Corrective Action Plans

U.S. Department of Health and Human Services 2023-002 Unaccompanied Alien Children Program – Assistance Listing No. 93.676 Recommendation: It is recommended that the Organization design controls to ensure expenses are supported by source documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Ascentria will review our current policy and procedures with directors and program managers regarding what proper support and approval process is for an expense. Ascentria has already implemented a monthly reminder that includes that expenses must include a receipt or invoice. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris Planned completion date for corrective action plan: 6/30/2024

Federal Program Title: Research and Development Cluster ALN: Various Recommendation: We recommend the University evaluate its cutoff procedures to ensure federal costs are identified and reported in the correct fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Boise State University will evaluate our cutoff and accrual procedures to ensure costs are identified and reported in the correct fiscal year. Name(s) of the contact person(s) responsible for corrective action: Jen Lutke, Assistant Director, Post Award: jenniferlutke@boisestate.edu Planned completion date for corrective action plan: June 2024

Pell Award Errors Finding: As noted in the audit report, there were 5 instances out of 60 students with Pell award errors. Auditors' Recommendation: The University should have appropriate policies and procedure, as well as safeguards in place to ensure Pell eligibility and awarding is correctly determined. School Response: The school agrees with this finding and has initiated corrective action. Corrective Action Plan: For student #5, there was a Pell awarding error where the student was under awarded Pell by $172. The school made the correction to the award and disbursed the additional Pell. For student #16, student was over awarded Pell Grant for $1723 due to incorrect refunds made while adjusting for changes in the student's schedule. The school has refunded the $1723 over award back to the fund source. For student #24, the student was initially awarded correctly, but withdrew during their 2nd term. Due to incorrect Pell Recalculation on the R2T4, the school refunded too much Pell grant, and the student was under awarded by $458. The school has disbursed the additional Pell so the student is now paid correctly. For student #27, the student was over awarded Pell by $350 due to in error in Pell Recalculation based on the student's schedule. The school has refunded the over award to the fund source. For student #43, the student was under awarded by $22 due to an error in Pell Recalculation based on the student's schedule. The school has disbursed the additional Pell grant funds to correct the error. Starting with the Fall 2023 semester the school has implemented a new student information system (SIS), Colleague. The school has also partnered with a third-party servicer, Financial Aid Services (FAS), to assist with packaging. The new SIS automatically adjusts Pell grant whenever there is a change to a student's schedule during the term through the school's census date for each term and module. The system will schedule a refund for any over awards and increase the Pell award for any that may have been under awarded. Since this is no longer reviewed solely by the financial aid office, this is expected to reduce the number of errors in Pell awarding. In addition to the system adjustments, the school's third-party servicer, FAS, will review packaging for any students with changes to the number of registered credits during the term to ensure the system is making adjustments properly and the students are correctly packaged. Name(s) of the contact person{s) responsible for corrective action: Financial Aid Director, Holly Hardnett and third-party servicer, FAS, representative Planned completion date for corrective action plan: • New Colleague SIS implemented live beginning in the Fall semester 2023. • Training for Pell Recalculations in Colleague July 2023. • Registration/schedule changes for term reviewed by FAS at least weekly.

FINDING No. 2023-004: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should improve monitoring of the payroll disbursement process to ensure the appropriate approved wages are paid. Action Taken: Additional payroll controls are being evaluated and implemented in 2024. This will include establishing procedures to ensure the completeness and accuracy of payroll and related oversight. If the audit Oversight Agency has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO

FINDING No. 2023-003: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should make sufficient monthly deposits to the escrow accounts in a timely manner. Action Taken: The shortfall was due to the property insurance premium unexpectedly increasing by more than $170,000. The account was subsequently analyzed, and the monthly escrow deposit is now sufficient to cover the new rates.

Recommendation: We recommend that the University review its procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agree with the audit finding and will implement procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Name of the contact person responsible for corrective action: Michelle Hegarty, CFO Planned completion date for corrective action plan: Already in place

Finding Number: 2023-002 Condition: Out of 60 allowability samples that were tested, one expenditure tested was determined to be incorrectly charged to this grant. Planned Corrective Action: The College of Cooperative Education and Professional Studies (CCPS) has instituted several reforms to prevent future instances of this nature. The Program Director is now required to review and sign-off on all transactions before they are charged to the project, to ensure all charges are appropriate. New staff have been assigned to the project to process transactions, and the CCPS business office is now meeting monthly to review project activity, discuss any questions, and address any concerns regarding financial activities. Additionally, the university is drafting a new policy to review and, if needed, provide additional administrative support for large, complex grant projects. This policy will require that grant proposals above a certain dollar threshold are reviewed by the Office of Research prior to submission to ensure proper resources will be available to manage the project if awarded. In cases where the Office of Research determines additional resources may be needed, they will be authorized to require additional support be included in the grant proposal, or else provide additional administrative help to the unit at the time of award. Contact person responsible for corrective action: CCPS: Jeremy Harvey, Jodi Sleyo, and Bailey Bartels. Office of Research: Patrick Clark Anticipated Completion Date: CCPS changes have been implemented as of 10/11/2023; policy changes to be completed by 6/30/2024.

WE HAVE REVIEWED AND ARE FAMILIAR WITH THE REQUIRED COMPLIANCE REQUIREMENTS UNDER THE COMPLIANCE STATEMENT WHICH GOVERNS THE ARP ESSER PROGRAM. WE HAVE REQUESTED AND RECEIVED DOCUMENTATION FROM EACH VENDOR THAT ATTESTS THAT THEY ARE CONFORMING TO DAVIS-BACON PREVAILING WAGE REQUIREMENTS.

Condition: The District claimed $136,026 of capital expenditures between their March 31, 2023 and June 30, 2023 reimbursement claim submitted to the Illinois State Board of Education that could not be supported by documentation. Plan: The District is in the process of restructuring finance and operations to align roles and responsibilities. We will implement additional procedures for review and approval of reimbursement claims prior to submission to ensure that expenditures are claimed within a reasonable period of time in relation to when a reimbursement claim is submitted. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Sheila Johnson, Assistant Superintendent of Finance and Operations

ACOE updated the purchasing procurement policy and offered agency-wide training.

ACOE updated the procurement and statement temp to match the requirements.

ACOE updated the new Time and Effort policy and offered agency-wide training.

The Financial Aid team is conducting staff training regarding return to Title IV calculations and compliance led by the Financial Aid Director. This includes all return to Title IV calculations being reviewed by the Financial Aid Director before final submission.

Management agrees with the finding. Management will submit the forms for USDA's approval.

CORONAVIRUS STATE AND LOCAL RECOVERY FUNDS, ASSISTANCE LISTING 21.027 : INELIGIBLE COSTS / UNIFORM GUIDANCE 2 CFR PART 200 UNIFORM ADMINISTRATIVE REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL AWARDS, SUBPART E: COST PRINCIPLES SECTION 200.403(F) STATE "EXCEPT WHERE OTHERWISE AUTHORIZED BY STATUTE, COSTS MUST MEET THE FOLLOWING CRITERIA IN ORDER TO BE ALLOWABLE UNDER FEDERAL AWARDS: (F) NOT BE INCLUDED AS A COST OR USED TO MEET COST SHARING OR MATCHING REQUIREMENTS OF ANY OTHER FEDERALLY-FINANCED PROGRAM IN EITHER THE CURRENT OR PRIOR PERIOD. / THE CITY OF EAST PRAIRIE RECEIVED ARPA FUNDS THROUGH MISSISSIPPI COUNTY, MISSOURI FOR THE REMOVAL OF ASBESTOS AND DEMOLITION OF A HAZARDOUS SCHOOL STRUCTURE IN ORDER TO FACILITATE THE CONSTRUCTION OF A PUBLIC HEALTH FACILITY IN AUGUST AND SEPTEMBER, 2022. IN DECEMBER OF THE SAME YEAR, THE CITY RECEIVED WAS AWARDED AND ARPA GRANT AND FUNDS THROUGH THE MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION FOR THE SAME PROJECT. THIS WAS A DUPLICATION OF ARPA FUNDS DUE TO THE CITY NOT BEING FULLY AWARE OF THE COST STANDARDS OF UNIFORM GUIDANCE AND A MISCOMMUNICATION REGARDING ELIGIBILITY OF COSTS. / THE CITY OF EAST PRAIRIE HAS CONTACTED MISSISSIPPI COUNTY AND WILL BE RECEIVING AUTHORIZATION FROM THE MISSISSIPPI COUNTY COMMISSION TO RE-ALLOCATE THOSE FUNDS FOR THE SAME PUBLIC HEALTH FACILITY PROJECT. WE ARE ALSO DEVELOPING A WRITTEN POLICY AND PROCEDURE MANUAL CONFORMING TO UNIFORM GUIDANCE.

Finding Number: 2023-003 Condition: The Seminary did not have controls in place to identify and document the students who have withdrawn and the applicability of performing a return of Title IV funds. Planned Corrective Action: Financial Aid Director has established a procedure to ensure that R2T4 calculations are completed and any funds due to be returned are sent back to the Department of Education within 45 days of the date of the student's withdrawal. The Financial Aid Director created a listing to track all student withdrawals (including details of withdrawal). The Registrar sends an email to the Financial Aid Director notifying when a student has withdrawn from the institution, which gets entered onto the list. The Financial Aid Director set up the Department of Education's R2T4 calculator for the 2023-2024 academic year. R2T4 calculations are completed for any student withdrawn and if necessary, funds are returned to the Department of Education. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/05/2023 (beginning of Fall 2023 term)

Finding 2023-004 Internal control deficiency and noncompliance over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting related to expenses attributable to coronavirus reported in the provider relief fund reports. The entity has excess lost revenues to cover all payments received (excluding the expenses submitted). Therefore, no refund is required for any payments received. Since the program has ended, the management has implemented the following procedures for future grants: 1) An education session occurred on February 15, 2024, with the relevant parties across Huntington Health entities to formally implement a review process whereby the Controller will review the support files prior to filings being made related to grant applications/programs across any of Huntington’s entities. Documentation of this review will be retained in the central file repository. These steps and controls will be updated and documented in the departmental policy. 2) A central folder on the Huntington Hospital’s main accounting drive has been created. This folder will be populated with all support for filed figures related to grant applications/programs across the hospital’s various entities. The support will be validated as having been placed into this folder as part of the reporting out process by the accounting manager and Controller handling the reporting. Files will be retained in this central drive for a minimum of 7 years. These steps and controls will be updated and documented in the departmental policy. Contact Person: Byron Davis, Controller and Steven Mohr, Senior Vice President and Chief Financial Officer, Huntington Hospital Anticipated Completion Date: Completed

Finding 2023-003 Internal control deficiency and noncompliance over Procurement related to small purchases. In response to this finding management will implement the following: 1) We are implementing internal controls to ensure small purchase procurements are consistently supported by price and rate quotations from an adequate number of qualified suppliers. The Executive Director, or their designee, will conduct a quarterly audit of 8% of the total number of purchase orders issued to Research within a 12-month period. The Audit sample selection will be using a random algorithm that accounts for materiality to assure the documents listed for small purchase procurements are supported by price or rate quotations from an adequate number of qualifies suppliers. The results will be reviewed by the Executive Director or their designee who will address any deficiencies with the assigned buyer. These steps and controls will be updated and documented in the departmental policy. 2) An education session occurred on February 15, 2024, with the relevant parties across Cedars-Sinai Supply Chain Procurement department. This was to re-enforce our policy PUR00318 – Bid Guidelines Procedure: Purchasing detailing the procedures to follow for small purchase procurements and the role each one has to ensure the process is followed every time. The education session also highlights that all documents need to be properly stored for further review or audits. Contact Person: Motz Feinberg, Vice President and Chief Supply Chain Officer Anticipated Completion Date: Education completed – quarterly audit procedure to be implemented by March 15, 2024

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Debra Clark, Business Manager Corrective Action: Regional School Unit 1 will take the following actions to address finding 2023-001 Regional School Unit 1 acknowledges that the Davis-Bacon guidelines were not followed properly for a construction contract in fiscal year 2023. This contract was an extension of a fiscal year 2022 contract and a deficiency was issued for that year as well. Regional School Unit 1 now has the proper federal award form and the U.S. Wage and Hour Division payroll form available to be included with new construction contracts moving forward. These forms will be provided with any future construction contracts. The Facilities Director and Business Manager have reviewed the process and we are confident that this will not be an issue in the future.

ALLOWABLE COSTS AND COST PRINCIPLES Department of Health and Human Resources (DHHR) Assistance Listing Number 97.036, COVID-19 97.036 The DHHR analyzed this finding and hereby offers more details into the condition and cause of the finding. Although the DHHR concurs with the condition statement in the finding, in that certain invoices were paid to one vendor without verifying their accuracy, the DHHR does not concur with the cause statement, which proclaims a lack of proper controls within the DHHR. While no set of internal controls can prevent unseemly or otherwise improper payment activities with absolute assurance, the DHHR does indeed have proper internal controls in place to provide reasonable assurance that invoices are verified for accuracy prior to payment. The DHHR is a large state agency with many spending units, divisions, and levels of oversight and approval. Accordingly, when paying invoices, the process includes a separation of duties. Authorization to approve cash payments begins with the DHHR spending unit, which was a programmatic unit in this case since the vendor in question was required to provide nasal swab diagnostic testing for COVID-19 and upload the test results immediately, as the tests were for specific DHHR programs and initiatives that were an absolute priority at the time. For these and other types of billings, the spending unit receives the invoice from the vendor, conducts an initial review for completeness and accuracy, and approves [or denies] the invoice for payment pursuant to the internal specifications at the spending unit level. If approved for payment, the invoice must be certified by the spending unit. Per the Code of State Rules, Title 155, Series 1, Standards for Requisition for Payment Issued by State Officers on the Auditor, the term “certify” means, “To verify that pertinent information is true and accurate by affixation of a manual signature by an authorized person.” To comply with the verification requirement, 155CSR1-3.1.3 requires the invoice to be stamped with the following certification: “I hereby certify that the items or services contained in the foregoing have been received and approved for payment.” Within the DHHR, the certification must be dated and signed by an authorized representative at the spending unit level with authority to approve such payments. The spending unit then enters the information into wvOASIS, which is the statewide accounting system, and forwards the related documentation to the DHHR central finance office. The central finance office performs a secondary review for completeness and accuracy pursuant to the specifications at the DHHR central level and, if acceptable, approves the documents within the wvOASIS workflow to the WV State Auditor’s Office for final review, approval, and processing of the payment pursuant to the specifications at the statewide level. For the invoices in question, the person authorized to certify the invoices and approve the payments was an upper-level supervisor, and his duties in that position had included reviewing and verifying the accuracy of certain invoices submitted to the DHHR by vendors supplying the aforementioned COVID-19 testing and mitigation services prior to certifying the invoices for payment. The supervisor originally proclaimed that he certified the invoices only after two individuals working with the program verified the invoices. The supervisor subsequently admitted that he certified the invoices without actually making any effort to verify their accuracy. The supervisor is no longer employed by the DHHR. It is important to note that although the supervisor certified the invoices without making any effort to verify their accuracy, it has yet to be determined if the vendor’s invoices were correct or erroneous. Currently, there are several internal and external organizations investigating the vendor and the overall condition that led to this finding. Those investigations began prior to the period of the audit. Once complete, the investigations will disclose additional details surrounding the validity of the invoices and the costs in question.

SPECIAL TESTS AND PROVISIONS – FRAUD DETECTION AND REPAYMENT West Virginia Department of Health and Human Resources (DHHR) Assistance Listing Number 93.575, 93.596, COVID-19 93.575 Per 45 CFR 98.68(b)(2), there is no requirement for lead agencies to recoup Child Care and Development Fund overpayments, except in instances of fraud as defined by the lead agency. Within the State of West Virginia, the lead agency is the DHHR. As indicated in Section 8.1.6 of the CCDF [State] Plan for West Virginia for Federal fiscal years 2022-2024, the DHHR Office of Inspector General (OIG) is responsible for pursuing fraud and overpayments. As indicated in Section 1.1.2 of the CCDF [State] Plan, the Division of Early Care and Education within the DHHR Bureau for Family Assistance (BFA) administers the CCDF program. Accordingly, the OIG and BFA strive to work as a unified team within the DHHR and State as a whole to identify and prevent fraud or intentional program violations; to identify and recover misspent funds as a result of fraud; and to otherwise fight fraud and ensure program integrity. As the lead agency, and as necessary to ensure program integrity, the DHHR has policies and procedures in place to define fraud and to identify and recover payments resulting from fraud, as the auditors indicated within the condition and recommendation sections of this finding and to track referrals and determinations from beginning to end (i.e., beginning in the year of identification and continuing through resolution or the establishment and enforcement of repayment agreements). The policies and procedures are specifically referenced in Chapter 8 of the BFA’s “Child Care Subsidy Policy and Procedures Manual.” Chapter 8 of the manual is titled, “Improper Payments: Prevention, Identification, Measurement and Recoupment.” Improper Payments Per Chapter 8 of the manual, an improper payment occurs when the funds go to the wrong recipient, the recipient receives the incorrect amount of funds, or the recipient obtains or uses the funds in an improper manner. Improper payments include 1) worker error in determining eligibility, authorizing care, or paying for care; 2) misrepresentation on the part of the parent or provider; and 3) programmatic infractions by parents or providers. 1. Worker Error – Improper payments due to worker error are defined as payments that should not have been made or that were made in an incorrect amount due to an error in determining and verifying eligibility, calculating the benefit, or entering the data into the eligibility system. Repayment of an improper payment due to worker error is not mandatory regardless of the amount. 2. Misrepresentation – Misrepresentation (i.e., fraud) occurs when a specific section of the child care policy is violated as a result of the information not having been reported by the client or provider or reported falsely. Improper payments made as a result of mis-interpretation must be referred to the OIG when the amount exceeds $1,000.00. If the amount does not exceed $1,000.00, the BFA must initiate repayment procedures. A willfully false statement is one that is deliberately given, with the intent that it be accepted as true, with the knowledge that it is false. It is an essential element in a misrepresentation charge that the client or provider knew the statement was false. 3. Programmatic Infraction – There are times when it is difficult to discern whether an improper payment occurred due to willful misrepresentation or is simply the result of a client or provider’s genuine confusion over subsidy program rules and responsibilities. When the case manager believes that improper payments were the result of the client or provider’s failure to understand, it is considered to be a programmatic infraction; it is the BFA’s responsibility to collect the improper payment in this instance, regardless of the amount. If the case manager is in doubt as to whether an improper payment is a programmatic infraction or is the result of misrepresentation by the client or provider, and the improper payment is less than $1,000.00, the case manager discusses the case with the supervisor and the supervisor subsequently consults with the program director; together, they make the decision whether to pursue repayment. Referrals from the Bureau for Family Assistance to the Office of Inspector General If the overpayment is $1,000.00 or greater and is due to misrepresentation by the client or provider, the case manager prepares a memo explaining the circumstances, the time period, and an estimate of the amount involved; indicates the person(s) who can verify the information within the memo; attaches a copy of all applicable documentation including, but not limited to, the payment form and attendance sheets that help support the complaint; states what corrective actions the case manager has taken on the case; and sends a copy of the memo and supporting documents to the Office of Inspector General, Division of Investigations and Fraud Management. Recovery of Improper Payments Resulting from Misrepresentation (i.e., Fraud) The supervisors within the BFA are responsible for negotiating repayment schedules with providers and clients and completing a Child Care Benefit Repayment Agreement to include the amount to be recovered, the period of recovery, the monthly recovery amount, and the procedure for repayment. If the provider or client is active, the case manager attempts to collect the payment in full; if this is not feasible, the case manager requests that the client or provider be asked to repay the amount in monthly installment payments of approximately 10% of the amount due. If a payment is more than 45 days late (15 days past the due date), the entire unpaid balance becomes due and must be paid in full. Failure to repay the requested amount results in case closure for clients or denial of participation in the certificate system for child care providers. Client services will not be reinstated until full payment is received. There are no policies or procedures to pursue repayments or collection beyond that point. There is no method to recoup overpayments from ongoing benefits, and the CCDF is not subject to the Treasury Offset Program, as other Federal programs are. Corrective Action Plan As previously stated, the OIG and BFA strive to work as a unified team within the DHHR to identify and prevent fraud or intentional program violations; to identify and recover misspent funds as a result of fraud; and to otherwise fight fraud and ensure program integrity. In response to the auditor’s recommendation for this finding, the OIG and BFA will revisit existing policies and procedures over fraud detection and repayment and will attempt to enhance the controls related thereto, particularly in relation to ensuring that all efforts concerning fraud detection and repayment are sufficiently documented, thus demonstrating full compliance with 45 CFR 98.60. Maintaining documentation of the decision-making process, the activities performed, and the results of those activities is of paramount importance in achieving that objective. A high level of documentation is necessary to support that the DHHR has policies and procedures in place and is following those policies and procedures. Maintaining adequate records and other documentary evidence will resolve this audit finding, prevent the occurrence of future audit findings, and provide a means to corroborate statements and assurances provided to regulatory agencies and other authorized individuals with regards to the DHHR’s overall compliance with 45 CFR 98.60. It is not enough to perform the activities; there must be an adequate audit trail to show the “who, what, when, where, and how” of the activities performed. As such, the OIG and BFA will also develop and maintain an appropriate system for categorizing their files and organizing their records, reports, and documents in a systematic and orderly manner to ensure, among other purposes, that they can substantiate their efforts when audited, reviewed, or evaluated by internal staff or authorized external organizations.

ALLOWABILITY AND ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.489, 93.575, 93.596, COVID-19 93.575 For the one payment out of 40 whereby the provider requested and was paid for 13 non-traditional days although records indicated that only 11 of the days were non-traditional, the West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA), agrees that the condition resulted in an overpayment of $12.00. The BFA Case Manager entered 13 non-traditional days in the Family and Children Tracking System (FACTS), but the record indicated that only 11 days were non-traditional days. Per WV Child Care Policy and Procedures: 8.3.1. Worker Error Improper payments due to worker error are defined as payments that should not have been made, or that were made in an incorrect amount due to worker error in determining and verifying eligibility, and/or calculation and input of information into the Family and Children’s Tracking System (FACTS). Incorrect amounts include overpayments, underpayments and inappropriate denials of payment. 8.3.1.1. Examples of worker error: A. The child care regulatory specialist enables the “accreditation” box, allowing the provider to receive an extra $4 per day, when the provider has not achieved accreditation, and is not entitled to the enhanced rate. B. The case manager enters an incorrect number of days when entering information from the payment form into FACTS. C. The case manager enters more time on the child care assessment than the client’s work or school schedule supports. D. The case manager fails to verify income, school enrollment, or special needs status. 8.3.1.2. Repayment of an improper payment due to CCR&R worker error is not mandatory regardless of the amount. The BFA Division of Early Care and Education employs Child Care Policy Specialists who visit contracted Resource and Referral Agencies to monitor and audit both electronic and hard records. Training and coaching also takes place during these visits. These visits continued throughout the reporting period. The BFA will evaluate the effectiveness of the current training programs for the use of the FACTS system (and subsequently for the West Virginia People's Access to Help (PATH) system) for CCDF payments. Furthermore, the BFA will follow established policies and procedures to ensure client information is appropriately obtained and maintained and that all data is input accurately. For the payment whereby the $3.00 daily supplement was not included in the calculation or paid, although the documentation in the eligibility system indicated that the child was covered under a CPS Safety Plan, this was not in fact a CPS Safety Plan case. The CPS Safety Plan was being used as a temporary means to address an executive order regarding COVID-19 and grant eligibility to essential workers who would otherwise not have qualified for the child care subsidy assistance due to their monthly income being above the Federal Poverty Level but below 85% of the State Median Income. The payment in question was in March 2023. Via a case assessment on November 1, 2023, this case [and other similar cases] were approved in the eligibility system as formalized Policy Exceptions rather than being selected as part of a CPS Safety Plan.

SUBRECIPIENT CASH MANAGEMENT Department of Health and Human Resources (DHHR) Assistance Listing Number 93.788 The West Virginia Department of Health and Human Resources, Bureau for Behavioral Health (BBH), analyzed this finding and hereby offers more details into the condition and cause of the finding. For the first noted exception, the grant was finalized on March 20, 2023. The BBH received the subrecipient’s first request for payment on April 12, 2023, at which point the reconciliation indicated that the subrecipient had incurred expenses of $118,186.21 to date. Although the reconciliation was not reviewed and approved by the BBH timely, it indicated that the subrecipient had not been reimbursed at all; therefore, the subrecipient had no cash on hand at the time of the request for payment. For the second noted exception, the BBH received the reconciliation on June 2, 2023. Although the reconciliation was not reviewed and signed by the BBH timely, it indicated $41,296.14 of cash on hand, which was under the 10% threshold established by the BBH when monitoring cash management for subrecipients of the Opioid program. For the third noted exception, the BBH received the reconciliation on March 14, 2023. Although the reconciliation was not reviewed and signed by the BBH timely, it indicated expenditures of $63,839.08 and cash on hand of only $18,070.92, which was less than the 10% threshold established by the BBH when monitoring cash management for subrecipients of the Opioid program. For the fourth noted exception, a processing error within the BBH caused the subrecipient to receive a payment that should have been held due to the subrecipient having sufficient cash on hand at the time of the payment. Nonetheless, after the period of performance, the subrecipient did not have excess cash on hand, or any cash on hand for that matter. The subrecipient returned $218,290.74 to the BPH on November 14, 2023 and $2,317.10 on November 29, 2023 in accordance with the closeout procedures referenced in 2 CFR 200.344(d). The total amount of $220,607.84 constituted the balance of unobligated cash that the BPH paid the subrecipient in advance and was not authorized to be retained by the subrecipient for use in other projects. In an effort to enhance internal controls, the BBH’s central level managers continue to work with internal and external parties to improve everyone’s understanding of the federal rules and regulations and the BBH’s existing policies, procedures, and overall expectations concerning subrecipient cash management.

ALLOWABILITY AND ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.659 The issues identified in the finding were due to a broad number of child welfare workers having access to select “Non-Recurring Adoption Expense” (NRAE) when issuing a demand payment through the eligibility system, causing the incorrect funding to be used. Two of the payments identified were manually entered to replace lost payments. The initial payments covered multiple children, but the replacement payment only identified one child’s name. For the Adoption Program, the DHHR phased in a new information technology system for determining eligibility, making payments, maintaining documentation, etc. during the State Fiscal Year 2023. The name of the new system is PATH (People & Access to Help). The PATH system replaced the Family and Children & Tracking System (FACTS). The PATH system will have additional controls and levels of review as compared with the FACTS system. For example, as specific to this finding, the ability to select NRAE when issuing a demand through PATH has been localized to adoption subsidy unit staff within the central office of the DHHR Bureau for Social Services.

ALLOWABILITY AND ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.658 As indicated in the Condition section of the finding, although the documentation related to safety considerations at child care institutions was not initially maintained in the official licensing files for 10 of the 40 cases tested for eligibility, the documentation was eventually provided to the auditors for eight of those 10 cases. For one of the remaining two cases, the child care institution is an out-of-state institution that is no longer in business. For the other case, the child care institution provided documentation, but the documentation did not include the dates of the institution’s safety checks. In an effort to enhance internal controls over the safety considerations at child care institutions, the West Virginia Department of Health and Human Resources, Bureau for Social Services (BSS), is continuing to analyze the condition that led to this finding and is considering a number of steps, including but not limited to the following as an immediate plan of action: • Transmit a copy of 2 CFR 1356.30(f) to all licensing personnel, supervisors, and other applicable staff within the BSS and oblige them to acknowledge that they have read and understand the requirements referenced therein. • Implement a formalized policy and develop written procedures for ensuring the licensing files for child care institutions contain documentation which verifies that safety considerations with respect to the staff of the institutions have been addressed. • Develop overall standards for the maintenance of documentation within licensing files (e.g., a consistent naming convention for the documents, which would improve internal tracking and ensure that requests from independent auditors are addressed efficiently and fully; personnel who have read-only access to documents versus those who can add, replace, and delete documents; record retention requirements; etc.). • Establish a formalized process for monitoring. Such a process would include a strategy for conducting internal reviews of all licensing files on a recurring basis, reporting the results of those reviews to appropriate officials internal and external to the DHHR, following up with those officials as may be necessary, and documenting the overall results accordingly. For example, if the results of a monitoring review indicated noncompliance [or potential noncompliance] on the part of a child care institution, the BSS would inform the institution, request a copy of the institution’s written policies and procedures regarding safety considerations, discuss it with the institution, and provide technical assistance to the maximum extent practicable. Once the BSS drafts the aforementioned policies and procedures and related monitoring process, or otherwise enhances their internal controls over the safety considerations at child care institutions, the BSS will discuss the matter with their regular programmatic contacts at the U.S. Department of Health and Human Services, Administration for Children and Families, and will ask the ACF if the BSS’s planned controls are aligned with the ACF’s universal expectations surrounding 2 CFR 1356.30(f).