Corrective Action Plans

The Department of Labor and Workforce Development (DLWD) transitioned from a manual contract agreement process to a web-based grant administration system in recent years that employs the System for Administering Grants Electronically (SAGE) and IntelliGrants (IGX) applications. The DLWD FFATA Reporting Unit has access to these automated systems and monitors them on a monthly basis to identify when new subaward contracts/agreements are approved in order to report required data in the FFATA system timely. DLWD corrective actions regarding FFATA reporting are expected to be fully implemented as of June 30, 2024. COMPLETION DATE/ CONTACT PERSON June 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) will continue to review and enhance controls to ensure that BAM quality control case investigations are completed timely, that reviews are signed as required by appropriate staff, and that all required case review supporting documentation is maintained in case files. DLWD corrective actions will be completed by September 30, 2024. COMPLETION DATE/ CONTACT PERSON September 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Reemployment Services and Eligibility Assessments (RESEA) policy and controls presently in place at the Department of Labor and Workforce Development (DLWD) require eligibility interviews to be conducted and eligibility review forms to be completed and signed by the participant and UI program representative. DLWD implemented a new process that allows staff to electronically obtain signatures through Simpligov, beginning June 2023. This process requires that staff obtain all necessary signatures before a RESEA claimant record is completed. Supervisors are assigned to monitor this process in order to mitigate the risk associated with missing information on any single RESEA customer registration. DLWD will monitor this process to ensure that all interviews are properly documented, and forms are signed and electronically uploaded to its electronic case management system of record for future reference. During the initial rollout of this process, there were records that didn’t migrate to the case management system of record. This issue has now been addressed through training. DLWD has also developed dashboards that will assist with monitoring data entry. Monthly reviews of RESEA data entry will be conducted to identify possible errors. These RESEA process changes that will be implemented by DLWD will ensure compliance with regulatory standards and assist with maintaining the integrity of its data management process. COMPLETION DATE/ CONTACT PERSON June 30, 2023 Baden Almonor (609) 777-1042 Baden.Almonor@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) has controls in place to only allow an FPUC payment to be made when an underlying Unemployment Insurance (UI) payment has also been processed. FPUC payments should not be issued to any claim without the underlying UI payment being made for the same week. The FPUC payments issued and noted as exceptions during eligibility testing will be reviewed independently by DLWD to determine if the payments issued were to eligible recipients or not. For the PUA exceptions noted during Eligibility testing, overall the DLWD issued PUA payments to over 680,000 claimants during the COVID-19 pandemic. DLWD had controls in place to require a COVID related reason to make the claim PUA eligible and the weekly PUA certification required claimants to choose a COVID related reason for why they were out of work before they could get paid. The PUA payments in question will be reviewed independently by the DLWD to determine if the payments issued under PUA were appropriate or if they should have been paid instead under the regular UI program. DLWD corrective actions related to FPUC and PUA payments were fully implemented as of September 2023. COMPLETION DATE/ CONTACT PERSON September 2023 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

2023-002 U.S. Department of Transportation, National Infrastructure Investments: Better Utilizing Investments to Leverage Development (BUILD) Grant Assistance Listing Number 20.933; Procurement Material Weakness in Internal Control over Compliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award the provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations and conditions of the federal award. Non-federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. The Port Authority’s formally documented policy pre-dates Uniform Guidance and does not include many of the necessary procurement provisions. Corrective Action Plan: An updated Procurement Policy is being drafted to meet the standards set forth in 2 CFR 200.317 to 220.237, then reviewed and approved by our Board at the next appointed board Meeting. Expected Completion Date: March 2024 Responsible Individuals: Kimbra Scott

Corrective Action Planned: The Board will comply with Title 29, U. S. Code of Federal Regulations, Part 5. Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the "Davis-Bacon Act") when using COVID-19 Education Stabilization Funds to fund construction contracts in excess of $2,000. Anticipated C'onipletion Date: March 15, 2024 Contact Person(s):): Cindy W. Parker; Chief School Financial Officer; cparker@blountboe.net

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