Corrective Action Plans

Finding 2023-002 - U.S. Department of Education (USD), Title IV Student Financial Aid Programs (material weakness): We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: (a) The College did not reconcile the following programs between the Office of Financial Aid and the Business Office. Per 34 CFR 685.300(b)(5). i. Federal Pell Grant Program ii. Federal Direct Student Loans iii. Federal SEOG (b) The Office of Financial Aid submitted unreconciled expenditures within the Fiscal Operations Report and Application to Participate (FISAP) for the programs below: i. Federal Pell Grant Program ii. Federal Work Study (FWS) Program (c) One (1) out of 6 students tested for withdrawals and the return of Title IV funds did not have their Title IV program funds returned within the 45-day requirement. HEA, Section 484B & 34 CFR 668.22. (d) One (1) out of 60 students had a credit balance on their account created by Title IV program funds longer than 14 days. 34 CFR 668.164(h)(1). (e) One (1) out of 60 students tested did not make satisfactory academic progress (SAP) for the academic year. The College did not provide supporting documentation for successful appeals and allowed the students to receive Title IV funding. 34 CFR 668.34. Questioned cost for this finding is: $6,198. (f) Five (5) out of 60 students tested did not have high school/GED to prove eligibility for the program they were enrolled within the College. HEA Section 484(d) and 34 CFR 668.32. Questioned cost for this finding is $41,443. (g) Four (4) out of 60 students tested were accepted as transfer students but did not have official (transfer) transcripts to prove eligibility for the program they were enrolled within the College. HEA Section 484(d) and 34 CFR 668.32. Questioned cost for this finding is $40,383. The College should implement corrective actions to ensure that the above findings are resolved and do not recur in future periods. Moreover, internal controls over compliance with federal program regulations should be revisited to ensure adequate supervisory controls, quality assurance reviews of processes, and policies and procedures are being updated and adhered to for compliance purposes. Corrective Actions – Philander Smith College concurs with this finding, and the following action has been taken. Philander Smith College improved the efficiency of reconciling between the Financial Aid Office and COD by standardizing procedures. Staff-wide calendar events have been set to standardize routine processing of reconciliation data. Direct Loan SAS files are imported into the COD "DL SAS Disb On Demand Reader" tool and converted to Microsoft Excel files. Pell SAS/ Reconciliation files are imported into the COD "Pell Recon Reader" tool and converted to Microsoft Excel files. The SAS files and financial aid management system (FAMS) files are imported into Microsoft Access tables and Microsoft Access queries are run to determine discrepancies between SAS file data and FAMS data. This standardization provides an efficient procedure for staff members to follow. Staff have been cross trained to reduce processing delays. This system, incorporating efficient technology, calendar reminders, and cross training has improved the efficiency of reconciliation activities. Financial Aid staff coordinate with Business Office staff for notification after the Financial Aid to COD reconciliation is complete. Financial Aid staff are updating the policies for SAP supporting documentation submission that require students to submit documents via the student financial aid portal where documents will be securely stored and backed up within the College servers. Financial Aid staff are updating processes among Financial Aid, the Registrar's Office, and Academic Affairs to strengthen timely identification of both official and unofficial withdrawals for timely Return to Title IV Funds processing. Finally, during the pandemic, the College experienced some difficulties obtaining official high school transcripts due to school closings. The College is continuing to work to review files to ensure this is fully addressed.

Corrective Action Plan: Due to staff turnover of key personnel in the Housing Division, the Finance Department has partnered with the Community Development Department to ensure that CDBG reporting is timely and accurate. In March 2024, a new consultant was contracted to assist the Housing Division staff with training and oversight for entering data to HUD's Integrated Disbursement and Information System (IDIS) which includes the Cash on Hand reports. Responsible Individual: Kimberly Cole-Muck, Director of Community Development Anticipated Completion Date: September 2024

Currently, the College marks students withdrawn on the date the withdrawal is officially processed in the system, indicating their last data of attendance. The withdrawal policy will be updated to indicate that the withdraw date to be reported for all students withdrawing at either the program or campus level should be processed as the "last date of attendance". In the case of the 5-year program (4+1 internally), we currently do not officially "enroll" a student into the master's program until their bachelor's degree is conferred. The official admit date will be updated to reflect the term a student enters the master's program officially, which will begin after the conferral of their bachelor's degree. Our policy and processes for the 4+1 program will be updated to reflect this change.

In April of 2023, the North Providence Housing Authority hired an outside company to perform yearly rent reasonableness studies. Nelrod has given us the tools to perform these studies fast and efficiently with the use of their software program. Additionally, due to being a small housing authority, with only one HCV staff member, we have hired an HCV Assistant to help the HCV Coordinator in obtaining all information needed to comply with HUD’s regulations. Planned Implementation Date of Corrective Action: April 2023 Planned Implementation Date of Corrective Action: Eileen Reyes/Michael McMahon/Cheryl Lonardo

Finding Number: 2023-001, 2022-001, 2021-001: Material Weakness and Material Noncompliance - Sliding Fee Recommendation: We recommend that sliding fee applications be completed for each sliding fee patient. Procedures should be implemented to verify applications are completed before the encounter is billed. Sliding fee discounts per policy should be agreed in the billing system to ensure the proper discounts are entered and updated. In addition, the Center could consider increasing its internal sampling throughout the year to verify sliding fee applications are obtained, completed, and agree to the discount applied. Action Taken: CHASS management concurs with the audit finding and will put the following corrective action plan in place to mitigate this finding in the future: During Sliding Fee Testing it was found that the actual charge to patient (after slidingfee applied) did not match the actual discount that patient should have had. We have reviewed all process on how EPIC loads up charges (table with applied slidingfee tiers) and found that no one had a master list of the charges, when Billing requests a CPT to be added they just go to accounting and gets added as well as when they request changes on charges for CPT code. There is not one set of approved CPT charges/discount creating discrepancies in patients accounts. In response to these audit findings, CHASS has developed and implemented a comprehensive series of improvements. First, implementation of key improvements involves the implementation of a one person only authorized to request changes on table of charges to EPIC. Second, implementation of a verification process for every patient receiving a sliding fee discount. To achieve this, the Center's Customer Service team now generates personalized labels for each eligible patient and cross-checks their entries by the end of each day. This process ensures each item is diligently reviewed to ensure if any errors are made within this process they are rectified immediately via a Supervisor/Team Leader. Through this process the Supervisor/Team Leader now conducts a second review of the labels to ensure accuracy of the Center's labeling system for each patient utilizing the sliding scale discount program. This review also includes the actual charges on EPIC and Discount being verified with CPI Tables. Third implementation, the Center's Billing Department is now responsible for performing regular weekly audits. During these audits, the Billing Department will now randomly select five claims with sliding fee discounts and examine the applied fees and the corresponding discounts applied to the patient's account (using the approved CPT Table). Through these improvements CHASS aims to ensure that the Sliding Fee Discount Policy is used accurately and appropriately. These methods have been incorporated into the Center's Sliding Fee Discount Policy to guarantee their utilization and accuracy, and to further strengthen the Center's initiatives in providing access to needed health care services. Responsible Parties: Angela Salgado, Chief Operating Officer

Finding 2023-003: Material Weakness in Internal Control over Compliance – Eligibility. Name of Contact Person: Phyllis Wimberley, Deputy Director. Corrective Action: The Heritage program will create and implement a checklist of required documentation to ensure all participants are eligible to participate in the program. Proposed Completion Date: June 2024

Management Response: Local background checks were completed, however when a consultant was hired to complete the federal background checks, the files were stalled at the adjudicator’s office in Albuquerque, NM due to some billing issues with the Tribe. We have 3 trained staff who are certified adjudicators however it was recommended to use an outside adjudicator and we were able to locate someone locally who agreed to perform the federal background checks. Anticipated Completion Date: Currently in progress March 31, 2024 Responsible Party: Troy Lunderman, HR Director Leah Running Bear, HR Assistant Independent adjudicator Jodee Wike

Delta Partners Manor II, Inc. (the "Project") respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit Firm: Harper, Rains, Knight & Company, P.A. 1052 Highland Colony Parkway, Suite 100 Ridgeland, MS 39157 Audit Period: Year Ended December 31, 2023 Audit Finding Reference: 2023-001 Planned Corrective Action: Management will ensure that these reconciliations are performed monthly against the month end bank statements. Name of Contact Person: If the U. S. Department of Housing and Urban Development for audit has questions regarding this plan, please call Scott Russell at 601-856-2362.

Finding: 2023-001 – Compliance and Controls over Compliance – Eligibility Supportive Housing for Persons with Disabilities (Section 811), CFDA No. 14.181 Material Weakness & Noncompliance In 2023, Home Share did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual making the initial determination or annual recertification. Actions Taken or Planned: Management agrees with this finding. Beginning in September 2023, management has changed the contractor they work with for the eligibility determination process. Management is working with the contractor to include a second individual in this process so that there will be a review performed by someone other than the individual making the initial determination or annual recertification. Contact Persons: Robert Pickering, Chief Financial Officer

2023-001 Special Tests and Provisions - Sliding Fee Discounts Corrective Action Plan Management will create a Procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all audit and record retention requirements are met. Anticipated completion date March 31, 2024 Contact person responsible for corrective action Kendra Newbold, Interim CEO

2023-007 - Special Tests – Internal Control and Compliance over Housing Quality Standards Inspections (Material Weakness) Condition: We found five (5) instances out of 9 in which the City did not conduct the HQS failed inspection follow up in a timely manner. We also noted three (3) instances out of 40 samples for eligibility testing has HQS inspections that are over a year apart, which shows that the City did not conduct the HQS biennial inspection in a timely manner. Management concurs. Corrective Actions: Management has directed staff to abide by the PHA policy and HUD regulations for the HQS inspection process. Management will continue to enforce HUD regulations and the use of the PHA’s administrative plan to ensure staff will conduct the HQS biennial inspection in a timely manner. Name of Responsible Person: Ron Garcia, Director of Community Development Imelda Delgado, Housing Manager Projected Implementation Date: Immediately implemented.

Official Responsible for Ensuring CAP Lorie Werle, business manager, will be responsible to ensure that the appropriate measures are taken. Correcting Plan The District will provide Lorie Werle, business manager, necessary training. The Planned Completion Date of CAP Immediately

Finding Number: 2023-002 Planned Corrective Action: We are confident that our ESSER expenditures align with the allowable purposes and intents of the grant application that was submitted in the CCIP. We also stand by the integrity of our identification of expenses in total in the American Rescue Plan ESSER Federal Grant Program despite differences identified between grant years. The FER process and the reallocation of funds by grant year was confusing. However, as in the response above, we recognize the responsibility to adhere to the strict timelines was our responsibility. All ESSER funds have now been expended and we are confident they are allowable expenses per the guidelines provided. The Treasurer, Superintendent, and Federal Funds Coordinator agree to work more collaboratively to ensure our expenditures are within the grant timeframes prior to FER submissions. Anticipated Completion Date: 03/08/2024 Responsible Contact Person: Lance A. Erlwein, Treasurer

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023

March 27, 2024 2023-002: Material Weakness in Internal Control/Material Noncompliance- Eligibility Condition: The Consortium did not provide documentation of eligibility for each participant selected for testing. Corrective Action: We agree with the finding. The consortium recognizes the importance of having support documentation for all eligibility determinations. During COVID-19 staff were allowed to work from home, as a result two staff were not following document saving protocol and saved vital documentation on their local drive (desktop). Upon the transition back into the office, those individuals did not follow protocol and ensure all files were backed up/saved to the networked database. Once of the individuals no longer worked for MWSE and the other employee as well as their manager both were made aware of the issue. After further conversations with the manager, management was assured this will not happen again. A process for spot checking and compliance sign-off by managers has been implemented to work to ensure this issue does not arise again. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: Completed January 2024 Respectfully, Shamar Herron

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Supplemental Nutrition and Assistance Program office has worked with Statewide Branch and Staff Development offices to address refresher training associated with budget calculations including the documentation and input of all data correctly. The Department is also in process of finalizing the new eligibility system – Benefit Eligibility Solution – slated to rollout statewide by late October 2024. As a condition of system rollout, all staff will be required to go through system training which will include a reinforcement of data entry practices and documentation requirements as a condition of eligibility determination. Expected Completion Date: October 31, 2024 Responding Officials: Ginet Hayes, Supplemental Nutrition and Assistance Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Fiscal Management Office will work with OIT to create a report to assist with reconciling the fiscal agent’s daily reports. Expected Completion Date: June 30, 2024 Responding Officials: Joey Wong, Fiscal Management Office Accountant

Views of Responding Officials: The Department agrees with the finding and will implement corrective action, however, notes the following: Letter dated April 29, 2022 was sent to ACF notifying of the temporary amendment to the Hawaii TANF State Plan, Part B, Section 10.1, suspending the interview requirement for TANF applications and annual recertification. The temporary suspension of the interview requirement aligned with the waiver granted by the Food and Nutrition Service for the Supplemental Nutrition Assistance Program (“SNAP”). The letter also informed ACF the interview requirement will resume for new TANF applications by July 31, 2022. No date was provided as to when the interview requirement will resume for annual recertifications. The Department received a letter dated May 9, 2022 from ACF that acknowledged the temporary amendment to the Hawaii TANF State Plan. A subsequent letter dated March 16, 2023 was sent to inform ACF that the suspended interview resumed for TANF applications effective July 1, 2022, however, will continue to be suspended for annual eligibility recertifications for TANF recipients. The Department received a letter dated March 29, 2023 from ACF that acknowledged the temporary State Plan amendment. A letter dated July 25, 2023 informed ACF that TANF will continue to align with SNAP and extend its suspended interview requirement for annual recertifications until May 31, 2024. The Department received a letter dated August 3, 2023 from ACF that acknowledged the extended temporary amendment to the State Plan. The Department did not need guidance from ACF on whether a particular action is allowable under program requirements. Pursuant to section 402 of the Social Security Act, ACF has the authority to determine whether a state’s TANF State Plan is complete but does not have the authority to approve or disapprove a plan. ACF acknowledged the temporary amendments made to the Hawaii TANF State Plan and expressed no concerns or determined that the temporary amendments were not allowable. Corrective Action Taken or Planned: No corrective action. The temporary amendment to the Hawaii TANF State Plan will end effective June 1, 2024, as noted in the July 25, 2023 letter to ACF. Expected Completion Date: Not applicable Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Hawaii implemented an upfront work participation requirement as a condition of eligibility for TANF applicants beginning 2009. The purpose of the upfront work participation is to prepare applicant families to engage in the TANF work program. Our state temporarily amended its TANF State Plan in response to the COVID 19 pandemic, suspending the upfront work participation requirements, described in Part B, section 15.1, effective March 27, 2020. This suspension coupled with relaxed administrative policies for all means-tested programs which included TANF, Supplemental Nutrition Assistance Program, and our state-funded General Assistance and Aid to the Aged, Blind and Disabled, and operational changes statewide allowed the Department to process applications expeditiously ensuring eligible families have access to their financial assistance benefits quickly. In March 2020, Hawaii’s unemployment rate was as low as 2.2% (seasonally adjusted) but it increased considerably to 22.6% in April 2020 following the state’s first shut-down due to the COVID 19 pandemic. The state’s TANF caseload increased by about 177%, from March 2020 with 3,969 recipient families to 7,040 families in December 2020 following the state’s second shut-down. While the upfront work program participation was suspended as a condition of eligibility for TANF applicants, Hawaii still required recipients to participate with the work program after they were determined eligible for TANF benefits. The good cause provision was exercised judiciously and to the extent allowable under TANF federal regulations and Hawaii administrative rules. Our TANF work program extended its services to provide families the opportunities to receive additional support such as case management and counseling services; to access information and referrals to community resources such as housing assistance and food distribution events; and to receive assistance in navigating through programs, benefits, and services that our department and other government agencies have available during this period of economic downturn resulting from the health emergency. It was not until March 25, 2022, when then Governor David Y. Ige ended the state’s emergency proclamation relating to COVID 19. The Department continued to suspend the upfront work participation requirements through May 31, 2023, allowing a transition period to adjustour operations. The upfront work participation requirement as a condition of eligibility was reinstated for families who applied for TANF financial assistance benefits beginning June 1, 2022, with only four months remaining in the fiscal year. Other administrative policies that were temporarily suspended or amended in response to the pandemic were reinstated effective July 1, 2022. The public health emergency and heightened period of COVID 19 restrictions forced the Benefit, Employment and Support Services Division (“BESSD”), who oversees the TANF and other means-tested public assistance programs, to immediately modify its operations statewide, ensuring the continuity of its programs and services and making them more accessible to the public. It was important to provide BESSD a transition period to review its policies and operational procedures and allow its staff of over 650 employees to adjust after two years of operating programs and services in a manner that was unprecedented for the division. On January 17, 2024, the TANF program office met with the Statewide Branch Administration (“SBA”), who oversees the state First To-Work (“FTW”) program staff, to discuss the concerns regarding the work participation rates, active TANF recipients who were referred to FTW but not yet participating in the program, and strategies to address the concerns. Subsequently, on January 25, 2024, SBA held a meeting with the state FTW unit supervisors to share the concerns raised on the work participation rates and to solicit comments and suggestions. TANF program administrator and lead program specialist were in attendance to notate comments and suggestions. Corrective Action Taken or Planned: Pursuant to 45 CFR 262.5, the Department requested consideration for reasonable cause from the Administration for Children and Families (“ACF”), for not meeting the two parent work participation rate for fiscal year 2022. Response and determination from ACF is pending. The FTW unit supervisors were instructed, during the January 25, 2024 meeting, to invite and schedule the active TANF recipients, who were referred but not yet participating, to attend a work program orientation as soon as possible. It is expected that remaining active TANF recipients will be invited to the FTW program by March 31, 2024. TANF program office is exploring the suggestions received during the January 25, 2024 meeting with SBA and FTW unit supervisors. For example, it was suggested that the FTW program provide additional supportive service payments to participants, who are in countable non employment related work activities, to incentivize them to maintain their program engagement. However, this suggestion has a fiscal impact and will require the FTW program administrative rules to be amended before it can be implemented. The TANF program office plans to require both parents of two parent households to participate in the FTW program. Due to capacity issues of both state and contract staff, only one parent is required to participate and meet work program requirements for the TANF recipient household. The TANF caseloads have declined; therefore, capacity is no longer a concern. Expected Completion Date: March 31, 2025 Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Subawards will be entered into the FSRS within the appropriate timeframe following the execution of the contract. Expected Completion Date: Not applicable as reporting of federal subawards is an ongoing requirement. Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action, however, notes the following: The referrals to the Child Support Enforcement Agency (“CSEA”) are done through an interface between the HAWI eligibility and CSEA’s KEIKI systems. When a recipient is determined noncompliant by CSEA, the information is sent via the interface from KEIKI to HAWI in the form of a system-generated alert. This process worked well when application processing and maintenance of recipient cases were done in a case management method (e.g., each eligibility worker assigned to process applications and/or maintain a caseload of active cases). Using this method, eligibility workers managed their caseloads and checked for incoming alerts for cases assigned to them; these alerts included the CSEA noncompliant alerts coming from the KEIKI system. Workers were able to take appropriate and timely action in response to the alerts received. However, necessary changes were made to how applications and active cases are managed. The division stopped the case management method and converted to “task-oriented” processing statewide. Workers are no longer assigned to caseloads but are assigned to “tasks” such as processing applications, incoming documents/verifications, reported changes, six month review and annual recertifications, etc. A case is not reviewed and worked in HAWI until a worker is prompted to do so, e.g., six-month review, annual recertification or a change was reported by the household. It is until such action occurs when an eligibility worker, who picks up the task, will check for alerts for the case. Aside from that, recipient cases will not be reviewed during their certification period. So how the “alerts” were developed in HAWI no longer works for the way we currently process applications and maintain recipient cases. We are unable to modify the HAWI system because we are currently developing a new eligibility system that will replace HAWI. The new eligibility system is scheduled to go into production in late 2024. Corrective Action Taken or Planned: As an interim solution until the new eligibility system rolls out into production, a shared folder is being created where CSEA will place the monthly reports of non cooperating TANF cases so designated TANF staff members, who are granted access to the shared folder, will be able to retrieve the reports. TANFPO will review the identified TANF cases. Individual lists will be forwarded to the Section Administrators to instruct the affected Processing Centers to take appropriate action (i.e., TANF case closure due to noncompliance with CSEA). Expected Completion Date: July 1, 2024 Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

Views of Responding Officials: The Department does not agree with this finding. According to 45 CFR section 205.55, it states, “…the State agency will request through the IEVS…”. However, the policy does not specify the State agency must “properly use IEVS information to evaluate benefit amounts…” as notated in this finding under “Effect.” Unless IEVS provides the necessary information for the applicable benefit month(s) used to determine a TANF applicant’s or recipient’s (“client”) eligibility, information obtained will only validate whether a household received an income source, after the fact, but will not verify the dollar amount. Hard-copy verification is obtained from the client to verify income source and dollar amount, for the applicable benefit months, to determine eligibility in accordance with §17 676 51, Hawaii Administrative Rules. For example, if a client applied for TANF on January 31, 2024, and the Department processes the application on February 29, 2024 (current month), verification of the household’s income received in January 2024 and received thus far in February 2024, must be obtained to determine eligibility for the month of application (January 2024) and subsequent months (based on projected income). Data obtained from IEVS are not current. For example, wage information through SWICA becomes available on a quarterly basis. The most current SWICA information available would have been for quarter ending December 31, 2023, for an application that was processed on February 29, 2024. Eligibility determination would have been improperly made if SWICA information was applied. Corrective Action Taken or Planned: The Department will continue to conduct IEVS check and utilize information obtained to determine eligibility if the information is applicable, otherwise, IEVS information will continue to be used to validate any source of income. Expected Completion Date: Ongoing Responding Officials: Catherine Scardino, Temporary Assistance for Needy Families Program Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Secure a copy of the missing modified guardianship/permanency assistance agreement, demonstrating support for the monthly assistance paid. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Investigate whether the child who attained the age of 14 was consulted regarding the kinship guardianship agreement. Discuss this with the youth and document. • Locate missing clearances or re run them if not located, placing note in record about audit re run. Note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. • Secure documentation for case regarding continuation of monthly subsidy payments after the child’s 18th birthday. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”), and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on-going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, notes the following: Adoption Assistance is an incentive program with payment beginning prior to the finalization of an adoption. The adoption decree is not required for payment as the Adoption Assistance Agreement must be entered into prior to the finalization of an adoption. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Research/review and document why licensing approval was granted to a household with an individual who was convicted of spousal abuse. i. If review determines that Adoption Assistance Agreement (“AAA”) was inappropriately authorized, provide family with an adverse action notice discontinuing the AAA and explaining the appeals process. • Investigate whether supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents can be located and added to the record. • Secure a copy of the missing adoption decree, although adoption assistance is an incentive program with payment beginning prior to the finalization of an adoption. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Document how income eligibility was verified. • Secure missing modified adoption agreements. • Locate missing clearances or re run them if not located. Note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”), and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator, and Tonia Mahi, Social Services Division, Child Welfare Services Program Development Office, Assistant Branch Administrator

Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (“CWS”) staff will be informed of the audit findings, the importance of diligent compliance of policies and procedures, records maintenance and this corrective action plan. 2. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. • Staff will be given coaching/supervisory support to correctly complete documentation. 3. Case specific audit findings and corrective action taken will be noted in each record where there was a finding. • Locate Police Protective Custody form, Voluntary Foster Custody Agreement, or other documentation which clarifies whether the child was removed as part of a voluntary placement agreement or judicial determination. • Locate missing clearances or re-run them if not located, placing note in record about audit re run. Note: Not all clearances are secured prior to placement; FBI clearances come later and are not required prior to placement in a “provisionally licensed” home. • Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. • Review resource caregiver licensing status and locate missing license or reissue license. • Investigate the case where the Judicial Determination was missing and therefore did not support the removal of the child was contrary to the welfare of the child, if the Department made reasonable efforts to prevent removal and finalize the permanency plan, and if the determination was within 60 days from removal. i. Locate court order documenting “contrary to welfare” language, verifying timelines, place in record and document findings. • Locate missing Imua Kakou minutes or secure additional documentation validating monthly meeting requirement was met. 4. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. 5. MICU staff will audit records with findings to ensure errors have been documented and corrected. • MICU will work with Branch Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 – 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2024 and on-going Responding Officials: Kisha C. Raby, Social Services Division, Child Welfare Services Program Development Office, Administrator