is 10% or less. The above percentages are well within this ALP. Anticipated Completion Date: Not Applicable Contact Person: Philip D’Ambra, Director, Income Support, Department of Labor & Training philip.l.dambra@dlt.ri.gov

Finding 2023-032 – Corrective Action Plan RIDOH agrees with the finding and recommendation. This finding is centered around some local agency staff being inactive for longer periods of time (60+ days) and the security risk around them not being terminated or made inactive in our Crossroads system. While RI WIC is routinely notified of terminations and transfers of local agency staff, there are instances of people with varying degrees of access going over 60 days without accessing the system. It is sometimes due to a local agency staff person who is in more of an administrator role and not routinely working in the Crossroads system. RI WIC will review policies and procedures regarding user access to the Crossroads System and will work to strengthen and monitor controls for system access. Policies and procedures will be updated as needed, and internal controls will be implemented and documented. Anticipated Completion Date: December 31, 2024 Contact Persons: Ann Barone, Chief, Office of Women, Infants & Children, Rhode Island Department of Health ann.barone@health.ri.gov Anthony Manzi, WIC Fiscal Manager, Rhode Island Department of Health anthony.manzi@health.ri.gov

Finding 2023-031 – Corrective Action Plan RIDOH agrees with the finding and recommendation. The RI WIC Program was cited by USDA for this issue over a year ago. The issue was caused by the Crossroads MIS system rounding up the calculation for converting formula upon issuance, resulting in over issuance in certain situations. RI WIC immediately changed the calculation and responded to the USDA finding with implementing an updated policy and changes to the system. On December 15, 2023, RI WIC received a response from USDA stating that the finding was closed. Anticipated Completion Date: Completed December 15, 2023 Contact Person: Anthony Manzi, WIC Fiscal Manager, Rhode Island Department of Health anthony.manzi@health.ri.gov

Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record

Our agency has implemented a scanning system which prints bar codes on each document that automatically goes to the correct tenant file. After documents have been signed they are scanned in. This will help alleviate misplaced documents/files. Staff has also been instructed to always put any type of correspondence with tenants in the electronic tenant file.

Department of Housing and Urban Development Housing Voucher Cluster - ALN Number 14.871 Recommendation: We recommend that the Authority implement procedures to ensure all required Income verification and other supporting documentation is obtained when completing the HUD-50058 forms, and to the extent they are not, that action be taken to resolve any issues, and that this action be documented Action taken: Updated "How To" and the file guides. The entire file will be reviewed at all Interims and Re certifications. The Operations Manager/Compliance Officer will review each file for quality control. I have attended training provided by Nelrod and will continue to do so.

Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Views of Responsible Official: There is no disagreement with this finding. Action taken in response to finding: On a monthly basis, the Deputy Director/General Counsel will run a LegalServer report on PAI time, including missing activity details, and will follow up with each person to correct their time records as needed. We will also provide additional training to staff on requirements for classifying time as PAI, and the importance of accuracy in timekeeping detail.

Finding Number: 2023-005 Assistance Listing, Federal Agency, and Program Name 10.558, U.S. Department of Agriculture, Child Care and Adult Food Program Federal Award Identification Number and Year 15-016-271P-00 Pass through Entity Illinois State Board of Education Finding Type Material weakness Repeat Finding No Criteria Per 2 CFR 200.303(a), the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal 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). Other requirements include: a) Per 7 CFR 226.10(c)(1), prior to submitting its consolidated monthly claim to the State agency, each sponsoring organization must perform edit checks on each facility's meal claim; per 7 CFR sections 226.16(g) and (h), a sponsoring organization must disburse advance and meal reimbursement payments to centers and day care homes under its sponsorship within five working days of receiving them from its state agency. b) Per 7 CFR 226.15(f), each sponsoring organization of day care homes shall determine which of the day care homes under its sponsorship are eligible as tier I day care homes c) Communication from the passthrough entity to return to pre COVID 19 monitoring, as required under 7 CFR 226.16(d)(4)(iii), effective October 1, 2022, where sponsoring organizations are required to perform onsite monitoring of each of its facilities three times every year, which includes requirements to ensure the amount of time between reviews does not exceed six months (unless review average is used). Condition A lack of documented controls as evidence of supervisory review and segregation of duties to ensure compliance with Federal program requirements, specifically over: a) monthly expenditure reports submitted to the passthrough entity b) tier (day care home eligibility) determinations c) subrecipient monitoring Questioned Costs None Identification of How Questioned Costs Were Computed N/A no instances of material noncompliance noted that would result in questioned costs Context a) During testing a sample of 5 monthly expenditure submissions, we noted no formally documented supervisory review in place. Additionally, during testing of 40 disbursements to providers, we noted no formally documented supervisory review to ensure disbursements to providers are made within 5 working days of receipt from the State passthrough entity. b) While gaining an understanding of controls over tier (day care home eligibility) determinations, we noted no controls established to ensure supervisory review of these determinations. c) While testing a sample 40 provider monitoring visits, we noted 3 visits without evidence of supervisory review and 6 visits where the visit was completed and validated in the software by the same individual. Additionally, we noted 16 day care homes and 2 day care centers with less than the required 3 annual on site monitoring visits for the year, and 15 day care homes and 2 day care centers where onsite monitoring performed were more than the required 6 months apart. Cause and Effect A lack of effectively designed, implemented, and operating controls in any of these areas could result in a material noncompliance with program requirements or Uniform Guidance. Recommendation We recommend management formalize documentation of a supervisory review of: a) monthly expenditure submissions before submitting to the passthrough entity, including documented supervisory controls to ensure disbursement timeliness is met within 5 working days as part of this review; b) of data used in making tier/eligibility determinations for accuracy and completeness; and c) of subrecipient monitoring. Additionally, we recommend management work with its passthrough entities to confirm compliance requirements, especially when compliance requirements change as the result of ending or expiring waivers and flexibilities. Planned Corrective Action Plan –Organization will document process that is used for second review of the monthly expenditure submissions by 04/30/2024. There are no instances of the Organization not providing funds to provider within the mandated 5 days, however, the Organization will document the process for provider payments within 5 days by 04/30/2024. The software required to be used by the funder for management of the program does have limitations on how the data input for making tier/eligibility determinations second review is documented. Organization will design process to document this second review has occurred by 04/30/2024. Staffing shortages coming out the COVID-19 waivers resulted in the inability to perform all required Subrecipient monitoring. This staffing shortage was rectified by 08/31/2023. Contact person responsible for corrective action: Loukisha Pennex, Chief of Youth and Family Potential, Anjanette Brown, CFO and Teresa Rodriguez, Senior Director of Grants and Contracts. Anticipated Completion Date: April 2024

Corrective Action Plan: I am in receipt of the draft finding letter for the audit that was recently conducted for the Housing Authority of McDonough County. Of the 15 tenant files randomly chosen to review, 7 were not in compliance. Discrepancies include: • Failing to gather proper income verification; • Failing to properly calculate annual income; • Failing to maintain EIV documentation; • Failing to maintain birth certificates or social security cards; and • Failing to maintain Declaration 214s. As I am Executive Director, I am responsible for the Corrective Action Plan that will include rental calculation and HOTMA training for a property managers and me. I am scheduled to attend a rent calc/HOTMA training seminar the week of March 18th. The managers are scheduled to attend a rent calc/HOTMA training seminar the week of April 3rd. In addition, a Quality Assurance program to monitor tenant files will be in effect by April 30, 2024. Anticipated Completion Date: April 30, 2024. Person Responsible: Annette Carper, Executive Director

2023-001 - Non-Compliance with Timely Student Enrollment Change Submissions to the National Student Loan Data System (NSLDS) Management View and Corrective Action Plan February 9, 2024 Inaccurate Graduated Student Enrollment Reporting Management View and Opinion NYU Registrar reports a student's enrollment, withdrawal and graduation status to the National Student Clearinghouse (NSC) weekly, per term, which includes a few weeks before and after the term has ended. NSC transfers this data to the National Student Loan Data System (NSLDS). During the degree/graduation reporting period to NSC, the graduation records for some students are not processed prior to NSC's calculated withdrawal which occurs at the start of the subsequent enrollment reporting period. As such, some students are reflected as withdrawn from a term, when in fact they graduated. This impacts the accuracy of student data reported to the National Student Loan Data System. Corrective Action Plan Currently, students self-identify when their loan servicer reflects an incorrect enrollment or loan repayment status. In these cases, the Office of Financial Aid or Registrar manually adjust the NSLDS/NSC file. NSC procedural timelines impact and limit NYU staff’s access to make manual adjustments. Going forward, the Office of Financial Aid and Registrar will collaborate to upload an NYU Graduated Student file directly to NSLDS to update the records of all students to ensure their graduation status are reported accurately and in a timely manner. This upload will be done through the Enrollment Spreadsheet Submittal function on the NSLDS website. The file will include graduated status information for each conferred student in our most recent conferral period. Timeline for Action Plan The corrective action plan will be implemented as follows: Starting in March 2024, the Office of Financial Aid will provide the NSLDS Graduated Student file template to the Registrar. At the close of each conferral period, the Registrar will populate the template spreadsheet with required data points for all graduating students. After the Office of Financial Aid securely receives the completed spreadsheet from the Registrar, it will be uploaded, within the required 60 days, to NSLDS for processing of the students’ graduation records. Responsible Individual: Jason Crowe Email: Jason.Crowe@nyu.edu

The following represents the Corrective Action Plan related to the audit finding listed in the Schedule of Findings and Questioned Costs included in the December 31, 2023 audited financial statements of McDonald Presbyterian Senior Housing, Inc. d/b/a HaveLoch Commons: Finding 2023-001: Incorrect Eligibility Assessment Condition and Criteria: The Corporation made a data entry error for the annual medical expenses of a resident. Accurate financial information is essential in order to calculate the correct subsidy each resident is eligible for. Management Response and Corrective Action Plan: Management agrees with the finding. The Corporation will perform re-education to its existing members on the importance of this data entry, and update its standard review process over these calculations in order to detect errors on a timely basis.

Finding Number: 2023-014 Federal Program: 10.557, U.S. Department of Agriculture – WIC Special Supplemental Nutrition Program for Women, Infants, and Children Condition Per Auditor: Controls in place were not adequate to ensure the County maintained responsibility for compliance with eligibility standards when eligibility determinations are made by the contractor. Planned Corrective Action: Management has fully implemented a process, as of January 2024, by which a county representee preforms review of contractor eligibility determinations. Anticipated Completion Date: 1/31/24 Responsible Contact Person: Nataline Dean-Woods

2. Finding 2023-002 c. Comments on the Finding and Each Recommendation The Enterprise Income Verification (EIV) was not completed within the 90 days period due to staffing changes. d. Action(s) Taken or Planned on the Finding The compliance monitoring report has now been completed. Staff reviewed the policies and procedures to prevent future occurrences.

OPPORTUNITY RESOURCE FUND CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2023 Opportunity Resource Fund respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit period: Year ended December 31, 2023. Contact Person: Kevin Fitzerald, Vice President of Finance & CFO The findings from December 31, 2023, schedule of findings and questioned are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding: Federal Award Finding: Finding 2023-001 Recommendation: We recommend Opportunity Resource Fund, in the future, implement a review process of applicant information to ensure that all data input into the loan system is accurate. Action to be taken: Opportunity Resource Fund (OppFund) will be implementing a review process to ensure that application information properly input it into the loan servicing system accurately. OppFund will be doing this in a two-part process first by hiring a loan closing position, (starts April 1st) one of their responsibilities will be to review the application and loan servicing software to ensure accuracy. The other part will be to automate the process to ensure that the manual errors do not occur.

Finding Reference Number: 2023-1 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Contact Person Responsible: Flynann Janisse, Executive Director, Equality Community Housing Corporation Joshua Allen, President, J. Allen Management Co. Inc. Completion Date: Open

Condition – Peak Vista (“the Organization”) determines the sliding fee discount charged to patients based on the patient’s annual gross income and household size. We found two encounters where applications were not retained. Therefore, we could not determine if the sliding fee discount applied was in accordance with the guideline. Recommendation – We recommend that the Organization's procedures be strengthened to ensure income is properly verified and adequately documented and retained. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. Peak Vista has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the enrollment and eligibility process, including our Enrollment, Reception, and Billing teams will be retrained on the process with emphasis on proper documentation. The Organization management plans to incorporate into our quality assurance audits the documentation for single service date discount applications and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – In progress. Action Taken – We have reviewed the recommendation and have developed a plan for addressing this issue. Person Responsible for Corrective Action Plan – Ryan Spillane, Chief Financial Officer Corrective Action Plan – Ryan Spillane, Deputy Chief Financial Officer

2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Significant Deficiency in Internal Controls over Compliance Federal Agency Name: Department of Education Federal Assistance Listing Number: 84.425E Federal Program Name: Higher Education Emergency Relief Funds (HEERF) Student Aid Portion Finding Summary: The College did not have consistent controls in place to formerly approve a plan for distribution of funds that was documented and circulated to the College. The lack of a documented plan for distribution of funds to students increases the risk that funds were inappropriately disbursed to students at the wrong amounts. In addition, it increases the risk that the disbursements were not equitable across the student population. Responsible Individuals: Dr. Lorelle Davies, Chief Financial Officer Michael N. Espinoza, Vice President of Student Services Corrective Action Plan: HEERF procedures and processes were adopted and provided to the auditors during the audit process. Three independent outreach efforts were implemented to contact, support, and release funding to students. Limited staffing and a sense of urgency in emergency disbursements contribute less than perfect execution. Documentation was provided for all sample disbursements with a few instances of missing documentation. The Rubric for disbursement through Student Services based on a Pell and enrollment need evaluation was not available to auditors. The college can reproduce criteria to support disbursement. All HEERF funding was distributed to students that met eligibility requirements withing the June 30, 2023, disbursement deadline. Ongoing efforts include the following:  The college will continue to archive and document all disbursement records.  Continued implementation of processes and procedures for all aid disbursement to prevent future instances. Anticipated Completion Date: Completed June 30, 2023

2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster U.S Department of Education Federal Assistance Listing Number: 84.063, 84.268, 84.007, 84.033, 84.379 Federal Program Name: Federal Pell Grant Program, Federal Direct Student Loans, Federal Supplemental Educational Opportunity Grants, Federal Work-Study Program Finding Summary: The College did not have adequate controls in place to ensure the appropriate and reasonable amounts were included in each eligible cost of attendance category for its students, that awards were properly calculated, refunds were disbursed timely and student records were accurate. The auditors were not able to conclude that the College is in compliance with eligibility requirements in the OMB compliance supplement. Repeat finding: No Responsible Individuals: Michael N. Espinoza, Vice President of Student Services Views of responsible officials and planned corrective actions: The college entered into a third-party contract to manage financial aid packaging and awarding. Calculation and reporting completed by prior Financial Director submitted national average as the college calculations instead of college service area specific calculations. The college worked with the third-party provider to ensure policies and processes adopted in July 2023 to ensure cost of attendance (COA) reporting and calculations are complete and accurate going forward. Corrective Action: The College will review their policies, procedures and controls to ensure that annually a cost of attendance schedule is approved, and that the approved schedule is used in packaging student financial aid. Rationale for adjustments made to the budgeted cost of attendance for individual students should be documented and support maintained. The College will review all processes and procedures related to eligibility to ensure controls are well documented and to properly adhere to requirements for eligibility of Title IV aid. Anticipated Completion Date: to be completed by June 30, 2024

2023-005 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Material Weakness in Internal Controls over Compliance and Material Noncompliance Student Financial Assistance Cluster Department of Education Finding Summary: This occurred because of lack of controls and processes in place to ensure supporting documentation is maintained for student’s withdrawal dates, and a lack of understanding of compliance requirements. This resulted in a failure to properly identify students requiring calculation for return of funds to the federal government, or eligibility for post withdrawal disbursement. As a result, the auditors were unable to determine if the College is remitting unearned funds to the federal government, or offering eligible students post withdrawal disbursements if available to them. Responsible Individuals: Michael N. Espinoza, Vice President of Student Services Corrective Action Plan: The college entered into a third-party contract to manage financial aid packaging and awarding. Integration and processes for the R2T4 calculation with the third-party processer was not completed correctly. New integrations, policies, and processes to be adopted in fiscal year 2023-24.  Develop and implement ongoing tracking and reporting for all financial aid reporting.  Financial Aid and Student Accounts work to regularly review and action student account files.  Continue to work with third-party service to review and promptly return Title IV funding in compliance with federal rulings. Anticipated Completion Date: to be completed by June 30, 2024

Enrollment Reporting Cluster: Student Financial Assistance Federal Awarding Agency: Department of Education (ED) Award Name: Federal Pell Grant Program, Federal Direct Student Loans Award Number: Not applicable Award Year: 2022-2023 Assistance Listing Title: Federal Pell Grant Program, Federal Direct Student Loans Assistance Listing Number: 84.063 and 84.268 Pass-through entities: Not applicable Facts of Finding: The University uses National Student Clearinghouse (NSC) to help report enrollment status changes to National Student Loan Data System (NSLDS). For students that had a gap in enrollment and were no longer with the University, the NSC system recognized these students as “withdrawn” regardless of whether they were reported as “withdrawn” or “graduated.” The University confirmed these students were properly reported to NSC as “graduated”; however, when the reporting from NSC to NSLDS occurred, it was based on the information recognized by NSC, and as such these students were reported as “withdrawn.” Acceptance of Finding: We agree with the above finding and will implement the corrective plan of action as described below: Corrective Plan of Action: After submission of enrollment information to the NSLDS, the University has not historically verified that the NSLDS has updated students’ enrollment status accurately. The University will formalize a process and establish procedures to regularly identify students whose enrollment status is improperly reported to NSLDS, particularly those reported as “withdrawn” instead of “graduated.” To the extent there are discrepancies between the University’s records and these students’ enrollment status in NSLDS, the University will correct the enrollment status of such students in NSLDS accordingly. This process and related procedures will be established and implemented by the close of the current fiscal year, July 31, 2024.

The State provided and updated the DHB-7078 - 2nd Pa1ty Review Worksheet which separated evaluation for appl ications and recertifications. The internal worksheet which was expanded to include a weighted score for monitoring error trends and patterns for individual staff and the unit as a whole was updated as well. The enhanced review sheet allows for measuring improvement and determining where additional training is needed. Supervisors complete second party reviews monthly for all staff, conduct targeted reviews for errors identified and hold individual worker conferences monthly to review discrepancies discovered and provide instruction as needed. Targeted training/instruction is also provided during monthly team meetings to review errors and provide guidance and instruction to staff for policy and NC FAST functionality updates. Based on the summary of fi ndings for this fiscal years' audit, a Single County Audit (SCA) Findings Checklist will be created and utilized to address worker processes and functiona lity concerns in NC FAST. The enhanced second party review worksheet will continue to be incorporated as an ongoing practice with review of findings to be conducted individually with staff and at each monthly unit meeting. Review of audit errors and specific instruction surrounding the errors discovered in regards to income, household composition, resources and requesting information wi II be provided to all Medicaid workers ind ividually and during the monthly unit meetings scheduled in November 2023. Following the un it meeting, targeted reviews using the SCA Findings Checkl ist focusing on these errors will be completed during the months of December 2023, January and February of 2024. Results will be compiled and shared with staff during the month ly unit meetings in March 2024 to recognize improvement and engage workers in the resolution process moving forward.

Title X – Assistance Listing No. 93.217Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, adequately documented, and retained for each patient in accordance with organizational policies and program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has put a process in place to ensure patient income and household size is accurately identified and documented. Patients report their income and household size to the health center staff, who enter the information into the electronic medical record system (NextGen). After the information is entered, a registration form (B209) is printed and given to the patient to review, verify, and sign. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: April 15, 2024