Corrective Action Plans

Finding 2023-057 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with BSCs to discuss common errors, answer questions, provide guidance, and on a quarterly basis discuss the results of the SER case reads. In addition, based on the results of the quarterly case reads, MDHHS updated SER policy on October 1, 2023 to require additional verification sources. MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support SER processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Anticipated Completion Date Ongoing Responsible Individual(s) Nicole Denson-Sogbaka, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS Nick Sakon, MDHHS Erich Holzhausen, MDHHS

Finding 2023-054 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. Planned Corrective Action LEO FSD will implement a policy and procedure and will assign the tasks outlined in the policy and procedure to staff to ensure that FFATA reporting is completed on a monthly basis. Anticipated Completion Date June 30, 2024 Responsible Individual(s) Dawn Lake, LEO Lora MacKay, LEO

Finding 2023-052 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action For part a., MDHHS will issue a memo to BSCs and local offices and provide training to local office staff regarding the requirements to maintain sufficient documentation to support Refugee and Entrant Assistance State/Replacement Designee Administered Programs eligibility. For part b., MDHHS corrected the reporting defect and properly adjusted the accounting records. MDHHS already had a process in place to identify the reporting defect and make necessary accounting adjustments. MDHHS will ensure that accounting adjustments are prioritized for any future reporting defects. Anticipated Completion Date a. September 30, 2024 b. Completed Responsible Individual(s) a. Mariah Schaefer, MDHHS b. Trish Bouck, MDHHS

Finding 2023-013 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Once this is completed, MDHHS will develop mandatory training protocols for eligibility workers. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS originally expected to have all cases corrected at the end of the public health emergency (PHE) unwind (July 2024), however, due to some of the mitigation strategies that the Centers for Medicare and Medicaid Services (CMS) developed to ensure children did not lose eligibility, not all cases had their coding updated when they were renewed. MDHHS expects that all existing cases will be updated by May 2025. Anticipated Completion Date May 2025 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

Finding 2023-010 MDE - FFATA Reporting Management Views MDE and the Michigan Department of Lifelong Education, Advancement, and Potential (MiLEAP) agree with the finding. Planned Corrective Action For part a., MDE and MiLEAP, going forward, will verify all grants will be tracked for the Federal Funding Accountability and Transparency Act (FFATA), reviewing all systems the grants are awarded from. For part b.1., MDE and MiLEAP will continue to coordinate with the program offices to improve the FFATA reporting process in order to submit subaward information in accordance with FFATA and other applicable federal guidance. The corrective action will begin on October 1, 2024 with an anticipated completion date of October 31, 2025. For part b.2., MDE and MiLEAP have completed FFATA reporting using the actual expenditures for the purpose of verifying subrecipients have not exceeded the awarded amounts. To meet the requirements as outlined in 2 CFR 170, MDE and MiLEAP will update the reporting process to include all key data elements, including the net dollar amount of federal funds awarded to the subawardee, including modifications. Part b.3., MDE will work with all MDE program offices and MiLEAP to include the correct program descriptions in the FFATA reporting. Anticipated Completion Date a. Completed b.1. October 31, 2025 b.2. October 31, 2025 b.3. December 31, 2024 Responsible Individual(s) Spencer Simmons, MDE Bethanie Kramer, MiLEAP

Finding 2023-058 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency - Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2023, Corrective Action Plan, Finding 2023-001.

Finding 2023-022 Pandemic EBT Food Benefits, ALN 10.542 - Lack of Documentation for School Modality Data Reviews Management Views MDHHS disagrees that not formally documenting the review details on the log rises to the level of a material weakness and material noncompliance. MDHHS selects a sample of schools that submitted data and verifies the accuracy of Pandemic EBT (P-EBT) school modality data reported, documenting the schools reviewed within a log. Following the written business process, P-EBT staff first identify public information available to verify the school’s modality data such as the school’s calendar or news articles, and then reach out to school administration if public information is not available. If additional steps are required to reconcile the data, P-EBT staff document the support and results, sign off on the reconciliation, and forward to a supervisor for review. For this review period, no discrepancies were identified between what the school reported, and school websites. Since no discrepancies were noted, staff verbally communicated the review results to the manager and the log of sample items reviewed were kept within a shared drive. Planned Corrective Action MDHHS has no corrective action planned at this time as P-EBT benefit issuance ended as of May 11, 2023. No additional benefits will be issued in fiscal year 2024. Anticipated Completion Date Not applicable Responsible Individual(s) Kathy Cornell, MDHHS

Finding 2023-021 SNAP Cluster, ALN 10.551 and 10.561 - EBT Reconciliations Management Views MDHHS disagrees that a material weakness and material noncompliance exist. MDHHS federal reporting conducts a daily reconciliation of federal draws and authorizations to retailers based on vendor EBT reports. In addition, MDHHS conducts a monthly reconciliation between Bridges, Bridges data warehouse, and vendor EBT reports using daily data to ensure the client information in Bridges and Bridges data warehouse is accurate. The monthly reconciliation process does not impact the federal draw because the daily reconciliation of the vendor EBT report is used for this purpose. MDHHS provided detailed and accurate descriptions of MDHHS daily and monthly EBT reconciliations to the designated federal awarding agency contacts at the United States Department of Agriculture Food and Nutrition Service Agency that are familiar with MDHHS processes and received confirmation that the current reconciliation processes in place are sufficient to comply with federal regulations. Planned Corrective Action MDHHS disagrees with the finding and does not intend to take further action. Anticipated Completion Date Not applicable Responsible Individual(s) Sara Gross, MDHHS

Finding 2023-004 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., and d. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees that a process is not fully established to monitor the electronic notifications provided to county/district office caseworkers to ensure they utilized the Income Eligibility Verification System (IEVS) information to determine the recipients' eligibility. Although MDHHS did not implement the Bridges change to require an action comment before the county/district office caseworkers dispose of the electronic notifications until July 2023, MDHHS had policies and procedures in effect during fiscal year 2023 to help ensure monitoring of electronic notifications was taking place. Review of IEVS information is fully incorporated into the case read procedure governed by Bridges Administrative Manual 301 and detailed further in desk aids and reading guides. The Economic Stability Administration (ESA) provides regular direction and reminders of case read requirements via ESA Memos. For part e., MDHHS disagrees that IEVS information is required to be requested and obtained for modified adjusted gross income (MAGI) based recipients since eligibility is verified upon determination through the MAGI eligibility determination process and then granted for a 12-month continuous eligibility period. Requesting and obtaining IEVS information throughout the eligibility period would be irrelevant since eligibility is continuous. Planned Corrective Action For parts a. and b., MDHHS’s ESA will continue to provide training and policy support to ensure that the local office specialists appropriately utilize the IEVS interface information in determining recipients’ eligibility when applicable. ESA implemented a technical solution during July 2023 for applicable interfaces to ensure the IEVS information is being addressed timely and used correctly in eligibility determinations. For part d., MDHHS is collaborating with other work areas to facilitate the match process for the IEVS interfaces for recipients funded by Temporary Assistance for Needy Families (TANF) adoption subsidies. For parts c., and e., MDHHS disagrees with the finding and does not intend to take further action. Anticipated Completion Date a. and b. Ongoing c. Not applicable d. September 30, 2024 e. Not applicable Responsible Individual(s) a., b., and c. Veronica Maxson, MDHHS d. Kathonya Rice, MDHHS e. Logan Dreasky, MDHHS

Finding 2023-002 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals. The DSA also includes semi-annual review of privileged users and annual review for all users. For parts b. and e., MDHHS will revise internal business processes to include an additional level of monitoring and review to ensure compliance with the existing directives related to monitoring and review requirements. Anticipated Completion Date a., c., and d. Completed b. and e. August 2024 Responsible Individual(s) a., c., and d. Deon Nelson, MDHHS b. and e. Veronica Maxson, MDHHS

Cambridge Public Schools' CFO or Grants Coordinator will review and sign-off on all tuition requisitions that will be charged to grants to confirm the grant approval date and compliance with the period of performance.

The Finance department will document the reconciliation of the City's GL ARPA expenditures and obligations to the Department of Treasury ARPA reporting portal report both quarterly and annually. All reconciling adjustments and GL report documentation will be properly retained.

The City will work with all HOPWA subrecipients to ensure that a complete and accurate CAPER is completed in the appropriate format as required by HUD. This will include a focus on inputting the correct (eg, actual expended vs. award amount) funding amount.

The City will use the contract start date (7/1) as the Obligation date, and will submit the FFATA report accordingly.

Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment. Four of the 19 sampled payment requests were received or processed after receipt of the FY22 audit findings, and all of those requests for reimbursement were paid within 30 days of receipt.

CSFO will begin reviewing and signing the Prior Period Comparison Report before payroll is ran each month.

Policies and Procedures for Federal Awards Corrective action planned: Management will consult an advisory firm to assist with providing sample policies and procedures for tracking and usage of federal awards. Management will review and implement policies and procedures no later than 60 days to ensure compliance with tracking and usage of federal awards. Anticipated completion date: June 30, 2024 Contact person responsible for corrective action: Angela St. John, CFO

Finding No. 2023-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material non-compliance and Material Weakness in Internal Control over Compliance This is a repeat finding of 2022-002 from September 30, 2022 (Originally reported as finding 2019-001 from September 30, 2019) Statement of Condition: Out of a total tenant population of approximately 1,142 vouchers, 25 files were selected for testing, and the following errors were discovered. • 1 tenant file had the following error: o The utility allowance was miscalculated by $32 (overstatement). The two-bedroom column utility rates were used when the 1-bedroom column utility rates should have been used. Correcting this error would cause which the HAP rent to decrease from $762 to $731. • 1 tenant file had the following error: o An EIV form was either not run or has been misplaced for the tenant’s annual recertification period. • 1 tenant file had the following error: o The utility allowance was miscalculated by $23 (understatement). The 2022 utility allowance schedule was used when the 2023 utility allowance schedule should have been used. Correcting this error would cause the HAP rent to increase from $494 to $517. • 1 tenant file had the following error: o The tenant did not check the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen. However, based on the birth certificate the tenant is a U.S. citizen. • 1 tenant file had the following error: o An EIV form was either not run or has been misplaced for the tenant’s annual recertification period. • 1 tenant file had the following error: o The tenant’s asset income was miscalculated. Correcting this error would increase the HAP rent by $4. • 1 tenant file had the following error: o The 50058-form reported childcare income support of $6,000, however, the support for the childcare income showed $5,800. Correcting this error had no effect on the HAP rent. • 1 tenant file had the following error: o No support for the tenant’s wage income of $23,296 on the 50058 form. Appears to be reported correctly, since the EIV shows an amount that approximates the tenant’s wage income of $23,296. Nonetheless, there needs to be support in the tenant file for the wage income. o Missing HAP contract. • 1 tenant file had the following error: o The utility allowance was miscalculated by $19 (understatement). Correcting this error would cause the HAP rent to increase from $924 to $943. In addition to the above, we noted the following during our new admissions testing (out of a total of 161 new admissions, 17 files were selected for testing.): • 1 tenant file had the following error: o The tenant did not check the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen. However, based on the birth certificate the tenant is a U.S. citizen. • 1 tenant file had the following error: o HAP contract was not executed timely (within 60 days). • 1 tenant file had the following error: o The voucher extension date was not documented on the voucher. • 1 tenant file had the following error: o The request for tenancy addendum was executed (dated) two days after the voucher extended due date. o The unit size on the voucher did not agree to the family voucher size on the 50058 and the wrong payment standard was applied to the tenant. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income, and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an “Other Adult” packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant's file. The Counselor's caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors' strength and weaknesses and to determine if additional training and/or monitoring is needed. A Counselor has been assigned to only handle specialty vouchers (EHV, VASH, Homeownership, and FUP). The FSS Coordinator is responsible for the full management of HCV FSS participants. The Authority has hired an Intake Housing Counselor/Portability Specialist to focus on determining eligibility of new applicants pulled from the waitlist and to manage the waitlist. This Counselor also determines eligibility and compiles document packet for portability clients. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor's processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. All new admissions move-in files are now being to the Housing Programs Director for review prior to approval. A sample size of 15% is now being reviewed at the end of month by the Compliance Director and Housing Programs Director for compliance. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV Counselors, except the new Intake Counselor, have attended Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training and successfully passed the certification exam. Effective Date: June 21, 2024 Contact Information Gwendolyn B. Dawson, CEO Ocala Housing Authority 1629 NW 4th Street Ocala, Florida 34475 (352) 369-2636

Finding 2023-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Medical Center had a revenue calculation error of $192,326 on the HHS special report with no impact to the actual lost revenues as the quarter with the error did not result in any lost revenue being reported (i.e., lost revenue claimed was accurate on the HHS special report but key line items were misstated). Responsible Individuals: Cathy Huss, CFO Corrective Action Plan: All tracking documents that have calculations will be reviewed by the CEO if the CFO compiles for accuracy and vice versa. The reviewer will sign off by email that they have reviewed and agree with the calculations. The calculation of lost revenues will be updated with our next reporting to HHS. Anticipated Completion Date: 6/30/2023

Condition: The District recorded a duplicate deposit of $133,868 in federal funds to the general ledger. Corrective Action Planned: The Central Office will ensure that the general ledger transactions are reconciled to the final financial reports before submission to DESE. Anticipated Completion Date: June 30, 2025 Contact: William Plunkett, Director of Finance

Corrective Action Plan The University will establish processes and policies to pull attendance reports after census date of each term/semester for any students who receive Title IV aid and are identified as non-attendance. We will use this information to recalculate Federal Pell Grant and Federal Direct Student Loan awards based on enrollment or change in enrollment status. At the end of each term/semester, the University will review F/FA grades for any student who receives Title IV aid and will adjust their aid accordingly to comply with Title 34 of the Code of Federal Regulations, Part 690.80. In addition, we are currently reviewing F/FA grades for the 2023-2024 academic year. Anticipated Completion Date: June 2024 Contact Person(s): Alicia Bookout Associate Vice Chancellor, Financial Aid

Condition: Tiered environmental reviews were not completed for the City’s emergency and minor home rehabilitation activities. The environmental review for major rehabilitation activities was incomplete and was not submitted in the HEROS system. Planned Corrective Action: This finding was partly due to the staff members' need for more training. HUD mandated that staff undergo training on the HERO system as part of the resolution. The extra training enabled staff to revisit and finalize previous environmental reviews, ensuring compliance with environmental review regulations. After a follow-up with HUD, the agency considers the issue resolved. Going forward, environmental reviews will be conducted once every five years, which is in compliance with HUD regulations. Tiered reviews will be added as projects are completed. Our rehab specialist will be responsible for entering HEROs, and the division director will be responsible for public notices and hearings. Contact person responsible for corrective action: Madison Bjertness Anticipated Completion Date: 5/22/2024

Eligibility – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: CLA recommends management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: : Following CLA’s recommendation, SVP of Housing Choice will audit a random sample of 10 files on a monthly basis. Agency working with Human Resources contractor to fill open staff positions Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

Finding 2023-003 Finding Summary: The Organization did not have adequate controls to document the review and approval of qualified invoices prior to payment. Responsible Individuals: CFO (Amanda Moon), CEO (Karen McCandless) Corrective Action Plan: Ensure that all invoices are approved as eligible program costs prior to issuing payment. Anticipated Completion Date: 7/1/2024

To address the discrepancy and ensure accurate capital asset records, the technology director will do a: 1. Physical Re-inventory: Conduct a comprehensive physical re-inventory of all capital assets, focusing on areas where misplaced items are suspected. 2. Records Reconciliation: Compare physical inventory findings with existing records. Identify and rectify any errors in location data, descriptions, or asset status. 3. Asset Tracking Improvement: Implement measures to improve asset tracking, such as: Updating asset tags with clear and accurate identification information; doing a major search to retire all old devices still in inventory; and cleaning out storage areas for all outdated assets. 4. Investigation: If theft or damage is found on any of these missing devices, an official investigation per the district's policies will occur.