Corrective Action Plans

Finding No. 2022 007: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Agriculture AL Number and Title: 10.551, 10.561, and COVID 19 ? 10.561 ? Supplemental Nutrition and Assistance (?SNAP?) Cluster Award Number and Award Year: 7HI4004HI, 7HI400HI4, 7HI430HI4, 7HI400HI5, 7HI430HI5, 7HI460HI6, 227HIHI7F1003 Condition During our audit, we selected a non statistical sample of 60 participant files which approximated $50,000 in monthly payments, out of a population of approximately 195,000 participant files which approximated $986 million in total annual benefit payments, for testing and noted exceptions in three case files as follows: ? One case file where manually entered unearned income and medical expense deduction amounts did not agree with the documentation retained in the participant?s case file. ? Two case files where manually entered income information did not agree with the documentation retained in the respective participant?s case files. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: Remind eligibility staff to ensure that verification submitted by the household and filed in household?s electronic case folder (ECF) along with documentation on cases through DHS 1006 and/or case notes are consistent with what is processed and recorded in the eligibility system - HAWI, and that processing is completed according to Supplemental Nutrition and Assistance Program (SNAP) policy to ensure that households are receiving the maximum amount of benefits they are eligible to receive. The SNAP office would also coordinate with the Staff Development Office to put an extra emphasis on this area when conducting SNAP basic training for new eligibility workers. Expected Completion Date: September 30, 2023 Responding Official: Manuel Banasihan, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator

Finding No. 2022 002: Special Tests and Provisions (Material Weakness) Federal Agency: Department of Health and Human Services AL Number and Title: 93.777, 93.778, and COVID 19 ? 93.778 ? Medicaid Cluster Award Number and Award Year: 2105HIMAP, 2205HIMAP, 2105HIADM, 2205HIADMN Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $21 million of payments out of a total payment population of $223 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned The conversion to the HOKU online provider enrollment system in 2020, the staffing and workload impacts of the COVID 19 public health emergency and the inability to fill key provider enrollment section positions have combined to tax the ability of the Department to come into compliance with the stated criteria. These factors have created backlogs in the processing turnaround time for new provider enrollment applications that have been submitted by providers and are waiting to be processed by the Department. These factors have also hampered the Department?s efforts to timely outreach with providers who are at/over the five-year revalidation threshold. The Department was able to fill the section administrator over the provider enrollment section in June 2022, and also fill a key contract specialist position in August 2022. The Department entered into a new provider enrollment staff augmentation contract with Maximus effective January 1, 2023, and initial vendor performance has been promising. New provider enrollment processing time has been reduced to no more than ten days for certain provider types, and Maximus is on track to eliminate the existing provider enrollment application backlog by the third quarter of 2023. The Department is expecting these changes to result in full compliance with the stated criteria by the end of 2023. Expected Completion Date December 31, 2023 Responding Officials Jon Fujii, MED Quest Division Health Care Services Branch Administrator

The School will more diligently assess the specific need of the school and put better procedures into place to ensure that the grant funds are being utilized on allowable expenditures.

Finding No. 2022 012: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition We selected a non statistical sample of 14 participant files for testing out of a population of 138 participant files that were initially determined by the Title IV-D agency as not cooperating with the child support enforcement requirements. We noted 3 files did not contain any correspondence, notices, or documentation to indicate whether any follow up action, up to and including case closure and cessation of benefits, were performed. Views of Responding Officials: The Department agrees with the finding and will implement corrective action; however, notes the following: Based on my review of the selected cases, particularly the cases that were properly closed due to non-compliance with child support requirements, I found that the Processing Centers received hard-copy notifications from the Child Support Enforcement Agency (?CSEA?). The three cases indicated as having no closure notices, there were no hard-copy notifications found in the clients? electronic case files. The referrals to CSEA are done through an interface between the HAWI and CSEA's KEIKI systems. When a recipient is determined non-compliant by CSEA, the information is sent via the interface from KEIKI to HAWI in the form of a system-generated alert. This process worked well when application processing and maintenance of recipient cases were done in a case management method (e.g., each eligibility worker assigned to process applications and/or maintain a caseload of active cases). This method, eligibility workers would manage their caseloads and check for incoming alerts for cases assigned to them; these alerts would include the CSEA non-compliant alerts coming from KEIKI system. Workers were able to take appropriate and timely action in response to the alerts received. However, necessary changes were made to how applications and active cases are managed. The division stopped the case management method and converted to "task-oriented" processing statewide. Workers are no longer assigned to caseloads but are assigned to "tasks" such as processing applications, incoming documents/verifications, reported changes, six-month review and annual recertifications, etc. A case is not reviewed and worked in HAWI until a worker is prompted to do so, e.g., six-month review, annual recertification, change was reported by the household, or when a document pertaining to a case is received by the Processing Center such as hard-copy notice sent from CSEA indicating a client did not comply with child support requirements. When any one of these occur, then the worker who is assigned to that task will check for alerts for the case. Aside from that, recipient cases are not reviewed. So how the "alerts" were developed in HAWI no longer works for the way we currently process applications and maintain cases. We are unable to modify the HAWI system because we are currently developing a new eligibility system that will replace HAWI. Corrective Action Taken or Planned: We created an ad hoc report to identify Temporary Assistance for Needy Families Program (TANF) recipient cases that received the HAWI alert, ?REASON [Numeric Code]: CLIENT FAILED TO COOPERATE W/CSEU ON [mmddyyyy]?, generated by the interface with the KEIKI system. The report identifies cases by Case Number, Case Name, and assigned Processing Center. The program office will disseminate the list to the Processing Centers to take appropriate and timely action. The ad hoc report will be requested from the Department?s Office of Information and Technology (?OIT?) and disseminated monthly. Expected Completion Date: On-going Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator

Finding No. 2022 011: Eligibility (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition We selected a non statistical sample of 60 participant files, representing approximately $39,000 of benefit payments, out of a population of approximately 8,700 cases, representing approximately $17.8 million of benefit payments, for testing and noted exceptions in 17 case files as follows: ? Nine case files where eligibility redeterminations were not completed in the timeframe required by the State Plan. ? Seven case files where there was no evidence of a TANF case worker?s signature on the eligibility redetermination form. ? One case file where the interview process was not conducted within the forty-five (45) day timeframe required by the State Plan. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Administration for Children and Families (?ACF?) will be notified in writing, within the required timeframe, if additional amendments will be or are made to the current Temporary Assistance for Needy Families State Plan. Expected Completion Date: On-going Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator

Finding No. 2022 010: Special Tests and Provisions (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.558 and COVID 19 ? 93.558 ? Temporary Assistance for Needy Families Award Number and Award Year: 1601HITAN3, 2001HITANF, 2101HITANF, 2201HITANF, 2021G990228 Condition We selected a non statistical sample of 60 case files for testing and noted 11 instances where the Department?s records did not support the use of the income information obtained through Income Eligibility and Verification System (?IEVS?) to evaluate or re-evaluate the benefit calculation. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken of Planned: It was noted in the Corrective Action Plan, in response to the State fiscal year 2021 audit finding, the DHS 1006 form, ?Eligibility Documentation? (formerly titled ?Interview Documentation?), was revised to require the eligibility of staff to notate the date the Income Eligibility and Verification System (IEVS) query was completed, the findings, and what information was used for eligibility determinations. However, for most of the State fiscal year 2022, the interview requirement for new applicants and annual recertifications for recipients were waived; therefore, the DHS 1006 form was not utilized. Form DHS 1006 will be revised further to create IEVS query fields specifically under Section IX ? Temporary Assistance for Needy Families (TANF) Requirements, and a policy clarification will be issued to remind staff of the IEVS query requirement and instructions on how to complete the DHS 1006 form. Expected Completion Date: September 30, 2023 Responding Official: Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator

Finding No. 2022 004: Special Tests and Provisions (Material Weakness) Federal Agency: Department of Health and Human Services AL Number and Title: 93.767 ? State Children?s Health Insurance Program Award Number and Award Year: 2105HI5022 Condition During our audit, we selected a non statistical sample of 60 providers for testing out of a population of approximately 1,800 providers. The providers selected for testing represented approximately $240,000 of payments out of a total payment population of $7.2 million. The results of our testing were as follows: ? Four providers where the DHS Form 1139 was not maintained. ? Eight providers where the DHS Form 1139 did not support revalidation within the most recent five year period. Views of Responding Officials The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned The conversion to the HOKU online provider enrollment system in 2020, the staffing and workload impacts of the COVID 19 public health emergency and the inability to fill key provider enrollment section positions have combined to tax the ability of the Department to come into compliance with the stated criteria. These factors have created backlogs in the processing turnaround time for new provider enrollment applications that have been submitted by providers and are waiting to be processed by the Department. These factors have also hampered the Department?s efforts to timely outreach with providers who are at/over the five-year revalidation threshold. The Department was able to fill the section administrator over the provider enrollment section in June 2022, and also fill a key contract specialist position in August 2022. The Department entered into a new provider enrollment staff augmentation contract with Maximus effective January 1, 2023, and initial vendor performance has been promising. New provider enrollment processing time has been reduced to no more than ten days for certain provider types, and Maximus is on track to eliminate the existing provider enrollment application backlog by the third quarter of 2023. The Department is expecting these changes to result in full compliance with the stated criteria by the end of 2023. Expected Completion Date December 31, 2023 Responding Officials Jon Fujii, MED Quest Division Health Care Services Branch Administrator

Finding Number: 2022-002 Finding Title: Reporting Program: 21.027 COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Shannon Coyle, County Auditor-Treasurer Corrective Action Planned: Morrison County management is aware that the annual Project and Expenditure Report submitted for Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) to the U.S. Treasury was done so incorrectly. The County has reviewed the U.S. Department of the Treasury guidance and form instructions to ensure it is correctly reporting its CSLFRF activity going forward. Anticipated Completion Date: The correction will be made on the Annual Project and Expenditure Report due in April 2024, for the reporting period ending March 31, 2024.

Finding Number: 2022-002 Condition: Participant files selected for testing did not include complete information to support participant eligibility Planned Corrective Action: Staff will be retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Supervisor. The Department Manager and Supervisor will continue to utilize all Yardi monitoring reports to ensure the Department is operating in accordance with industry standards. Reporting will be done and monitored monthly to meet set goals. We know and maintain we will work in accordance with HUD rules and regulations where Annual Recertification processes are concerned. Weekly, Department Manager will review the certification pipeline to ensure compliance and follow up with the Housing Specialist to ensure compliance and meeting set weekly and monthly goals and metrics. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2023

Finding Number: 2022-004 Condition: Participant files selected for testing did not include complete information to support participant eligibility Planned Corrective Action: While the Detroit Housing Commission works towards implementing Rent Cafe, an electronic platform to allow applicants, residents, and Management the ability to streamline the continued occupancy and eligibility process, DHC will continue to utilize the manual application process with the following controls in place: 1. There will be ongoing training to support staff in Public Housing Rent Calculation. Within the designated training, Housing Specialists, Property Managers, Assistant Property Managers and Compliance Specialists will focus on correctly calculating subsidy for applicants and residents. Trainings will include but are not limited to properly identifying and verifying income, expenses, allowances, adjusted income, total tenant payment (TTP), utility standards, PHA payment and subsidy standards. 2. Regional Managers will conduct the first line of quality control file reviews. Upon Housing Specialist, Property Manager and Assistant Property Manager's completing Initial Eligibility, Annual and Interim recertifications, Regional Managers will review the proposed certification against the certification's checklist for approval. 3. The Compliance Department will conduct ongoing Quality Control File Reviews on a 10% sample selection of households to ensure timely completion and accuracy of ongoing participant rent determination. a. When deficiencies are identified during a Quality Control review, site staff will have 7 days to cure and upload the corrective file to SharePoint. b. The final quality control review will also include reconciliation for acceptance of the electronic file to PIC. 4 . To address the incorrect utility allowance amounts being utilized to calculate tenant rent, the following will occur: a. DHC's REM Department will work with DHC's IT Department of update the Utility Allowance tables in the housing's Yardi Software. Current utility allowances will be entered in the software's utility allowance table and will prepopulate based on the action type and effective date of the recertification. b. Site staff will include the printed utility allowance chart within the certification with the allowance amount provided clearly identified for review by the Regional Manager when conducting the first line of quality control file review. Contact person responsible for corrective action: Scharre Leslie, Operations Analyst & Compliance Manager Anticipated Completion Date: 6/30/2023

We were under the false notion that purchases made through the Commonwealth of Pennsylvania?s cooperative purchasing program (COSTAR) satisfied compliance of quote/bid requirements of federal purchases. We will follow our policy for federal purchases subject to quotation/bid requirements moving forward. When federal money is used, we will not use cooperative purchasing programs as the only source of quotation/bid for federal purchases. We also implemented processes to improve documentation relating to purchases that meet sole source criteria. Anticipated Completion Date: The District will implement the above procedure immediately.

Finding No. 2022 009: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.090 and COVID 19 ? 93.090 ? Guardianship Assistance Award Number and Award Year: 2101HIGARD, 2201HIGARD Condition We selected a non statistical sample of 60 case files which approximated $55,000 in monthly benefit payments, out of a population of approximately 380 case files which approximated $3.9 million in total annual benefit payments, for testing and noted exceptions in 17 case files as follows: ? Seven case files where the initial or modified guardianship/permanency assistance agreement was missing and therefore did not have any support for the amount of monthly assistance paid. ? Four case files where the ?difficulty of care? determination was missing and therefore did not have any support for the assistance amount paid. ? One case file where we were unable to determine if a child who attained the age of 14 was consulted regarding the kinship guardianship agreement. ? Three case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing in the case files. ? Two case files where documentation regarding continuation of monthly subsidy payments after the child?s 18th birthday was missing. ? One case file where the supporting documentation regarding whether the State determined that the guardian/permanent custodian has a strong commitment to caring permanently for the child was missing. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (CWS) will make a note in each specific case record identified in this audit explaining the audit findings, and secure missing/incomplete eligibility documents for cases identified in the audit. 2. The identified errors and the related corrective action step above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within ninety days to ensure missing documentation has been secured and properly noted in record. ? Additionally, the MICU will complete a random Guardianship Agreement audit review approximately six months later. i. MICU will share random audit findings with CWS Administration. ii. CWS Administrators will take corrective action based on MICU audit findings. 3. CWS supervisors will ensure that line staff are familiar with these policies and procedures and monitor through individual supervision meetings and work product review. ? Staff with errors identified in this audit, during individual supervision meetings or through work product review will: i. Be given coaching/supervisory support to correctly complete documentation. ii. Be required to participate in refresher training on Title IV-E Foster Custody, which is offered three times a year with participation documented by Staff Development Office. ? All staff who manage payment-only cases will review a quarter of their cases each month with their supervisor, during monthly supervision. i. Each month a different quarter of their cases will be reviewed, so that all cases are reviewed three times a year. ii. During this review between the supervisor and the staff, documentation in the case file, as well as Child Protective Services System (CPSS) coding and payments, will be examined for completeness and accuracy. iii. Needed corrections will be made to the documents and/or CPSS, as identified in the monthly reviews. iv. If a supervisor notices consistent errors by a staff member in Guardianship Agreement documentation, they shall refer the staff to the Staff Development Office for refresher training. v. The supervisor shall document which cases were reviewed each month. 4. At the next Management Leadership Team meeting, CWS Branch Administrators will share with staff the results of this audit, explaining the direct correlation between documentation (or lack thereof) and financial penalties to the State. ? Reminder conversation about this audit and the importance of following current policies and procedures will be held during CWS weekly huddles. 5. As CWS implements this corrective action plan and monitors the results, the action steps proposed in one through four may be modified based on input from CWS Administrators and/or focus/exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2023 Responding Officials: Kisha C. Raby, Social Services Division Program Development Administrator, Elladine Olevao, Social Services Division Child Welfare Social Services Manager, and Carolina Anagaran, Social Services Division Administrative Officer

Finding No. 2022 008: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.659 and COVID 19 ? 93.659 ? Adoption Assistance Award Number and Award Year: 2101HIADPT, 2201HIADPT Condition We selected a non statistical sample of 60 case files which approximated $33,000 in monthly benefit payments, out of a population of approximately 2,500 case files which approximated $15.4 million in total annual benefit payments, for testing and noted exceptions in 38 case files as follows: ? 19 case files where the initial or modified adoption agreement was missing and therefore did not have any support for the amount of monthly assistance paid. ? 21 case files where the State, Federal Bureau of Investigation, and/or child abuse and neglect clearances were missing. ? Eight case files where the ?difficulty of care? determination was missing and therefore did not have any support for the assistance amount paid. ? Eight case files where documentation of a child?s special needs was missing. ? Eight case files where the supporting documentation regarding whether the State determined that the child cannot or should not be returned to the home of his or her parents was missing. ? One case file where documentation of monthly non-recurring expenses was missing. ? One case file where documentation regarding continuation of monthly subsidy payments after the child?s 18th birthday was missing. ? One case file where the final approval was granted to a household with an individual who was convicted of spousal abuse. ? Five case files where the adoption decree was missing from the case records. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (CWS) will make a note in each specific case record identified in this audit explaining the audit findings, and ? secure current modified adoption agreements for the nineteen missing documents, ? locate missing clearances for the twenty-one cases or re-run them if not located, Note: Not all clearances are secured prior to placement; Federal Bureau of Investigations (FBI) clearances come later and are NOT required prior to placement in a ?provisionally licensed? home. ? document the need precipitating Difficulty of Care (DOC) determination for the 8 records, showing how DOC was calculated. i. ensure that the written Adoption Assistance Agreement (AAA) matches the calculations and amount in the payment system or update/modify the AAA as appropriate, ? secure documentation of child?s special needs for the eight cases, noting categorical eligibility qualification as special needs for children adopted from foster care. Note: Hawaii is in the process of developing its new Comprehensive Child Welfare Information System (CCWIS) and plans to use this system to automatically code children in foster care as meeting the eligibility criteria for special needs. ? secure a copy of the court order which specified that the child should not be returned home, i.e., the order containing the ?contrary to the child?s welfare? language for the eight cases, ? document monthly non-recurring expenses in the missing case, ? document the reason for continuation of monthly subsidy payments after the child?s eighteenth birthday in one case, ? research/review and document why final approval was granted to a household with an individual who was convicted of spousal abuse. i. If review determines that AAA was inappropriately authorized, provide family with an adverse action notice discontinuing the AA and explaining the appeals process, ? Although adoption assistance is an incentive program with payment beginning prior to the finalization of an adoption, secure a copy of the five missing adoption decrees. Note: The adoption decree is NOT required for payment as the AAA must be entered prior to the finalization of an adoption. 2. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within ninety days to ensure missing documentation has been secured and/or properly noted in record. ? Additionally, the MICU will complete a random AA audit review approximately six months later. i. MICU will share random audit findings with CWS Administrators. ii. CWS Administrators will take corrective action based on MICU audit findings. 3. CWS supervisors and Social Services Division (SSD) Staff Development Specialists will ensure that line staff are familiar with these policies and procedures through individual supervision meetings and work product review. ? Staff with errors identified in this audit, consistent errors identified during individual supervision meetings or through work product review will: i. be given coaching/supervisory support to correctly complete documentation, ii. be required to participate in refresher training on Title IV-E Foster Custody, which is offered three times a year with participation documented by Staff Development Office. iii. During this review between the supervisor and the staff, documentation in the case file, as well as Child Protective Services System (CPSS) coding and payments, will be examined for completeness and consistency. iv. Needed corrections will be made to the documents and/or CPSS, as identified in the monthly reviews. 4. In consultation with the Department of Accounting and General Services (DAGS), CWS will develop and implement a new AAA form which identifies payment amounts by age, informing families of the progression. This will eliminate the need for a new agreement when a child moves from one payment category to another, as they age. ? Should the standard AA amounts change, an addendum to this universal agreement will be sent to families noting the change(s). ? Once a new AAA form has been created, the Staff Development Office will update the AA training module to include this new form and offer the updated training in the regular training rotation. 5. At the next Management Leadership Team meeting, CWS Branch Administrators will share with staff the results of this audit, explaining the direct correlation between documentation (or lack thereof) and financial penalties to the State. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in one through five may be modified, based on input from CWS Administrators and/or focus/exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2023 Responding Officials: Kisha C. Raby, Social Services Division Program Development Administrator, Elladine Olevao, Social Services Division Child Welfare Social Services Manager, and Carolina Anagaran, Social Services Division Administrative Officer

Finding No. 2022 015: Eligibility, Activities Allowed or Unallowed, Allowable Cost (Material Weakness) Federal Agency: U.S. Department of Health and Human Services AL Number and Title: 93.658 and COVID 19 ? 93.658 ? Foster Care ? Title IV E Award Number and Award Year: 2101HIFOST, 2201HIFOST Condition We selected a non statistical sample of 40 case files which approximated $32,000 in monthly benefit payments, out of a population of approximately 981 case files which approximated $4.89 million in total annual benefit payments, for testing and noted exceptions in 13 case files as follows: ? Three case files where the Police Protective Custody form or Voluntary Foster Custody Agreement was missing and therefore did not support whether the child was removed as part of a voluntary placement agreement or judicial determination. ? Three case files where the State, FBI, and/or child abuse and neglect clearances were missing. ? Seven case files where the ?difficulty of care? determination was missing and therefore did not support the assistance amount paid. ? Two case files where the ?Certificate of Approval? was missing and therefore did not support whether the prospective foster parents were licensed. Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: 1. Child Welfare Service (CWS) will make a note in each specific case record identified in this audit explaining the audit findings, and secure missing/incomplete eligibility documents for cases identified in the audit. 2. The identified errors and the related corrective action step above will be reviewed by CWS Administrators, staff supervisors, and Management Information Compliance Unit (MICU) within ninety days to ensure missing documentation has been secured and properly noted in record. ? Additionally, the MICU will complete a random Title IV-E Foster Custody payments audit review approximately six months later. i. MICU will share random audit findings with CWS Administrators. ii. CWS Administrators will take corrective action based on MICU audit findings. 3. CWS supervisors will ensure that line staff (especially those responsible for Licensing and Placements) are familiar with these policies and procedures and monitor through individual supervision meetings and work product review. ? Staff with errors identified in this audit, during individual supervision meetings or through work product review will: i. be given coaching/supervisory support to correctly complete documentation, ii. be required to participate in refresher training on Title IV-E Foster Custody, which is offered three times a year with participation documented by Staff Development Office. ? All staff who manage Title IV-E Foster Custody payments will review a quarter of their cases each month with their supervisor, during monthly supervision. i. Each month, a different quarter of their cases will be reviewed, always starting with the newest cases. ii. During this review between the supervisor and the staff, documentation in the case file, as well as Child Protective Services System (CPSS) coding and payments, will be examined for completeness and consistency. iii. Needed corrections will be made to the documents and/or CPSS, as identified in the monthly reviews. iv. If a supervisor notices consistent errors by a staff member in Title IV-E Foster Custody payments documentation, they shall refer the staff to the Staff Development Office for refresher training. v. The supervisor shall document which cases were reviewed each month. ? All licensing staff shall review a quarter of their cases every month with their supervisor, during monthly supervision. i. Each month, a different quarter of their cases will be reviewed, always starting with the newest cases. ii. During this review between the supervisor and the staff, documentation (including all background clearances) in the case file will be examined for timeliness and completeness. iii. Needed corrections will be made to the documents and/or new documents added, as identified in the monthly reviews. iv. If a supervisor notices consistent errors by a staff member in Title IV-E Foster Custody payments documentation, they shall refer the staff to the Staff Development Office for refresher training. v. The supervisor shall document which cases were reviewed each month. 4. At the next Management Leadership Team meeting, CWS Branch Administrators will share with staff the results of this audit, explaining the direct correlation between documentation (or lack thereof) and financial penalties to the State. ? Reminder conversations about this audit and the importance of following current policies and procedures will be held during CWS weekly huddles. 5. As CWS implements this corrective action plan and monitors the results, the action steps proposed in one through four may be modified based on input from CWS Administrators and/or focus/exploration groups with line staff who complete this documentation. Expected Completion Date: May 31, 2023, and On-going Responding Officials: Kisha C. Raby, Social Services Division Program Development Administrator, Elladine Olevao, Social Services Division Child Welfare Social Services Manager, and Carolina Anagaran, Social Services Division Administrative Officer

NORTHEASTERN ILLINOIS UNIVERSITY JUNE 30, 2022 Corrective Action Plan Finding Number: 2022-006 Condition: Northeastern Illinois University (University) charged unallowable expenditures to the Federal TRIO Program (TRIO) - Student Support Services grant. Planned Corrective Action: The Principal Investigator in coordination with Grants and Contracts Office will frequently review expenditures charged to the grant and ensure expenses are allowable within federal requirements and grant agreement. In addition, the University already removed the questioned costs incorrectly charged to the grant. Contact person responsible for corrective action: Amie Jatta, Director of TRIO Student Support Services Anticipated Completion Date: 6/30/2023

Finding Number: 2022-003 Condition: Of the 21 students selected for Return to Title IV testing, the University: -For 4 of the students, utilized inappropriate withdrawal dates -For 2 of the students, inaccurately calculated returns -For 5 of the students, returned funds in an untimely manner -For 1 of the students, student authorization wasn?t obtained prior to crediting account for post-withdrawal disbursement Planned corrective Action: One Stop Center staff were retrained on September 7th on the process of backdating a drop/withdraw to the appropriate date. This training will continue to be ongoing to be sure they are aware and understand the importance of the backdating being accurate. An error report has been created that can identify if the last date of attendance is equal to the date the transaction took place. If students appear on this report further investigations will be done to determine if it is the accurate date to use. R2T4 calculations are always processed on students who withdraw without regard to percentage of time attended. The staff will continue to process R2T4 in Banner for withdrawn students who receive federal aid, with a secondary calculation using the COD online R2T4 calculator to confirm outcomes. The student found regarding post-withdrawal was an oversight. Notification letters will be mailed to students who are eligible for the Post Withdrawal disbursements requesting the student acceptance of offered aid. This area will also become a review item in our process to review R2T4 calculations weekly. Contact person responsible for corrective action: Noreen Ferguson, University Registrar Anticipated Completion Date: September 7, 2022. The error report is already developed and in use. The additional training will be ongoing.

Recommendation: In conjunction with Rivendell Homes, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, Rivendell Homes, Inc. should pay the invoice amount on a monthly basis. Action Taken: The auditors have worked with the auditee in conjunction with their local HUD field office to determine a course of action. All parties agreed with the recommendation to avoid unauthorized distributions.

Response to 2022-002 We agree there were errors in the calculation of lost revenue. The PRF guidance on reporting changed/updated several times over the course of 2 years and some requirements were missed right before the reporting was due. However, the organization?s eligibility did not change and the funded amount was fully supported by the actual loss of revenue calculation required by DHHS. Management will closely monitor future grant reporting. Contact person responsible for corrective action: Eden Ballatan, CFO Anticipated Completion Date: 3/31/2023

Finding Number: 2022-001 Condition: Controls in place did not identify an inaccurate calculation of assistance. Planned Corrective Action: The corrective action plan in response to Finding 2021-001 was implemented on September 22, 2022; and therefore the fiscal year ended June 30, 2022 was complete before implementation of the corrective action plan, which is as follows: Case Managers, Quality Review and Agency Managers can see supporting documentation and review cases in real time. All cases are processed by Case Managers, who consult with Agency Managers on questions, and 100 percent of cases are quality reviewed by a team from CLA (an outsourced professional services firm specializing in grants management) prior to processing payment. As Heart of West Michigan United Way receives MSHDA written guidance updates, we continue to hold twice-weekly meetings with CERA Agency Managers to discuss the frequent changes to the MSHDA guidance in order to gain a full understanding of the program requirements and regulations. Information is then disseminated to Case Managers. We will continue to hold regular trainings for CERA Case Managers to ensure consistency in approach and understanding of required documentation and proper assistance calculation. CLA continues to conduct a quality review check of 100 percent of applications to enhance internal controls and oversight. Additionally, the CERA Program Manager completes random checks of assistance calculations and payments. Contact person responsible for corrective action: Gail Montgomery, Vice President of Finance Anticipated Completion Date: September 23, 2022

Finding 2022-002 Name of contact person: Vivian Tookes, DSS Division Director for Economic Services and DSS Director when appointed. Corrective Action: All cases will utilize guidance provided by Treasury to determine eligibility and will clearly document and store all copies of evidence to support the elig1ibility determination to issue payments. This will also be clearly documented as to the evidence gathered in the case file for each determination. Proposed Completion Date: February 28, 2023.

FINDING 2022-006 Contact Person Responsible for Corrective Action: Mindy Byers Contact Phone Number: 765-364-6401 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: ALN changed during middle of audit period. Will inquire mid-year with departments managing grants to see if any ALN changes. If so, new grant fund will be created. Anticipated Completion Date: 08/2023

2022-006 Special Education Cluster (IDEA) Recommendation: The School Corporation should design procedures and controls to ensure compliance with suspension and debarment provisions. Before entering into a contract, a check should be performed and retained to support the contractor status. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation will check vendors on the SAMS site to verify the contractors are not suspended. Documentation of the verification will be retained. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

Mountain Park identified replacement COVID related costs to evidence the spend down of period three Provider Relief funds. These funds are not subject to repayment as the Organization was able to attest and comply with the terms and conditions of the funding, including demonstrating that the distributions received were used for qualifying expenses or lost revenue attributable to COVID-19. Expected completion date: Completed Owner: Sandra Curtice, CFO

FINDING 2020-003 Contact Person Responsible for Corrective Action: Shane Hacker, CFO; Tracy Boss, Deputy Treasurer; Jordan Ryan, Coordinator of Nutrition Services Contact Phone Number: 317-852-5726 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: Moving forward, the Nutrition Services Coordinator will ensure that a contract between the district and the vendor is in place when purchases are over $150,000 annually, per the district?s Child Nutrition Procurement Plan. Anticipated Completion Date: July 1, 2023

The Organization will contact the affected federal agency for guidance on resolution of the billing error. Additionally, the Organization will train management and staff working on the program to ensure an understanding of the program and its allowable costs. Furthermore, management and staff will be trained to review expenses throughout the year to ensure only allowable expenses are charged to the program. The review will include confirming that costs charged to the program are in conformity with any allowable cost elections. The contact person for this corrective action is Annette Kovamees, VP of Revenue and Financial Operations