Corrective Action Plans

Finding: 2024-004 Federal Agency Name: U.S. Department of EducationAssistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: Awards must be coordinated among the various programs and with other federal and nonfederal aid (need and non-need-based aid) to ensure that total aid is not awarded in excess of the student’s financial need or cost of attendance (34 CFR 668.42, FWS, and FSEOG, 34 CFR 673.5 and 673.6; Direct Loan, 34 CFR 685.301). Financial need is defined as the student’s COA minus the student’s EFC (as computed by the central processor and included on the student’s SAR/ISIR). During the testing of compliance for Eligibility, it was noted students who worked as Resident Advisors for the University, did not have their Title IV aid adjusted for amounts they received via direct payments to cover the cost of their housing. As a result, the University compensated the students for the cost of their housing outside the normal processing and packaging of Title IV aid, resulting in $26,572 of Direct Loans being disbursed to student’s in excess of their financial need. Responsible Individuals: Kella Helyer, Director of Financial Aid Corrective Action Plan: The current year (2024-25) Resident Assistant benefits have been taken into consideration for all applicable students. Anticipated Completion Date: 9/10/2024

Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to State award findings. Finding: 2024-005 Name of contact person: Lindsey Cearlock Corrective Action: Proposed Completion Date: Immediately. To review all grant documentation carefully and ensure the County is compliant with all requirements. Section IV - State Award Findings and Questioned Costs Jessica Wall, Director YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 50 cases to verify that appropriate requests for informaiton are made. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recertifications that would ensure that appropriate information requests have been made and evaluated. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of information requests. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 50 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24. Supervisors will provide staff with a report at least once per month that includes terminated SSI cases that require a full eligibility evaluation. Staff will return this report each month with their initials to indicate that they have initiated full evaluations. Training will be provided by 11/30/24. Training will be provided by 11/30/24 and staff will received SSI Termination Report by 11/30/24. Jessica Wall, Director

Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to State award findings. Finding: 2024-005 Name of contact person: Lindsey Cearlock Corrective Action: Proposed Completion Date: Immediately. To review all grant documentation carefully and ensure the County is compliant with all requirements. Section IV - State Award Findings and Questioned Costs Jessica Wall, Director YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 50 cases to verify that appropriate requests for informaiton are made. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recertifications that would ensure that appropriate information requests have been made and evaluated. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of information requests. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 50 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24. Supervisors will provide staff with a report at least once per month that includes terminated SSI cases that require a full eligibility evaluation. Staff will return this report each month with their initials to indicate that they have initiated full evaluations. Training will be provided by 11/30/24. Training will be provided by 11/30/24 and staff will received SSI Termination Report by 11/30/24. Jessica Wall, Director

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs Jessica Wall, Director YCHSA will inititate income calculation quizzes for staff following training to ensure understanding of training around this finding. YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 50 cases to verify appropriate income calculations and household members. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recerts that would ensure that determinations in the case and correct outcomes. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of accurate information entry. Calculation quizzes will be in use by November 30, 2024. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 50 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24. Jessica Wall, Director YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 15 cases to verify appropriate resource entry. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recertifications that would ensure that appropriate resources have been entered and evaluated. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of accurate resource entry. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 15 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24.

Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs Jessica Wall, Director YCHSA will inititate income calculation quizzes for staff following training to ensure understanding of training around this finding. YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 50 cases to verify appropriate income calculations and household members. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recerts that would ensure that determinations in the case and correct outcomes. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of accurate information entry. Calculation quizzes will be in use by November 30, 2024. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 50 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24. Jessica Wall, Director YCHSA will continue second party at least 76 Medicaid cases per quarter and will do a targeted second party review of an additional 15 cases to verify appropriate resource entry. YCHSA will implement a checklist to be used prior to eligibility decision for applications and recertifications that would ensure that appropriate resources have been entered and evaluated. YCHSA will develop a shared training platform that will include powerpoint presentations and handouts around the areas of accurate resource entry. Checklist will be developed and implemented by 11/18/24. YCHSA will complete an additional targeted review of at least 15 cases per quarter beginning with Quarter 2 of Fiscal Year 2025. YCHSA will develop shared training platform with the expectation that staff will have completed at least one module by 11/30/24.

2024-007 – Child Nutrition Cluster – Eligibility - The District is aware of the missing eligibility documents for the Child Nutrition program and will implement new procedures and a plan to reduce the missing documentation. Responsible Officials – Joe Dawidziak, Superintendent Anticipated Completion Date – The District will correct this in the subsequent fiscal year.

Views of Responsible Officials and Corrective Action Plan The College, with support from the District, will implement an annual review of compliance requirements and training for all staff associated with eligibility requirements for calculated disbursements amounts to ensure accuracy. Norco College Student Financial Services reviewed the workflow and processing procedures of flagging student files in a timely manner for those that qualify for the additional Pell indicator. The intention of these efforts is to meet regulatory compliance requirements as they are related to student Pell eligibility when awarding and packaging students for additional Pell. There was staff turnover during the 2023-24 award year resulting in procedures misunderstood and not followed consistently which caused the student to not be flagged at the appropriate time in the awarding and disbursement process. An Assistant Director position was approved and filled as of May 2024. The Assistant Director is responsible for Pell grant payment oversight during the authorization and approval of the institution’s monthly disbursement process to ensure federal guidelines are adhered to. The Assistant Director has completed thorough training regarding the disbursement process and Pell eligibility. Additionally, training is conducted on a regular basis to review student Pell disbursement eligibility for accuracy.

Corrective Action: Application checklist updated to include a line items to ask if the client owns their home; does the client have to pay rent or any other living expenses; and was the case evaluated for 1/3 reduction if applicable. These additions to the checklist will serve as a reminder to the worker that all of these areas are covered when working the case. Training will be conducted with all workers on MA-2261 1/3 Reduction, and MA-2230 Financial Resources. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST matches the information in determinations. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Name of contact person: Virginia Ewuell and Angel Joyner, Medicaid Supervisors. Denise McKnight, Social Services Program Administrator Corrective Action: SSI termination reports are being worked and monitored to ensure that SSI terminated recepients are reviewed and acted on timely. Application checklist has been updated with the line item to check to see if SSI has been terminated. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST matches the information in determinations.

Corrective Action: Application checklist updated to include a line items to ask if the client owns their home; does the client have to pay rent or any other living expenses; and was the case evaluated for 1/3 reduction if applicable. These additions to the checklist will serve as a reminder to the worker that all of these areas are covered when working the case. Training will be conducted with all workers on MA-2261 1/3 Reduction, and MA-2230 Financial Resources. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST matches the information in determinations. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025. Name of contact person: Virginia Ewuell and Angel Joyner, Medicaid Supervisors. Denise McKnight, Social Services Program Administrator Corrective Action: SSI termination reports are being worked and monitored to ensure that SSI terminated recepients are reviewed and acted on timely. Application checklist has been updated with the line item to check to see if SSI has been terminated. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST matches the information in determinations.

Finding: 2024-004 Inaccurate Information Entry Finding: 2024-005 Inaccurate Resource Calculation Finding: 2024-006 Inadequate Request for Information Corrective Action: Application checklist updated to include a list of persons in the household, a line item also added to ask if changes have been applied in NCFAST. A line item was also added to list the children in the home and request for IV-D referral if applicable. Medicaid Supervisors and Quality Control workers will review files internally prior to approval or denial of a case to ensure that verifications match the evidence in NCFAST and changes have been applied to the cases. This will serve as a second check to catch things prior to the case being completed. MA-3300 Income training will be conducted with all workers. Corrective Action: Application checklist updated to include a line item to check to see if the bank account information in evidence matches what shows in determinations. Caseworkers will be trained to enddate old evidence and start a new evidence for a new period to show when the information has been updated. Medicaid Supervisors and Quality Control workers will review files internally to ensure verifications received and put into evidence matches information in determinations once an eligibility check has been ran. They will also ensure that changes have been applied. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025.

Finding: 2024-004 Inaccurate Information Entry Finding: 2024-005 Inaccurate Resource Calculation Finding: 2024-006 Inadequate Request for Information Corrective Action: Application checklist updated to include a list of persons in the household, a line item also added to ask if changes have been applied in NCFAST. A line item was also added to list the children in the home and request for IV-D referral if applicable. Medicaid Supervisors and Quality Control workers will review files internally prior to approval or denial of a case to ensure that verifications match the evidence in NCFAST and changes have been applied to the cases. This will serve as a second check to catch things prior to the case being completed. MA-3300 Income training will be conducted with all workers. Corrective Action: Application checklist updated to include a line item to check to see if the bank account information in evidence matches what shows in determinations. Caseworkers will be trained to enddate old evidence and start a new evidence for a new period to show when the information has been updated. Medicaid Supervisors and Quality Control workers will review files internally to ensure verifications received and put into evidence matches information in determinations once an eligibility check has been ran. They will also ensure that changes have been applied. Proposed Completion Date: Training and implementation of additional reviews and procedures will be implemented by January 15, 2025.

Finding: 2024-003 IV-D Non-Cooperation Edgecombe County County Administration Building 201 St. Andrew St., PO Box 10 Tarboro, NC 27886 252-641-7834 ∙ Fax 252-641-0456 www.edgecombecountync.gov For the Year Ended June 30, 2024 Corrective Action Plan Edgecombe County, NC Proposed Completion Date: June 30, 2024 Name of contact person: Linda Barfield, Chief Financial Officer Corrective Action: The budget variance in Debt Service stemmed from the reclassification of lease and subscription expenses originally budgeted at the departmental level. For financial reporting purposes, ease and subscription principal payments were reclassed to debt service to ensure accurate reporting. While the original departmental budgets were within approved limits, the reclassification affected the Debt Service budget after the fiscal year ended. FY24 is the first year of implementation of GASB 96 for subscriptions and the second year of GASB 87 for leases. The impacts of both these GASBs, was not fully known at the time the budget was adopted. The County will make the necessary budget amendments to FY25 budget before the end of the fiscal year to align the budget with anticipated financial reporting. Additionally, the County implemented additional review procedures to monitor such reclassifications closely and will continue to assess our budget tracking processes to prevent similar instances in future periods. Section II. Financial Statement Findings Proposed Completion Date: June 30, 2024 Name of contact person: Linda Barfield, Chief Financial Officer Corrective Action: The County initiated a rate study to assess the adequacy of our current rate structure in supporting both operating expenses and debt service obligations. The rate study analysis is still being finalized, so the impact to the rates is not yet known. The County plans to carefully consider adjustments or operational improvements based on the study’s findings to ensure compliance with bond covenants. Section III - Federal Award Findings and Question Costs Name of contact person: Brandy Dawes and Tina Radford, Medicaid Supervisors. Denise McKnight, Social Services Program Administrator Corrective Action: Application checklist updated to include line items to list all children in the household and absent parents. This list will ensure that the workers include IV-D referrals for all children when a parent is receiving benefits. Medicaid Supervisors and Quality Control workers will review files internally to ensure policy is applied to all cases and that the evidence entered into NCFAST and shows that a IV-D referral have been sent to Child Support.

Finding 2024-001 – Housing Choice Voucher Program Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Material Weakness - Housing Choice Voucher Program – ALN 14.871 Corrective Action Plan: Timeliness of Annual Recertifications RHA has implemented all strategies identified in the Corrective Action Plan in response to the previous audit’s finding regarding later annual recertifications, including, but not limited to: • Competitive compensation to attract and retain qualified employees. • Housing Choice Voucher Certification and other training to enhance RHA’s ability to comply with HUD regulations. • Reorganization of the department to implement case management to replace conveyor-belt style approach to annual recertifications to inject greater accountability for outcomes. • Improved supervisor to employee ratios to ensure that managers have reasonable supervisory loads (maximum of 1 TO 6). • Implementation of YARDI software to increase efficiency of our annual recertification processes. In addition to these corrective action strategies, RHA has also implemented state of the art information tools to track recertifications, measure timeliness and completion performance, and motivate staff and teams to perform at the highest level. The results of these efforts are in line with the expectation that was included in the previous corrective action plan: Anticipated Completion Date: These are mainly system changes that will be fully implemented in 2024, for example, new software, with significant improvements that will be evidenced by December 31, 2024. The results so far in December 2024 have exceeded expectations. For example, • As of December 1, 2024, 87% of recertifications with an effective date of January 1, 2025, had been completed. • As of December 16, 2024, 94% had been completed. • As of December 16, 2024, 73% of recertifications with a due date of January 1, 2025, and an effective date of February 1, 2025, have been completed. Our goal is to complete 90 to 95% by the due date, allowing for cases where participants are late in submitting their information. Having completed all corrective action strategies and plans, RHA expects results that will be in full compliance with completing annual recertification by their due date by July 31, 2025. Person Responsible: Priscilla Batts, HCV Director, is principally responsible and accountable for the outcome above.

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Inaccurate Resources Entry The County met with all Adult Medicaid Staff to discuss inaccurate resource entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28 through 10/29/24 Finding: 2024-004 Corrective Actions for findings 2024-002, 2024-003, 2024-004, 2024-005, and 2024-006 also apply to the State Award findings. Finding: 2024-005 Inaccurate Information Entry The County met with All MAGI and Adult Medicaid Staff to discuss inaccurate information entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings Section IV- State Award Findings and Questioned Costs Finding: 2024-006 Untimely Review of SSI Terminations The County met with all Adult Medicaid Staff to discuss the untimely review of SSI terminations and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28/24

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Inaccurate Resources Entry The County met with all Adult Medicaid Staff to discuss inaccurate resource entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28 through 10/29/24 Finding: 2024-004 Corrective Actions for findings 2024-002, 2024-003, 2024-004, 2024-005, and 2024-006 also apply to the State Award findings. Finding: 2024-005 Inaccurate Information Entry The County met with All MAGI and Adult Medicaid Staff to discuss inaccurate information entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings Section IV- State Award Findings and Questioned Costs Finding: 2024-006 Untimely Review of SSI Terminations The County met with all Adult Medicaid Staff to discuss the untimely review of SSI terminations and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28/24

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Inaccurate Resources Entry The County met with all Adult Medicaid Staff to discuss inaccurate resource entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28 through 10/29/24 Finding: 2024-004 Corrective Actions for findings 2024-002, 2024-003, 2024-004, 2024-005, and 2024-006 also apply to the State Award findings. Finding: 2024-005 Inaccurate Information Entry The County met with All MAGI and Adult Medicaid Staff to discuss inaccurate information entry and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings Section IV- State Award Findings and Questioned Costs Finding: 2024-006 Untimely Review of SSI Terminations The County met with all Adult Medicaid Staff to discuss the untimely review of SSI terminations and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/28/24

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Finding: 2024-003 IV-D Non-Cooperation The County met with All MAGI Medicaid Staff to discuss the noncooperation with child support procedures and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/29/24 Section III - Federal Award Findings and Questioned Costs Corrective Action Plan Meeting held 10/28/24 Inadequate Request for Information The County met with all Adult Medicaid Staff to discuss inadequate request for information and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Reconciliation of Records and Reporting Holly Martinez-Borja, Finance Director The County has made great efforts to achieve the timely completion of the annual audit and issuance of the financial statements. The County will ensure the appropriate year-end accounting adjustments to be properly recorded. The County has hired an experienced Finance Officer with 20 years of experience. An Assistant Finance Officer position has been added to the department to assist with the daily operations to increase capacity within the department. Board policies and procedures are implemented to increase oversight and accountability. For the Year Ended June 30, 2024 Section II - Financial Statement Findings Finding: 2024-001 Imminently.

Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Name of Contact Person: Nia Broadway, Medicaid Manager Corrective Action: Proposed Completion Date: Finding: 2024-003 IV-D Non-Cooperation The County met with All MAGI Medicaid Staff to discuss the noncooperation with child support procedures and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Meeting held 10/29/24 Section III - Federal Award Findings and Questioned Costs Corrective Action Plan Meeting held 10/28/24 Inadequate Request for Information The County met with all Adult Medicaid Staff to discuss inadequate request for information and the policy associated with the findings. The County will continue Second Party Reviews and conduct trainings based on findings. Reconciliation of Records and Reporting Holly Martinez-Borja, Finance Director The County has made great efforts to achieve the timely completion of the annual audit and issuance of the financial statements. The County will ensure the appropriate year-end accounting adjustments to be properly recorded. The County has hired an experienced Finance Officer with 20 years of experience. An Assistant Finance Officer position has been added to the department to assist with the daily operations to increase capacity within the department. Board policies and procedures are implemented to increase oversight and accountability. For the Year Ended June 30, 2024 Section II - Financial Statement Findings Finding: 2024-001 Imminently.

Management agrees that 2 of the 25 patient files selected did not have timely recertification of their eligibility for Ryan White services. The 2 patients did meet the criteria for eligibility however documentation of this eligibility is required on an annual basis. The Family Care Center at CHOP is committed to full compliance with reporting requirements for all funders. We have since implemented a monthly report of patients who need updated documentation of their Ryan White eligibility (including financial, residential, and diagnostic assessments) which our medical case managers will complete in EPIC. Once they are complete in EPIC, this will be documented in CAREWare, and we will be able to pull reports to ensure we are meeting this requirement. Any questions about compliance with Ryan White eligibility can be directed to Kathryn Pultman, LCSW, Program Manager at pultmank@chop.edu.

The District will ensure personnel receive additional training regarding the verification process for the National School Lunch Program and properly complete the verification process in future years.

Section 8 Project-Based Cluster – Assistance Listing No. 14.195 / 14.856 Recommendation: The Commission should implement processes to ensure that fatal errors occurring during PIC/TRACS submissions are corrected in a timely manner Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Previously,Pratum was responsible for completing the certifications and the HOC team was responsible for transmitting the certifications through TRACS. Effective October 1 2024, Pratum assumed responsibility of ensuring that all certifications are transmitted to TRACS in alignment with the HAP reported date. The Regional Property Manager will conduct monthly reviews of HAP and TRACS submissions to ensure accuracy. HRD staff will provide weekly internal staff training to correct PIC errors and procure additional training from a third party consulting company.. Name(s) of the contact person(s) responsible for corrective action: Carmen McLaurin, Vice President of Operation with Pratum, Darcel Cox, Vice President of Compliance with HOC and Lynn Hayes, Vice President of Housing Resources. Planned completion date for corrective action plan: Pratum immediately implemented the corrective actions as outlined above and will commit to correcting all specific discrepancies by March 31, 2025. The HRD team has corrected the errors and will attempt to secure training from a consultant company no later than March 31, 2024.

Section 8 Project-Based Cluster – Assistance Listing No. 14.195 / 14.856 Recommendation: The Commission should implement processes to ensure that all proper documentation is being maintained during the recertification process for every client. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HOC’s third-party management agent, Pratum Companies, will ensure that all site staff with access to files complete the "Intro to Affordable Housing" training hosted by Pratum Compliance within the next 60 days. Pratum will also mandate that Regional Managers conduct random quarterly reviews of move-in files and annual recertifications. Furthermore, Regional Compliance Managers will perform spot checks and file reviews throughout the year. Currently, every move-in file is reviewed by Pratum’s corporate Compliance team for program compliance, with Community Managers conducting an initial review before submission to the compliance team for final approval. Pratum will ensure that each recertification packet includes a completed application, documentation of income, assets, expenses, and an executed recertification checklist. Additionally, Pratum will generate and send reminder letters at 120, 90, 60, and 30 days to all households to minimize late annual recertifications. The Pratum Regional Managers and the Vice President of Operations will provide oversight and conduct weekly check-ins with the team to assess progress and completion of tasks. Regional Property Managers will review all corrective actions to ensure accuracy. A tracking spreadsheet will be maintained and reviewed during these weekly check-ins. This information will also be shared with the HOC compliance team during the monthly compliance and operations meetings to ensure alignment and transparency. HOC’s Property Management Division now has a Compliance Manager who has updated the internal review process to mandate that all new move-ins and annual recertifications include a completed application, documentation of income, assets, expenses, and an executed recertification checklist. The HOC compliance team will focus on conducting site visits for the Project Based Rental Assisted properties following the same guidelines used for the annual financial audit. The goal is to perform a 100% file review for properties with 25 or less units and a 50% file review for properties with more than 25 units. The Compliance team will continue to conduct bi-monthly quality control reviews for the HOC managed properties, after which relevant parties will convene to discuss corrective actions and training opportunities. This interactive process aims to ensure that discrepancies are addressed and corrected effectively. Name(s) of the contact person(s) responsible for corrective action: Carmen McLaurin, Vice President of Operation with Pratum, Darcel Cox, Vice President of Compliance with HOC and Ali Ozair, Vice President of Property Management with HOC. Planned completion date for corrective action plan: Pratum immediately implemented the corrective actions outlined above and is committed to correcting all specific discrepancies by March 31, 2025. The HOC compliance team will start the site visits in January 2025 and will review files from the start of the fiscal year. The PM Division has begun the updated internal review process outlined in the corrective action and has committed to correcting the discrepancies by November 30, 2024.

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.