Corrective Action Plans

Corrective Action Plan: The University experienced significant staffing changes in the TRIO programs. The changes in staffing lead to a loss of institutional knowledge, and interrupted policy and process enforcement. In many instance the documentation wasn’t available due to the transition of key individuals. During the period of staff transition for the McNair program, original communication showing previous approval from the Program Officer was not accessible. While the Department of Education provided correspondence granting McNair projects permission to reallocate travel funding to increase stipends for participants, given the limitations on travel capabilities due to the COVID-19 pandemic, which was subsequently confirmed by the Program Officer, we encountered difficulty locating explicit documentation approving the specific stipend increase amount. Continuous monitoring of program records will be implemented to ensure compliance with federal, Institutional and program requirements. The programs will review existing program operating procedures manuals to identify needed updates to current policies and procedures to align with federal, Institutional and program requirements. The program stall will also engage in professional development opportunities to improve grant management. Anticipated Completion Date: July 31, 2024

April 1, 2024 Finding Number 50000 (2023-001) Noncompliance and Internal Control over Federal Compliance Federal Program – Child Care and Development Fund Cluster – Assistance Listing 93.575 and 93.576, Federal Alternative Payment Corrective Action Plan: Anticipated Completion Date April 30, 2024 Prior to Mono County Office of Education (MCOE) taking over this program, another agency was responsible for the original eligibility determinations and special tests and provisions, including the files selected for this audit. After discussion about the audit findings, MCOE investigated further, and it was noted that the staff at the time were not following the procedures and forms that were in place. Items were either not completed or filled out correctly in many instances. Since this discovery, MCOE has developed a corrective action plan as follows to adhere to the program’s requirements: • MCOE will ensure that existing and new staff are trained to adhere to the policies and procedures for the program. • MCOE will be conducting annual reviews of all service providers and children served to ensure MCOE is maintaining the required documents on file. • MCOE has developed a double-check procedure to ensure that staff is keeping the required documentation on file for both providers and children served moving forward. I, Jennifer Weston, CBO, will be responsible for the implementation and monitoring of the corrective action plan. Sincerely, Jennifer Weston Chief Business Officer Mono County Office of Education

Finding No. 2023-007 Department(s): New York City Administration for Children’s Services Program(s): Assistance Listing Number 93.658, Foster Care – Title IV - E Corrective Action(s): • ACS will review all outstanding non-finalized Redetermination packages and re-request outstanding Court Orders. • Moving forward, if the hard copy Court Order has not been received by ACS within 90 days of the Permanency Hearing, ACS will request a court transcript of the Permanency Hearing. • ACS will finalize IV-E Redetermination packages if a Reasonable Effort determination finding has not been conferred within four months of the request for court action. • ACS will work with the Office of Court Administration to address challenges in timely completion of hearings and receipt of Court Orders. Anticipated Completion Date: September 2024 Person(s) Responsible for Implementation: Andrew Martin, Executive Director, Central Eligibility Office (212)-341-2816

Finding No. 2023-013 Department(s): New York City Administration for Children’s Services and New York City Human Resources Administration Program(s): Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s): ACS: ACS will work with other agencies to promote compliance and internal controls going forward. HRA: In response to the findings, HRA made the following training requests to address the specific findings identified in this audit: 1. Training ID 2344 - Childcare liaisons and Childcare Review Team (CCRT) require training for the appropriate documentation necessary for the approval and provision of childcare. Audit findings confirmed that the staff charged with approval and authorizing childcare will take refresher training about the appropriate documentation requirements (i.e., CS-274w, LDSS 4699, LDSS 4700, etc.). The training will emphasize the requirement that any approved childcare must have support underlying employment/education documentation to justify the provision of the childcare. Childcare is a supportive service, so any childcare must have employment/engagement/education as a condition precedent. 2. Training ID 2343 - The training will include information about the client's employment, rate of pay, frequency of pay, and getting the appropriate documentation into the case records. Audits confirmed that 1) when the agency budgeted income and approved supportive services (i.e., childcare), the record did not have supporting income and employment related documents; 2) training will include the process for budgeting the earned income and applied any earned income disregards. Anticipated Completion Date: April 2024 and ongoing Person(s) Responsible for Implementation: ACS: Rahel Getachew, Associate Commissioner (212)-676-8818. HRA: Ramon E. Flores, Deputy Commissioner, Family Independence Administration (FIA) floresra@hra.nyc.gov

Finding No. 2023-016 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Number 14.871, Housing Voucher Cluster: Section 8 Housing Choice Vouchers Corrective Action(s): During the pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of adverse actions. Although HPD continued to request recertification packages during the period of the waivers until today, from February 2020 through December 2021, HPD did not penalize families who did not submit complete recertification packages. Additionally, HPD is among the City agencies that experienced a staff retention crisis, with attrition rates among its Rental Subsidy Program administrative teams swelling from 12 percent in 2020 to 27 percent in 2022. During the audit period, HPD was experiencing its highest vacancy rate. This meant standard recertifications were delayed because participants did not respond to recertification packages they were asked to complete, HPD did not have the capacity to revoke subsidies for those who did not comply, and the agency had significant backlog as a result of staff vacancies. Though HPD’s vacancy rate improved, it takes significant time to train and prepare staff to do the work. Finally, even though HPD’s COVID-era policies involving adverse action have ceased and normal processes are now in effect, due process requires intensive tracking and follow up to ideally have participants comply with requirements but if necessary to terminate assistance for those who do not comply. Therefore, there will be a significant lag between the re-implementation of HPD’s policy to take enforcement actions when recertification packages are not completed or missing and HPD’s actually terminating assistance. Corrective Action(s): 1. Build on existing systems to more closely track recertifications that are mailed and not returned. 2. Develop more robust digital operations that were started during the pandemic leading to reporting capabilities that will help with tracking overdue recertifications. 3. Work more closely with Community Based Organizations that can assist participants complete and return recertification package. 4. Continue close coordination to implement the Housing Access and Stability staffing plan and identify priority hires to onboard critically needed staff timely. 5. Invest in a training team to meet the training needs of new staff. Anticipated Completion Date: April 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

Finding No. 2023-014 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance Program – Section 8 Moderate Rehabilitation Corrective Action(s): During the pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of adverse actions. Although HPD continued to request recertification packages during the period the waivers, February 2020 through December 2021, HPD did not penalize families who did not submit complete recertification packages at that time until more recently. Additionally, HPD is among the City agencies that experienced a staff retention crisis, with attrition rates among its Rental Subsidy Program administrative teams swelling from 12 percent in 2020 to 27 percent in 2022. During the audit period, HPD was experiencing its highest vacancy rate. This meant standard recertifications were delayed because participants did not respond to recertification packages they were asked to complete, HPD did not have the capacity to revoke subsidies for those who did not comply, and the agency had significant backlog as a result of staff vacancies. Though HPD’s vacancy rate improved, it takes significant time to train and prepare staff to do the work. Finally, even though HPD’s COVID-era policies involving adverse action have ceased and normal processes are now in effect, due process requires intensive tracking and follow-up to ideally have participants comply with requirements (but if necessary to terminate assistance for those who do not comply). Therefore, there will be a significant lag between the re-implementation of HPD’s policy to take enforcement actions when recertification packages are not completed or missing and HPD’s actually terminating assistance. Corrective Action(s): 1. Build on existing systems to more closely track recertifications that are mailed and not returned. 2. Develop more robust digital operations that were started during the pandemic leading to reporting capabilities that will help with tracking overdue recertifications. 3. Work more closely with Community Based Organizations that can assist participants complete and return recertification package. 4. Continue close coordination to implement the Housing Access and Stability staffing plan and identify priority hires to onboard critically needed staff timely. 5. Invest in a training team to meet the training needs of new staff. Anticipated Completion Date: April 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

Finding No. 2023-005 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Numbers 14.241, Housing Opportunities for Persons with AIDS (HOPWA) Corrective Action(s): HASA will enhance its data management system to flag housing units where rent amounts are reportedly above the prevailing Fair Market Rent (FMR) limits per bedroom size, and document follow up activities accordingly. Staff will continue to review support documentation during monitoring visits to ensure client rent calculations are current and accurately completed. HASA will continue facilitating monthly technical assistance meetings and convene training sessions with housing providers to address emerging issues and contract compliance findings from monitoring visits. Anticipated Completion Date: April 1, 2024 and ongoing Person(s) Responsible for Implementation: Xiomara Pamela Farquhar, Assistant Deputy Commissioner farquharx@hra.nyc.gov

Finding No. 2023-002 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): This FY23 audit was conducted on the heels of the FY22 audit where the questioned cost finding is a similar error type but significantly decreased to $296 from over $18,000. Included in the FY22 recommended Corrective Action was the onboarding of the Executive Director to shepherd the charge with strengthening the teams’ internal governance, appropriate monitoring and future compliance. Adversely, the onboarding of the executive director was lengthy and only recently finalized in the 2nd quarter of FY24. HRA agrees to strengthen internal controls and the new Executive Director is working with the team to ensure they are intentional in appropriately applying the correct formula for calculating allowable cost, particularly the inclusion of “gross” and not “net” income. The Quality Assurance Tool has been updated including specific sub-items to ensure allowable cost is correctly calculated as well as the other deliverables. Corrective Action(s) • Strengthen internal governance and future compliance. • Executive Director for the Home-TBRA now on board. • Update the Quality Assurance tool that includes sub-items information that supports improved review and approval. • Provide refresher training for staff involved with TBRA to improve performance and outcomes. Anticipated Completion Date: June 30, 2024 and ongoing Person(s) Responsible for Implementation: Dori Hopkins-Figeroux, Director - HTBRA hopkinsfigerouxd@hra.nyc.gov 929-252-6089 Jordan Worrell, Executive Director RAP/HTBRA worrellj@hra.nyc.gov 929-252- 5403 Dwana Abraham, Assistant Deputy Commissioner abrahamd@hra.nyc.gov 929-221-6726

Views of Responsible Officials and Planned Corrective Actions: The City disagrees with the finding. A project was determined to be ineligible and was adjusted accordingly in the third quarter report due October 30, 2023. The original first quarter submission report did not tie to the balance after the entries were made to reclass the expenditures. Staff was not able to recreate the report from the first quarter to tie to the ending balances charged to the fund as of June 30, 2023. When the original first quarter report was filed, the financial system expenditure reports reconciled to what was submitted. Finance Department personnel have established procedures to prevent the need for corrections and resubmissions to prior period quarterly Project and Expenditure submissions and will properly document the changes for verification if corrections occur.

The Finance Department personnel will carefully review vendor status in the System for Award Management and produce documentation of eligibility for use of Federal Funds before procurement of goods and services.

Identifying Number: 2023-002 – Eligibility Finding: The Code of Federal Regulations (CFR) Section 200.303(a) states the non-federal 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). The State of Florida’s Department of Financial Services’ State Projects Compliance Supplement Part Five: Internal Controls Section D. Eligibility states that recipients should develop Control Objectives to provide reasonable assurance that only eligible individuals and organizations receive assistance under state projects, that subawards are made only to eligible subrecipients, and that amounts provided to or on behalf of eligibles were calculated in accordance with project requirements. During our testing of participant eligibility, we noted that supervisory personnel did not properly review and approve their eligibility documentation prior to the participant entering the program for ten of 80 participants selected for eligibility testing. Corrective Actions Taken or Planned: Corrective measures were taken with the Program Leadership responsible for the eligibility documentation noted above. The following corrective actions are in the process of being implemented: • CHS’s Program Leadership and their teams will conduct a review of respective intake forms completed after July 1, 2023 to ensure that all were properly reviewed and approved. Any unapproved intake forms identified will be verified and retroactively approved by the designated supervisor. • In cases where there are instances of unapproved intake forms, the Program Leadership will collaborate with the respective Talent Business Partner to follow up with formal corrective action. Such corrective action will include: o A thorough review of the CHS policies and practices relative to the management and approval of intake forms. o Mandatory refresher education and training with all staff to ensure they understand the steps required to document review and approval of the intake process, as well as the importance of maintaining evidence that the process was adequately performed. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Brungardt, Chief Program and Clinical Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.

FINDING 2023-3- Overawarded Federal Direct Loan Amounts The Institute had not correctly calculated the federal loan eligibility for two (2) students. A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned Previous FA administrator failed to consistently calculate student enrollment hours. This caused incorrect loan awards to be prorated and disbursed. We have revised our method of requesting aid and the enrollment status of each student will be verified individually prior to requesting loans. We have also removed FA administrator (effective 12/2023) and third-party servicer from their role (effective 4/2024). We will be returning $1,056 to the Department of Education. Signed Betsy Bremke, Administrative Campus Director Date: _3/29/2024__

FINDING 2023-4- Untimely Paid and Unpaid Credit Balances The Institute had Untimely Paid and Unpaid Credit Balances while Participating under the Zone Alternative and the Heightened Cash Monitoring 1 Payment Method A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned We have revised the process of student stipends ofdisbursements. Each student whose account receives a disbursement whom results in a credit balance, will be given stipend prior to any draw down. We shall also make process and procedures with new third-party servicer to ensure stipend is sent prior to drawdown. Signed Betsy Bremke, Administrative Campus Director Date: _3/29/2024__

FINDING2023-2- Incorrect Pell Grants The Institute incorrectly calculated Pell Grants for thirteen (13) students. A.Comments on Findings and Recommendations: The Institute agrees with the finding and Auditor's recommendation. B.Actions Taken or Planned Previous FA administrator failed to consistently update student enrollment status in software. This caused incorrect Pell awards to be requested and disbursed. We have revised our method of requesting aid and the enrollment status of each student will be verified individually prior to requesting Pell. We have also removed FA administrator (effective 12/2023) and third-party servicer from their role (effective 4/2024). We will be refunding $3,097 to the Department of Education and crediting $4,239 to the affected student accounts. Signed Betsy Bremke, Administrative Campus Director Date: _3/29/2024__

Identifying Number: 2023-003: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: For one student out of 61 students tested, an incorrect amount of subsidized and unsubsidized loan was awarded. Corrective Action Taken or Planned: STC Financial Aid Office will request a list of Build Dakota students and estimated scholarship amounts at the beginning of the academic year. This information will be added into the student’s financial aid packaging formula to review for potential changes needed in federal aid awards. Once the Business Office has completed applying Build Dakota funds for the term, the information will be shared with the Financial Aid Office to make adjustments to the original estimates used. Contact person: Micah Hansen, Director of Financial Aid, Southeast Technical College Status of finding – The above corrective actions will be implemented beginning July 1, 2024.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 26, 2024 regarding a reportable audit finding related to inadequate internal controls over eligibility determinations. LDH appreciates the opportunity to provide this response to your office's findings. Finding: Inadequate Internal Controls over Eligibility Determinations. Recommendation: LDH should ensure its employees follow procedure relating to eligibility determinations and redeterminations in the Medicaid and CHIP programs to ensure the case records support the eligibility decisions. LDH Response: LDH partially concurs with LLA's finding of inadequate controls over eligibility determinations. For the one noted Medicaid error of failing to discontinue coverage for a recipient who moved of out of state, LDH concurs. The LDH staff member who received the reported out of state address noted in the case record that coverage was already terminated and no further action was necessary when in fact it was not terminated at the time. For the one noted Medicaid error of not performing all required eligibility determinations before enrolling the recipient, LDH concurs. The eligibility determination system approved coverage for the recipient based on self-attestation of resources prior to checking the electronic data sources for verification. For the one noted Medicaid error of not perform all required eligibility determinations before transitioning the recipient, LDH concurs. In transitioning the recipient from a program without a resource test to one with a resource test based on a change in circumstance, LDH used existing resource information in the case record without requesting or checking for any new information. For the fourteen noted Medicaid errors of renewals not performed, LDH does not concur. When possible, LDH attempted to perform an ex parte renewal per federal guidelines. If an ex parte renewal could not be completed to extend benefits, a "standard" renewal is required which involves mailing a renewal form to the recipients to complete and return. During the public health emergency (PHE), LDH was operating under a March 25, 2020 CMS approved waiver for certain flexibilities in meeting the timeliness of Medicaid renewals. LDH used the flexibility to suspend processing of standard renewals. Audit staff were informed the noted cases would have needed a standard renewal and therefore not processed per the waiver. For the one noted CHIP error of not discontinuing coverage on a recipient that was invalidly enrolled prior to the start of the PHE, LDH does not concur. The recipient was validly enrolled. LDH staff did not timely act on a task to terminate coverage for this beneficiary prior to the beginning of the PHE in March 2020. Under the continuous eligibility provision of the FFCRA of 2020, a state could not terminate individuals from Medicaid if such individuals were enrolled in the program as of the date of the beginning of the emergency period, unless the individual voluntarily terminates eligibility or is no longer a resident of the state. No exceptions were noted for delays in taking negative action, therefore, out of an abundance of caution to not jeopardize the entirety of enhanced federal funding for keeping recipients enrolled during the PHE, LDH reinstated the coverage. For the one noted CHIP error for not discontinuing coverage on a recipient who became ineligible for a separate CHIP program, LDH concurs. The recipient was covered under the CHIP conception to birth option and coverage should have been terminated when her pregnancy terminated. She was inadvertently reinstated for coverage by the eligibility system. For the thirteen noted CHIP errors of not following policies and procedures regarding documentation of renewals, LDH does not concur. When possible, LDH attempted to perform an ex parte renewal per federal guidelines. If an ex parte renewal could not be completed to extend benefits, a "standard” renewal is required which involves mailing a renewal form to the recipients to complete and return. During the PHE, LDH was operating under a March 25, 2020 CMS approved waiver for certain flexibilities in meeting the timeliness of Medicaid renewals. LDH used the flexibility to suspend processing of standard renewals. Audit staff were informed the noted cases would have needed a standard renewal and therefore not processed per the waiver. As for the performance audit report issued in August 2023, the LDH formal response dated August 10, 2023 addressed the concerns that were noted at that time. Corrective Actions: 1. For the out of state finding in this audit and the August 2023 performance audit report, the LDH formal response dated August 10, 2023 addressed this issue. 2. LDH will make changes to the Medicaid eligibility system to ensure resources are re-verified when recipients transition from programs without a resource test to those that require a resource test. LDH has already implemented changes effective June 2023 to automate checking of electronic data sources for verification of resources as part of the recipient's annual renewal. 3. By the end of the PHE Unwind process, LDH will have completed a renewal and/or closed any separate CHIP cases that inadvertently remained open during the PHE and are no longer eligible for coverage. 4. LDH did adhere to regulations, guidance, and/or approved waivers in processing or suspending renewals and transitioning recipients to other coverage during the PHE. LDH continues to firmly believe the "case record" contemplated in CFR 435.912(f) includes all aspects of data repositories or system actions in the case, along with text fields in the case notes and the documents in the LDH document management system. In accordance with 42 CFR 433.112(b) and 45 CFR 164.312(b), LaMEDS logs system activity and enables the State to examine and document system actions. You may contact Kimberly Sullivan, Interim Medicaid Executive Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Rhett Decoteau, Medicaid Section Chief at (225) 342-9044 or via email at Rhett.Decoteau@la.gov with any questions about this matter.

Dear Mr. Waguespack: The Division of Administration, Louisiana Office of Community Development (LOCD) is submitting the following in response to the audit finding titled "Restore Louisiana Homeowner Assistance Program Awards Identified for Grant Recovery." LOCD acknowledges the LLA finding of "Restore Homeowner awards identified for Grant Recovery." In response to the 2016 Floods, the LOCD created the Restore Louisiana Homeowner Assistance Program (HAP). Grant recapture procedures were established from the beginning of the program and have been implemented timely. It is impossible to administer a disaster recovery program that will not have certain files requiring grant recapture during the life of the program. The Restore Program requires a duplication of benefits check on all files prior to grant execution. For example, it is always possible an applicant may receive additional funding, e.g., insurance proceeds that are deemed duplicative by law. The Restore Program has controls in place to capture these amounts in the grants management system, subrogation agreements executed with each applicant, and recapture procedures to recover the funds. From the very beginning, the Restore Program was created to minimize the potential of applicants' ending up in recapture. As a result, the state has issued over $670 million to 17,262 homeowners of which 86, or 0.50% are in recapture. As the Restore Homeowner Program comes to a close, LOCD does not anticipate further files requiring recapture of funds. LOCD agrees with the observation of 10 files with a potential grant recapture as a necessary ongoing activity for the Program. LOCD will continue to follow the established recapture procedures for these grant awards to ensure ultimate compliance, however, this is not a corrective action, but rather the continued implementation of program protocols. The contact person responsible for these ongoing compliance activities is Ginger Moses, OCD Chief Operating Officer. The anticipated completion date for activities addressing this finding will coincide with the closing of the Restore Louisiana program. If you have questions or require additional information, please feel free to contact me.

Dear Mr. Waguespack : The Division of Administration, Louisiana Office of Community Development (OCD) submits the following in response to the audit finding titled "Inadequate Recovery of Small Rental Property Program Loans." The Small Rental Property Program (SRPP) has two tiers of compliance obligations. The federal compliance requirements are for the CDBG funds issued to a borrower to meet a National Objective and be expended on an Eligible Activity. On top of the federal requirements, the State has its own program requirements. Upon the initial placement of an eligible tenant in a habitable unit at a restricted rent amount, the U.S. Department of Housing and Urban Development (HUD) requirements have been satisfied. Most of the matters made the subject of your report deal with the borrower's non-compliance with the State's program rules, not the HUD requirements. OCD has allocated approximately $653 million to the SRPP program to fund approximately 4,500 applicants and we maintain an ongoing monitoring process to promote compliance and continued availability of affordable housing. Consistent with the program's mission of preserving and expanding much needed affordable housing, OCD's primary focus for the SRPP is to assist property owners in achieving and maintaining compliance, i.e., creating and continuing affordable housing opportunities, as opposed to foreclosure and/or recapture of funds, and are, therefore, not subject to recapture by HUD. In summary, as of June 30, 2023, the LLA reports that 814 applicant files have been identified as noncompliant. Of these, 166 files have been determined to be uncollectible, leaving 648 files that are actively being addressed. OCD's compliance and repayment efforts relating to the state imposed continuing requirements of the program are ongoing. The optimal outcome of these efforts is the continued availability of affordable housing through compliance. In June 2016, OCD, working with the Louisiana Housing Corporation (LHC) and HUD, identified 397 SRPP borrowers that did not meet a National Objective. Immediately thereafter, OCD's Legal Section and LHC program staff began communicating with non-compliant borrowers and evaluating proposed workouts. OCD sent default letters to and initiated recapture efforts on all borrowers. Each file is processed with a goal of either achieving compliance, securing repayment, or identifying another viable workout plan. As of June 30, 2023, of the 397 files identified, 83 borrowers have become compliant, 20 have either partially or fully repaid their loans, 18 borrowers have transferred their housing obligations to other compliant properties and 166 have been determined uncollectable for various reasons. As noted in the audit, OCD continues to seek technical assistance regarding the enforcement of mortgages through the judicial foreclosure/public auction process. In conclusion, OCD will continue the efforts to recover those loans determined to be ineligible in accordance with policies and procedures that are acceptable to HUD. Concurrently, OCD will also continue to assist rental property owners to become compliant and to resolve any program compliance issues, thus increasing available affordable rental housing and reducing or eliminating the need to recapture funds from rental property owners, where appropriate. The contact person responsible for the corrective action is Ginger Moses, OCD Chief Operating Officer. Once approved by HUD, the anticipated completion date for this corrective action plan will coincide with the closing of the SRPP program. If you have questions or require additional information, please feel free to contact me.

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Public Health Award No. and Year: 1946001347 A7, 2022/2023 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County agrees that eligibility determinations and redeterminations including obtaining documentation and verifications should be performed annually to determine if individuals are eligible in accordance with the compliance requirements of the programs. There are overdue redeterminations in our system for a myriad of reasons related to increasing number of IHSS cases due to Medi-Cal expansion and increasing community need for IHSS services, limited Social Worker staffing due to budget restrictions, uncovered IHSS caseloads related to Social Worker job transition or leave; and more complexity of clients requiring case management during the year and additional fair hearings. Of the 36 instances out of the 60 sampled, two of the cases sampled were Intercounty Transfer (ICT) cases where the referring county sent us these overdue reassessments. According to ICT policy and practice standards, we evaluated these clients timely. These cases should be removed from the findings. Currently, of the remaining 34 cases, 2 case were terminated due to death; 15 cases are current, meaning the reassessment has been completed within the last 12 months; 9 cases have been completed since the September 2023 audit, 7 cases have been assigned to Social Workers to be seen in the next 30 days. One client case is in process of authorization. In regards, to the two missing forms, these forms have been obtained to complete the clients’ file. To address the Social Worker staffing issue and rising caseloads, we do have pending County budget requests for additional Social Worker staff. We have two Extra Help Social Worker vacancies which have been difficult to fill over the last 18 months. For about 6 months, we filled an Extra Help Social Worker who transferred to a regular County position. We participate in State level discussions related to advocacy, budget requests for IHSS administrative funding and related issues. Responsible Individual(s): Gwendolyn Gill, Health Services Administrator Bela Matyas, Chief Deputy Director Anticipated Completion Date: July 1, 2024

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2022/2023 Compliance Requirement: Allowable Costs, Eligibility, and Special Tests and Provisions Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County has policies and procedures as well as systematic processes set up to ensure the required collection and documentation of the applicant’s intent to cooperate with child support. It is Solano County’s policy that the Child Support Questionnaire and Notice and Agreements be processed which require workers to: • Conduct an interview either via telephone, or in-person with the applicant, print the forms, and document the County Use Section which requires worker’s signature and date. • Mail the form to the applicant for a wet signature or collect the signature via electronic means. • Upon return, review the CW2.1 form(s) for completeness. • Initiate the required case action(s) based upon information provided on the forms. Solano County has a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent this error in the future: • The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the pertinent CalWORKs Eligibility Handbook sections with verbiage to emphasize the following: o The requirement to review and collect the information needed to complete the notice and agreement (form CW2.1) for child, spousal, and medical support from the applicant. o That the case be authorized according to program rules only after required forms are received by the county, reviewed to ensure that the case is updated with the correct information, documented in the case journal, and the form(s) scanned into the document imaging system. o Highlight these requirements when training this topic. • The CalWORKs Program Specialist will discuss the findings and requirement in the following ways: o Monthly Program Support Forum conducted with managers, supervisors, and lead workers. o Issue a reminder to all staff. o Written material will be published in the Monthly Program Support Newsletter to all staff. Responsible Individual(s): Daniel Horel, Employment and Eligibility Services Manager Thomas West, Employment and Eligibility Services Manager Diana Hernandez, Employment and Eligibility Services Manager Anticipated Completion Date: May 31, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. The PHA should establish and maintain policies for the selection of tenants from the waiting list. As documented in the CMR, the PHA did not properly maintain its waiting list. In addition, the PHA is required to obtain an executed General Depository Agreement for all bank accounts. Tenants were selected and traced to the waiting list. However, as documented in the CMR, the waiting list did not include applicants that had been ineligible when they originally applied. We also were not provided with an executed General Depository Agreement. Due to the change in management, some bank accounts have not been able to update the authorized signers on the accounts. Auditor’s Recommendation: The Authority should update its waiting list requirements and ensure that applicants are selected in the proper order. The PHA should obtain the required General Depository Agreement and make sure that current management and board members have access to all bank accounts. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent, safe, and affordable housing to low-income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family’s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following: f. As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility.g. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent.h. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. i. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies.j. Re-examine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary.We selected twenty public housing tenant files for testing, but the Authority was not able to locate one of the requested files. It appears that the utility allowances had not been reviewed during the fiscal year as required by HUD standards. Auditor’s Recommendation: All files should be maintained and available for review. Utility allowances should be studied to determine if a change should be made. Grantee Response: We will comply with the auditor’s recommendation. We are currently making changes related to our response to the CMR. We have completed our utility allowance study and implemented the new allowance amounts. Anticipated Completion Date: June 30, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent, safe, and affordable housing to low-income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family’s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following:a. As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. e. Re-examine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary.Testing of ten HCV family files, it appeared the housing assistance payments were being computed correctly based on documentation in the file. However, and based on results from the CMR, it appears that incorrect payment standards and outdated utility allowance forms were being used in the computations. Auditor’s Recommendation: A thorough review of tenant files should be performed for the purpose of eliminating the deficiencies. Utility allowances should be studied and determined if a change should be made. Payment standards should be approved and consistently applied. Grantee Response: We will comply with the auditor’s recommendation. We are currently making changes related to our response to the CMR. We have completed our utility allowance study and implemented the new allowance amounts. Anticipated Completion Date: June 30, 2024

Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. As such, HUD requires the Authority to comply with special tests and provisions relating to its Housing Choice Voucher program. The Authority must inspect the unit leased to a family at least annually to determine if the unit meets Housing Quality Standards (HQS) and the Authority must conduct quality control re-inspections. The Authority must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). In addition, the PHA is required to obtain an executed General Depository Agreement for all bank accounts. During our testing of 10 HCV tenant files, we noted annual HQS inspections for all the tested units. However, the Authority did not perform the required quality control re-inspections. Tenants were selected and traced to the waiting list. However, as documented in the CMR, the waiting list did not include applicants that had been ineligible when they originally applied. We also were not provided with an executed General Depository Agreement. Due to the change in management, some bank accounts have not been able to update the authorized signers on the accounts. Auditor’s Recommendation: The Authority should perform housing quality control re-inspections according to HUD guidelines. The Authority should update its waiting list requirements and ensure that applicants are selected in the proper order. The PHA should obtain the required General Depository Agreement and make sure that current management and board members have access to all bank accounts. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2024

Finding Number 2023-223: Managed Care providers lacked documentation to support continued eligibility within the Medicaid Program. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare; 93.778 Medical Assistance Program Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The 21st Century Cures Act requires all states to enroll both fee-for-service and managed care providers. Idaho Medicaid is currently out of compliance with this requirement for most of the providers within managed care contractor networks. The state is also working to come into compliance with a requirement in the Affordable Care Act to revalidate all enrolled providers at least every 5 years. The Division has begun the systems work necessary to come into compliance with both of these requirements and anticipates working through enrollment and revalidation activities into CY2025. Once completed, the Division will have an accurate and complete provider file that will be shared with contracted managed care plans to support their contracting efforts. Any providers who contract with the managed care plans will be required to be fully enrolled and credentialed with Idaho Medicaid before rendering services and billing. Pursuant to the Consolidated Appropriations Act of 2023, states are required by July 2025 to have a searchable and regularly updated provider directory for both managed care plans and fee-for-service programs. Idaho Medicaid is working to develop processes to validate directories and ensure that providers are providing updates to their information as necessary. Through this effort, Idaho Medicaid will further bolster internal processes and controls to ensure accurate provider network information is shared with Medicaid participants and maintained within our systems. Anticipated Corrective Action Date: July 2025 Responsible for Corrective Action: Juliet Charron, Division Administrator Juliet.Charron@dhw.idaho.gov 208-364-1831 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814