Corrective Action Plans

View of Responsible Officials We concur. The Department has contracted with Myers & Stauffer (M&S) to conduct the periodic audits of all three of its Managed Care plans for State Plan Rate Year 2020. We anticipate the audits will be completed by August 2023. Anticipated Completion Date: September 2023 Contact Person: Shirley Iacopino

View of Responsible Officials We concur and have developed a corrective action plan in conjunction with Conduent. See attached plan. The SOC report will include auditing the change management of the quarterly NCCI edit checks. The auditing firm will also update the control objective 5 activities to include a population of claims specifically with NCCI edits. Anticipated Completion Date: The completed 6/30/2023 SOC report. Contact Person: Roger Boissonneau, MMIS Director

View of Responsible Officials We concur with the finding. Corrective Action: Condition A The Bureau of Employment Supports has been undergoing massive programmatic changes over the past 2 to 3 years. As part of those changes, there has been an updated Work Verification Plan submitted which will help to address some areas where errors have occurred. Keeping in mind that for a period of close to 2 years, due to the COVID pandemic, NHEP was not holding participants accountable for not returning signed employment plans to NHEP staff. The focus for that time was to ensure that families were housed, fed and safe, therefore, services focused on their immediate needs. Participants who entered the NHEP program during that time were not held accountable to returning a signed employment plan therefore it did not become part of their routine with NHEP. While COVID restrictions have been lifted, participants seem to have needed some time to reintegrate into the NHEP program and the mandatory expectations. NHEP staff and leadership will continue to remind participants and become more diligent in ensuring that signed employment plans are on the forefront of their daily responsibilities. It should be noted that in a couple of instances, employment plans were created as part of a Service Determination Appointment and very quickly after the participant was deemed exempt from the Work Program (NHEP) so the employment plan was not necessary and became a moot point. A Director?s Memo will be sent out by the end of this week which will allow Employment Plans to be acknowledged and accepted by the participant in multiple ways (not just with a wet signature) thereby increasing the likelihood of participants returning accepted employment plans to NHEP staff. Making this shift will mitigate the difficulties that are causing participants to not return their signed employment plans to NHEP staff and will decrease instances where there is not an accepted employment plan on file. NHEP leadership will hold a state wide mandatory staff training where ways to prioritize the monitoring and obtainment of accepted employment plans will be outlined and discussed. Field Support Managers will continue to monitor their staff on a quarterly basis, however, will add a monthly check on having accepted employment plans to their responsibilities. Condition B Part of the changes that NHEP has implemented have included a new Activity Tracking form which has made tracking hours more efficient and easier for the participant as well as the Employment Counselor. We believe that this activity tracker as well as the decrease in mandatory forms will allow for more accuracy and fewer errors moving forward. Uploading documents into the e-folder was found to be error prone, therefore, on March 1, 2023, NHEP leadership provided guidance and training on a specific process of indexing and scanning documents to ensure that moving forward the Employment Counselors are checking their e-folder?s to ensure that documents are properly uploaded and visible. This process was initially sent out to the field as a suggestion in 9/2022, however, on 3/1/23 this process was sent out as an expected process moving forward. Also, through cursory investigations, we believe that this new process, combined with the new Activity Tracking form, has already shown to be effective in improving the accuracy of supporting and recording hours. NHEP leadership has also been working with the NEW HEIGHTS system to streamline the process of uploading documents to further decrease the potential for errors. A change request form was submitted approximately one year ago. Also during the time period of this audit, NHEP was requiring pay stubs from employed participants and completing ?overrides? of the number of work hours that a participant worked during the week if that number was different than what was auto-populating based on information obtained by and entered by eligibility. NHEP discontinued that practice. NHEP no longer requires pay stubs from participants as that is a function of eligibility. NHEP utilizes the number of hours worked per week based on the number of hours entered by eligibility. This change will ensure that employment hour errors no longer occur. In order to address issues of audit findings, within the next 90 days, NHEP leadership is holding a state wide mandatory staff training where more in-depth information on the audit process will be shared including audit ?tests?, ?questions? and ?corrective action plans?. Historically in NH, the audit process was not shared with the NHEP staff making them unaware of the expectations and/or findings of the audit. NHEP staff were trained to complete certain processes and enter particular data but were never able to connect that back to anything. While we have been introducing this process more and more to our staff, we intend to hold a training to help them more thoroughly understand why they are doing what they are doing and remind them that what they do is reviewed for accuracy as part of the federal audit process. We believe that this transparency will create buy-in from the staff to put systems in place for themselves and to self-monitor more. Anticipated Completion Date: December 31, 2023 Contact: Brigitte Bowmar, Program and Workforce Administrator III

Finding 2022-001 ? Eligibility ? Material Weakness in Internal Controls Over Compliance and Material Non-Compliance Condition and Context: As part of our testing of eligibility, using a random number generator, we selected 25 days the Organization was open for food distribution during the year ended December 31, 2022. Out of the 25 days tested, the Organization did not follow intake guidelines for required eligibility and data collection prescribed by the Washington State Department of Agriculture for 12 different days. Planned Corrective Action: The organization implemented procedures to collect client intake data for one of the programs identified in testing and expects to continue making progress on the remaining program during 2023 and 2024. Responsible Division/Office and Individual: Mike Cohen, Executive Director Estimated Completion Date: 12/31/2024

FINDING 2022-0005 Contact Person Responsible for Corrective Action: Chris Richie Contact Phone Number: 219-987-4711 ext. 1113 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Before submissions, grant reports will be reviewed by someone other than the preparer of the report to ensure the information submitted was accurate. Individuals will initial and date a hard copy of final the report acknowledging the accuracy and submission of the report. Anticipated Completion Date: March 31, 2023

FINDING 2022-0004 Contact Person Responsible for Corrective Action: Chris Richie Contact Phone Number: 219-987-4711 ext. 1113 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In the future, the treasurer will maintain a list of capital assets that includes serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, and the use and condition of the property. The list will be verified by a central office employee each December and June. Individuals will initial and date a hard copy of final the report. Anticipated Completion Date: June 30, 2023

Finding Number: 2022-002 Condition: Covenant HealthCare's controls in place for reporting submissions did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: Covenant Healthcare will implement additional layers of expense review prior to submission to ensure that reports are submitted within the established guidelines. Contact person responsible for corrective action: Andrew Young, Corporate Controller Anticipated Completion Date: 3/31/2023

Finding Number: 2022-001 Condition: Covenant HealthCare's controls in place for reporting submissions did not identify that guidelines were not followed related to the inclusion of expenses that had previously been reimbursed. Planned Corrective Action: Covenant Healthcare will implement additional layers of expense review prior to submission to ensure that reports are submitted within the established guidelines. Contact person responsible for corrective action: Andrew Young, Corporate Controller Anticipated Completion Date: 3/31/2023

Management?s Response: We agree with the following findings. Finding 2022 ? 005 NHA has hired a Front Desk staff member to conduct the routine task of the front desk. Over the next several months this staff member will be trained to take over additional duties to provide the agency with better internal controls. As an Agency we will continue to more forward towards better internal controls by creating checklist, spreadsheets, and policies to assure the work being processed here at Newton Housing Authority is complete and accurate.

Finding Number: 2022-001 ALN, Federal Agency, and Program Name - Student Financial Assistance Cluster-Federal Direct Student Loan Program ALN 84.268 Condition: The College was not sending notifications meeting the required criteria during the year. Planned Corrective Action: The College has updated notifications to include the required elements beginning in the Fall 2022 semester. Contact person responsible for corrective action: Nicole Hatter Anticipated Completion Date: 11/22/2022

Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 4 reporting required an organization to illustrate how PRF and ARP funds received were used. An organization was allowed to include eligible expenditures from January 1, 2020 through December 31, 2022 depending on the period reporting. Condition: During the process of identifying expenses that were incurred to prevent, prepare for, or respond to the coronavirus pandemic, management properly incurred and reported reflected expenses within the period of availability; however, the quarterly expenses reported on the portal submission did not reflect the actual quarter in which the expenses were incurred. Planned Corrective Action: Management will continue to refine its processes to more diligently review expenditures to ensure accurate reporting of expenses by quarter in future reporting. Planned Completion Date: December 31, 2023 Person Responsible: Chase Dudzinski, Chief Financial Officer

FINDING 2022-001 Material Weakness - Reporting Contact Person Responsible for Corrective Action: Julie Flores Contact Phone Number: 765-382-3779 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The Controller?s Office will send the monthly appropriation reports for transportation to the Administrative Assistant (AA) and to the Transportation Manager to review and reconcile. After the monthly report has been reconciled by the transportation Administrative Assistant, it will be initial and dated by the AA, the work will be forwarded to the grant administrator, transportation manager and controller?s office. The Controller?s Office will review to ensure accurate information was forwarded to the grant administrator. These changes will be reflected in the City of Marion?s Internal Control Policy. Anticipation Completion Date: 09/01/23

Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Reporting Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria: The OMB Approved Award No. 1505-0271 requires that reports submitted to the federal awarding agency include all activity of the reporting period, and are supported by applicable accounting or performance records. The County of Orange (the County) must submit quarterly Project and Expenditure Reports that contain costs incurred during the covered period. Critical information includes: ? Obligations and Expenditures o Current period obligation o Cumulative obligation o Current period expenditure o Cumulative expenditure ? Subawards ? Detailed information on any loans issued; contracts and grants awarded; transfers made to other government entities; and direct payments made by the recipient that are greater than $50,000. For amounts less than $50,000, the recipient must report in the aggregate for these same categories of loans issued; contracts and grants awarded; transfers made to other government entities and direct payments made by the recipient. Condition: Expenditure information was materially different from expenditures reported on the SEFA. This was due to the County identifying additional expenditures after year-end, related to the June 30, 2022 fiscal year. Cause: The County prepared the Project and Expenditure Reports as of a point in time, but internal controls did not allow for consistent reporting or expenditure recognition, to avoid material variances. Effect: Expenditure information in the Project and Expenditure Reports for December 2021, March 2022, and June 2022 reflected modified cash basis expenditures at a point in time, but contained material differences from the amounts included in the SEFA. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A non-statistical sample of three (3) out of four (4) Project and Expenditure Reports submitted during the year were selected for reporting testing. The cumulative impact is as follows: ? Cumulative expenditure o Reported - $89,613,061 o Per audit/supporting records - $296,907,350, a difference of $207,294,289 Repeat Findings from Prior Years: No. Recommendation: We recommend the County enhance internal controls to ensure Project and Expenditure Reports are prepared in accordance with governing requirements, and updated timely if revisions are made by the County, to avoid material variances to the underlying expenditures reported on the SEFA. Management Response and Corrective Action: Auditor Controller: 1. Person Responsible: Bertalicia Tapia, Financial Reporting & Mandated Costs (FRMC) Manager 2. Corrective Action Plan: While the County reconciles the Project and Expenditure Reports filed with the US Treasury to the County?s accounting records, a temporary difference between the reported amounts on the SEFA and US Treasury reports was caused by a one-time permitted adjustment to reallocate expenditures for government services subsequent to filing the US Treasury reports. While currently in compliance with US Treasury reporting guidelines, the County will reflect the permitted adjustment on its subsequent quarterly Project and Expenditure Report due to the US Treasury on April 30, 2023. 3. Anticipated Implementation date: April 30, 2023

Finding Number: 2022-007 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Housing and Urban Development, Housing Opportunities for Persons With Aids (HOPWA) and COVID-19 HOPWA Condition: Original Finding Description: In conjunction with eligibility testing, instances of noncompliance specific to the rental assistance calculation were identified. Contact Person Responsible for Corrective Action: Denise Fair and Angelique Tomsic Anticipated completion date: July 2023 Planned Corrective Action: In FY23, the City implemented a review of 100% of clients who received subsidy services. The intensive review is being performed to help ensure all required documents are saved and accurate. A corrective action plan will be documented and further reviews put in place to help ensure compliance and consistency for all rental calculations. The city will also continue to work with its contractor on process improvements. In addition, as part of the AFCAP process, the City will work with the department to perform internal reviews to help ensure processes are being followed

Finding Number: 2022-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City of Detroit did not have adequate controls in place to exercise its oversight responsibility of eligibility determinations that were performed by a contractor for the program. Contact Person Responsible for Corrective Action: Denise Fair Anticipated completion date: July 2023 Planned Corrective Action: The City will implement controls to ensure that Health Department provides oversight of the contractor and the participant eligibility process. The Health Department has hired a WIC Program Director who will monitor participant eligibility compliance and ensure that eligibility policies and procedures are maintained and followed. Through the AFCAP project process, the City will also review the contract in detail to help ensure full compliance

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: The operations of HealthCenter Northwest, LLC (HC) were consolidated into Kalispell Regional Medical Center d/b/a Logan Health Medical Center (LHMC) as of December 31, 2020. When LHMC calculated their lost revenues, they included HC's revenue for both 2020 and 2021 instead of only the 2021 information. This resulted in LHMC reporting higher lost revenue than the detailed reports supported in Period 1. This also affected the lost revenues reported in Period 2 for LHMC. HC filed its own report for Period 1, which included their revenues for 2019 and 2020. Zeros were entered for 2021, which resulted in reporting higher lost revenues than the detailed reports supported in Period 1. Responsible Individuals: Craig Lambrecht, CEO and Cole Turner, CFO. Corrective Action Plan: The lost revenue calculation will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal will be updated in future periods. Anticipated Completion Date: 3/31/2023

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: In some of the quarters for certain entities, it was noted that bad debt expenses were higher than revenues, creating a negative revenue for the quarter. As the HHS reporting portal would not allow negative amounts to be entered, a zero was entered into the HHS reporting portal. These negative amounts should have been offset to other quarters or other revenue line items, but were not, which resulted in higher revenue amounts being reported than the detailed reports supported. Responsible Individuals: Craig Lambrecht, CEO, and Cole Turner, CFO Corrective Action Plan: The lost revenue calculation for these three locations will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal will be updated in future periods. Anticipated Completion Date: 3/31/2023

CORRECTIVE ACTION PLAN The Rockport Housing Authority (RHA) acknowledges the findings in our annual audit completed by Marcum. We will implement the following to resolve the current issues: Federal Awards - Section 8 Housing Choice Voucher Program Instances of Income, Asset, or Medical Miscalculation or Insufficient Verification RHA has already put together a checklist to make sure that all items are collected and calculated properly. All annual re-examinations are currently up to date. In addition, the Executive Director will periodically select files to audit. Incorrect Payment Standard RHA has noted on future calendar to have the Board of Directors approve Payment Standards within 30 days of HUD releasing the rates. RHA's HCV Specialist will be notified immediately of the new rates to enter into PHA web and begin using with Annual and Interim certifications. This item has been added to the file checklist. Utility Allowance The Utility Allowance was add to the file checklist and will be reviewed during each annual and interim exam to assure that the proper amount is given to each Section 8 participant. RHA did experience some significant staffing changes over the last 18 months with both Executive Director and HCV Specialists. An interim Executive Director is currently in place and keeping a watchful eye on all items. In addition, a new HCV Specialist has been on board since February and RHA was able to secure an experience Section 8 consultant to train the new associate. Person Responsable for Corrective Action: Marie Mathes, Interim Executive Director Planned Implementation Date: Already complete.

CORRECTIVE ACTION PLAN The Rockport Housing Authority (RHA) acknowledges the findings in our annual audit completed by Marcum. We will implement the following to resolve the current issues: Federal Awards - Section 8 Housing Choice Voucher Program Instances of Income, Asset, or Medical Miscalculation or Insufficient Verification RHA has already put together a checklist to make sure that all items are collected and calculated properly. All annual re-examinations are currently up to date. In addition, the Executive Director will periodically select files to audit. Incorrect Payment Standard RHA has noted on future calendar to have the Board of Directors approve Payment Standards within 30 days of HUD releasing the rates. RHA's HCV Specialist will be notified immediately of the new rates to enter into PHA web and begin using with Annual and Interim certifications. This item has been added to the file checklist. Utility Allowance The Utility Allowance was add to the file checklist and will be reviewed during each annual and interim exam to assure that the proper amount is given to each Section 8 participant. RHA did experience some significant staffing changes over the last 18 months with both Executive Director and HCV Specialists. An interim Executive Director is currently in place and keeping a watchful eye on all items. In addition, a new HCV Specialist has been on board since February and RHA was able to secure an experience Section 8 consultant to train the new associate. Person Responsable for Corrective Action: Marie Mathes, Interim Executive Director Planned Implementation Date: Already complete.

FINDING 2022-003 Contact Person Responsible for Corrective Action: Susan Sleeper Contact Phone Number: 260-925-2362 Views of Responsible Official: I concur with the finding. Description of Corrective Action Plan: New Internal Controls will be implemented, with review of the COIVD-19 annual report prior to submission with email correspondence kept as documentation. Anticipated Completion Date: 06/30/2023

Finding 2022-003 ? Child Nutrition Cluster - Reporting Contact Person Responsible for Corrective Action: Tracy Wilson Contact Phone Number: 317-936-5444 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: All claims submitted for federal reimbursement will be reviewed prior to submission. Control will be put in place to verify entries to sales reports through CNC website and initialed by two parties to confirm accuracy over the process. Anticipated Completion Date: Effective Immediately

Finding Number: 2022-1 Untimely and Inaccurate Returns of Title IV Funds (R2T4) Planned Corrective Action: Timeliness: Upon the completion of the Fall 2021 term, the Director of Financial Aid became aware of a deficiency regarding the tracking of attendance for students enrolled in online courses due to the higher than usual number of students will All F grades due to non-attendance. Prior to the start of the Spring 2022 semester, the Director of Financial Aid, Registrar, and Dean of Distance Education met to discuss the issue and developed a plan to require all professors of online courses to report the names of students who were not submitting assignments in their courses. The Dean of Distance Education sends multiple email reminders to professors throughout the term, and members of the Distance Education Office perform periodic spot-checks of course data to ensure that professors are performing required duties. Accuracy: All financial aid staff are encouraged to participate in as many R2T4 training events as possible but are required to participate in at least three training events (one led by NASFAA, one led by ED, and one internal training event). Additionally, performing R2T4s will become the responsibility of the entire team beginning with the Fall 2022 semester. With more staff members calculating and reviewing the data, it is believed that the potential for human error will decrease. Person Responsible for Corrective Action Plan: Timeliness: Donovan Smith (Director of Financial Aid) Accuracy: Donovan Smith (Director of Financial Aid) Anticipated Date of Completion: Timeliness: Implemented prior to Spring 2022 semester and resulted in no findings of this nature for Spring 2022 Accuracy: Implemented beginning with the Fall 2022 semester and will be completed by the end of the Spring 2023 semester

Finding 2022-002 - Continuum of Care Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end September 30, 2023: a. Program Coordinators will maintain all Continuum of Care Tenant files in individual file folders designated by special purpose voucher program. All loose documents will be anchored in tenant files. b. An action plan has been developed for the Continuum of Care programs to ensure that all program files are HUD, State, and GHA compliant starting with October 1, 2022, files through the current. c. Continuum of Care fiscal year 2023 (October 2022-September 2023) re- exams and interims will be caught up and complete as they become effective. All tenant files will be reviewed and compliant by FYE2023 . d. All late/overdue re-exams will be compliant by FYE2023. e. During FYE2023, the Deputy Executive Director/COO or designee will perform quality controls on all Continuum of Care tenant files processed each month prior to initialization. f. File checklist sheets will be placed in each file upon quality control review to be signed off by the Deputy Executive Director/COO or designee. g. Additional training will be required and ongoing for Program Coordinators. h. Other internal control measures will be implemented to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2023

Management is currently confident with the abilities of the accounting staff to prepare interim financial statements. The District has also accepted the additional risk associated with the auditor drafting year-end financial statements including the notes to the financial statements. Management will review, approve, and take responsibility for the financial statements.

Finding Number: 2022-003 Program: 14.218 ? Community Development Block Grant Compliance Requirement: Reporting ? Performance Reporting Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Condition: Prince George?s County (County) did not submit a report of Section 3 activities for a specific project to IDIS as required. Cause: The County?s policies and procedures were not sufficient to ensure that Section 3 reports were completed and submitted to IDIS as required by program regulations. Internal controls did not prevent or detect the error. Resolution: DHCD established Policies and Procedures governing all entitlement programs, including the Community Development Block Grant Program. All projects subject to Section 3 must have a preconstruction conference where Section 3 is discussed, among other required regulations. They must also submit Section 3 documentation before the project is closed- out and reimbursement is processed. Responsible Party: Aspasia Xypolia, Director, DHCD Anticipated corrective action plan completion date: The Department will continue to follow the established procedures going forward to ensure that all projects subject to the Section 3 requirement will be reviewed and approved for compliance prior to the approval of close-out and reimbursement. The department does have the Section 3 report for all project including this specific project, however it was not processed through the Integrated Disbursement and Information System (IDIS), which was effective July 2021. This particular report (attached) will be submitted through the FHEO Section 3 Performance Evaluation and Registry System (SPEARS). Any questions concerning the findings or corrective action plan can be directed to Aspasia Xypolia, Director, DHCD at (301) 883-5501.