Corrective Action Plans

Deposits required by HUD were not made during fiscal year 2023 to the reserve fund. Recommendation: CLA Recommends the Project make all fiscal year 2023 deposits as soon as funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has received the delayed rental income payments and is working to make the back deposits. Name of the contact person responsible for corrective action: Matthew Fontaine, Controller DeMarco Management Corp. Planned completion date for corrective action plan: April 1, 2024

The audit finding noted one Consultative Examination (CE) provider where the qualified provider review was not completed timely and this was an oversight on the part of the Department of Labor and Workforce Development’s Division of Disability Services (DDS) due to attrition of staff. Going forward, each DDS Professional Relations Officer will be responsible for reviewing eight to 10 CE provider’s qualifications each month until the yearly review is completed for each vendor. The Chief of Professional Relations will submit a monthly report to the DDS Assistant Director detailing how many sites were visited that month and any findings that may have occurred. Each month, the report will detail how many reports remain outstanding in order to complete the yearly reviews. COMPLETION DATE/ CONTACT PERSON & PHONE# April 9, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

There is no change to the prior year corrective action plan provided by the Department of Human Services, Division of Medical Assistance and Health Services (DMAHS) as corrective actions have been fully implemented as of January 2023. Current Managed Care Organization (MCO) contracts no longer contain the language requiring an audit conducted specifically in accordance with generally accepted accounting principles and generally accepted auditing standards and now specify that AUP reports are acceptable. Section 7.25.1(B) of the MCO Contract was updated effective January 2023 and removed the language requiring audits in accordance with generally accepted accounting principles and generally accepted auditing standards, and specifies that an AUP report is acceptable per guidance provided under Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) Frequently Asked Question number Q10. COMPLETION DATE/ CONTACT PERSON January 2023 Robert Durborow (609) 775-7298 Robert.Durborow@dhs.nj.gov

The Department of Community Affairs (DCA) Low-Income Home Energy Assistance Program (LIHEAP) staff have been fully trained to coordinate with the Applied Public Policy Research Institute for Study and Evaluation (APPRISE) and the federal U.S. Department of Health and Human Services (HHS) to ensure that all required reports are submitted timely. DCA has created a schedule of required reports that includes corresponding submission due dates and the process is designed to ensure adequate time is available to accommodate the necessary back and forth communications between DCA and APPRISE required to complete all reporting timely. COMPLETION DATE/ CONTACT PERSON April 30, 2024 Fidel Ekhelar (609) 815-3905 Fidel.Ekhelar@dca.nj.gov

The Division of Aging Services (DoAS) implemented the FFATA reporting process in June 2023; however, DoAS fell behind on timely submission of FFATA reports due to staffing constraints. To address this issue, the DoAS plans to hire a fiscal analyst dedicated to managing FFATA reporting. DoAS is planning to be up-to-date on FFATA reporting and timely submission within 90 days. COMPLETION DATE/ CONTACT PERSON June 30, 2024 Hetal Bhatt (609) 438-4586 Hetal.Bhatt2@dhs.nj.gov Dennis McGowan (609) 438-4739 Dennis.McGowan@dhs.nj.gov

The New Jersey Department of Education (NJDOE) Office of Grants Management (OGM) understands the need to be compliant with FFATA reporting in accordance with the Uniform Guidance. Internal controls and processes are in place to ensure NJDOE’s FFATA reporting process is working efficiently and timely. This noncompliance finding is not due to a lack of controls within NJDOE but lies squarely on system issues at SAM.gov and the FFATA Subaward Reporting System (FSRS) sites and until the issues listed below are corrected on these federal system sites, NJDOE will continue to be noncompliant with timely FFATA reporting. Issues with the SAM.gov and FSRS sites: • SAM.gov has approved NJDOE’s local education agency (LEA) registrations without a ZIP+4, but FSRS reporting system for FFATA uploads requires ZIP+4 for each LEA. The two systems use the same database, which means information registered on SAM.gov feeds directly into the FSRS system. However, because FSRS batch uploads require a ZIP+4, those LEAs that were approved by SAM.gov without a ZIP+4 during the registration process, are rejected from the FFATA report batch upload. There is an option to manually load each LEA and their details into the system, but the process becomes incredibly time consuming, given the 700+ LEAs in the state, the number of federal awards granted, and the steps for identifying & removing rejected LEAs from the batch upload. • Issues NJDOE has with SAM.gov and FSRS have been shared with the federal helpdesk and a USED representative without avail, as the systematic issue remains unresolved and continues to delay our FFATA reporting process. • There are several rural LEAs in the state that do not have a ZIP+4. These LEAs will continue to be rejected from the batch upload, delaying our FFATA reporting process, if SAM.gov and FSRS do not come up with a viable solution. • There were a number of LEAs that were continuously rejected from the upload by FSRS for no obvious reasons. The error message received was the same exact error we receive for incorrect zip codes. After spending much time investigating the cause with the helpdesk support, it was identified that FSRS did not update their system to reflect the Congressional District code changes during New Jersey’s redistricting process. • The FSRS system rejects batch uploads if a single lower-case SAM UEIs is entered in the batch file. However, SAM.gov search box and the FSRS manual uploads are not case sensitive. Batch uploads are the only place where SAM UEIs are case sensitive. Further, this information is not included in any of the FSRS User Guides or manuals. I have shared this with the FSRS helpdesk, but no solution was provided. Again, this discrepancy in their system affects and delays our FFATA reporting processes. NJDOE dedicated personnel, including the director of OGM, continuously work with SAM.gov, FSRS system, and both system sites’ help desks, to bring to light the issues mentioned above in order to express the urgent need for corrective actions at the federal system sites to allow for timely FFATA reporting. In addition internal controls and procedures are in place at NJDOE related to FFATA reporting and corrective actions are constantly performed in real time to perform the below NJDOE Internal Controls and Procedures. Some of these procedures include reviewing internal SAM applications and troubleshooting with NJDOE’s local education agencies (LEAs) to correct data in the application and resubmit to the federal reporting system sites with more detail included below. NJDOE Internal Controls and Procedures: • Due to the large number of LEAs in the state (700+), each FFATA report must be submitted via batch upload, which saves an enormous amount of time it takes to input data manually for every single LEA, for every grant. To address this need and to expedite the process, our vendor has created a reporting tool that generates a FFATA batch report. • We have been contacting the federal helpdesk to address the issues on their sites and asking for support. Some of those tickets were closed without providing any support and most were not helpful. • We have created and implemented an in-house System for Award Management (SAM) application, mandatory for all of our federal grant recipients. This was done specifically for FFATA reporting purposes to ensure data in these applications are directly tied to the FFATA batch reports. • The SAM applications go through a thorough review process, where data entered by the districts is compared with the data registered with SAM.gov (applicants are required to upload a copy of their Entity Overview Record, issued by SAM.gov). • SAM applications are returned for changes whenever an applicant has entered data that is inconsistent with data on SAM.gov (i.e.. Incorrect SAM UEI, incorrect zip code, incorrect zip+4, incorrect City name). • We have asked many of our districts to contact SAM.gov and update their physical address information to include the full 9-digit zip code, which was SAM.gov reviewers’ oversight. Our school districts have commented that this process can take months. • We are communicating with our districts/applicants on a daily basis through the review summary checklist, outlining the changes that must be made, as well as by email and phone. • We have implemented an automatic messaging system, where applicants are reminded to update their SAM registration expiration date, multiple times a month leading up to their expiration date. Due to the system discrepancy in the FSRS system’s batch upload, we had to create a workaround pertaining to the district’s SAM UEIs. As stated above, SAM UEIs, in batch FFATA reports, are case sensitive while not case sensitive anywhere else in the two system sites. We have updated our instructions in NJDOE’s SAM application and have added another layer of application review, to ensure that all UEIs entered are in all capital letters. Because the federal helpdesk has ignored this discrepancy and did not resolve the issue, we are obligated to take additional steps and spend additional time on FFATA batch reports. COMPLETION DATE/ CONTACT PERSON Indeterminate – Completion based on federal implementation of fixes to SAM.gov and FSRS portal as noted in views. Martin Egan, Director NJDOE Office of Grants (609) 376-9089 Martin.Egan@doe.nj.gov

The Department of Labor and Workforce Development (DLWD), as the prime recipient of the federal awards, will ensure that all first-tier subawards made to entities totaling $30,000 or greater will be entered timely into the FSRS in accordance with FFATA reporting requirements. The audit sample selections in question were based on manual DLWD notice of awards that were not communicated correctly to staff who are responsible for entering the required subaward information into FSRS. Going forward, DLWD staff who are responsible for entering data into the FSRS will be copied on all emails containing the manual notice of award(s) once the notice is signed by the DLWD Commissioner. These email communications will trigger the information to be entered into the FSRS. COMPLETION DATE/ CONTACT PERSON April 4, 2024 Michael Varga (609) 351-3000 Michael.Varga@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) continues to monitor all first payment and non-monetary time lapse figures in order to meet the established USDOL Acceptable Levels of Performance (ALP). As workloads return to normal levels after the increased activity from the COVID-19 pandemic related claims, greater emphasis will continue to be placed on meeting all ALPs. Specifically relating to first payments and the previously discussed issues with claimants verifying their identity before any payments can be made, the DLWD has made some internal changes to how returned verified IDs from our ID verification partner (ID.me) are handled. These modifications to the internal process used to clear verified IDs are expected to have a positive impact on overall time lapse numbers as verified claimants will not be delayed longer than they previously were under the old process. The month of April starts the new reporting year for these figures to USDOL and New Jersey expects to see significant increases to first payment and non-monetary time lapse figures by the third quarter of calendar year 2024. COMPLETION DATE/ CONTACT PERSON September 2023 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

Recommendation: The design of the current controls should be reviewed to ensure tenant files are accurate, complete, and orderly and include a checklist of required documentation and retention guidelines. Procedures should also be established to ensure that the Form 50059 is completed timely and properly executed. The documentation in the files should support the data used in preparing the Form 50059 and calculating the tenant’s share of the rent. Action Taken: Management has started the process of reviewing, revising, streamlining and educating all staff on the HUD guidelines related to tenant file documentation requirements and proper completion of the Form 50059, including the documentation required to support the rent calculations.

We recently completed the transition and onboarding of departmental staff which would allow the University to fully enact its plan to ensure both the financial aid and the Registrar's office will perform prompt review of processing University withdrawals. The Registrar's office will develop process and procedures documentation as an internal control measuring tool to ensure that Administrative Withdrawals (AW) and Withdrawals for lack of attendance (WA) that affect student emollment are identified immediately. Staff in the Financial Aid and the Registrar's office will actively take part in training workshops and webinars provided by the Depatiment of Education and NASF AA for continuing education to stay abreast of new developments and best practices in the industry.

Finding 2023‐001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: Taylor County experienced personnel openings in FY 2023 for the position anticipated to prepare this report. Taylor County will continue to have the County Auditor prepare the performance reports, with a mechanical review of the report performed by an individual within the Auditor’s Office. Anticipated Completion Date: 04/30/2024 (Next reporting deadline)

Views of Responsible Officials: IW is utilizing a procedure to ensure that procured units are compliant with rent reasonableness standards. Currently, the Housing Locator identifies rental units of similar size and within a similar geographic region. The asking rental cost for each unit is compared to the daily FMR rate. Based on the audit results we have revised this procedure to include documentation of this process in a spreadsheet. The unit once chosen by the client will be clearly indicated. The rent reasonableness rate during the selection period will also be indicated on the spreadsheet.

UNDEFUNDING OF THE RESERVE RECOMMENDATION: WE RECOMMEND THAT MANAGEMENT TAKE THE NECESSARY STEPS TO ENSURE THAT FUTURE DEPOSITS ARE MADE IN ACCORDANCE WITH HUD REGULATION. PAYMENTS SHOULD BE MADE MONTHLY INTO THE REPLACEMENNT RESERVE. THERE IS NO DISAGREEMENT WITH THE AUDIT FINDING. ACTION PLANNED IN RESPONSE TO FINDING: THE PROJECT'S OPERATING SYSTEM AND ANNUAL PROCEDURES ARE BEING ADDRESSED TO COMPLY WITH HUD. NAME OF THE CONTACT PERSON RESPONSIBLE FOR CORRECTIVE ACTION: JOHN WESTERVELT, PRESIDENT PLANNED COMPLETION DATE FOR CORRECTIVE ACTION PLAN: JANUARY 31, 2024

The County will ensure that businesses are registered and in good standing with SAM.gov prior to entering any contracts over $25,000.

HCSO agrees with the audit finding regarding our lack of documentation on criminal convictions for inmates claimed as qualifying for our 2020 SCAAP submission. This audit has helped us recognize that criminal justice databases housing conviction information are dynamic and ever changing, which makes current verification of historical data very difficult. For this reason it’s very important to maintain detailed documentation of the information used to identify qualifying convictions. For future SCAAP submissions our plan is to take screenshots from the criminal justice databases used to verify convictions and maintain that documentation in files that are routinely backed up. In addition, we will ensure this documentation is reviewed by management to ensure adequacy based on SCAAP requirements.

Going forward, all students who withdrawal from the College will be forwarded to the financial aid team to review whether a student is still eligible for the full funding of the specific semester in question or whether funding needs to be returned based on the withdrawal date. If it is deemed that funds need to be returned, the Bursar will provide the financial aid team with a copy of the student charges for that period and the Registrar will provide proof of the withdrawal date and the financial aid team will determine the amount of funding that needs to be returned. Financial Aid will then complete the return through the student's account and notify the Controller and VP of Finance and Administration to process the return to G5.

When SAP is run in the spring, students will be notified of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.

The North Providence Housing Authority will be creating a check list which will include Income Verification as part of the participants file to be used for examinations, and reexaminations of income. This check list will be completed by the Housing Authority staff member, signed, and dated, showing that all required documents have been obtained and used for a successful processing of the tenants rent. Additionally, due to being a small housing authority, with only one HCV staff member, we have hired an HCV Assistant to help the HCV Coordinator in obtaining all information needed to comply with HUD’s regulations. Planned Implementation Date of Corrective Action: January 1, 2024 Planned Implementation Date of Corrective Action: Eileen Reyes/Michael McMahon/ Cheryl Lonardo

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Plans are in place to move accounts to another bank. A RFP for a new bank will be released in 2024. Planned Completion Date for CAP June 30, 2024

Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all HQS inspections and abatements are monitored. Staff have been trained on when to properly abate a payment and how to properly document abatements. Planned Completion Date for CAP March 1, 2024

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has implemented a new software program that provides rent reasonableness documentation. Staff have been trained on the proper way to utilize the software and are also now aware of when to run a rent reasonableness comparison. Planned Completion Date for CAP March 1, 2024

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all files are accurate and follow all local, state and federal compliance guidelines. An Independent entity has also been hired to review all current files and all corrections have been made. Planned Completion Date for CAP April 30, 2024

Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages and there was no documentation in their records. Management has reinforced the policy requiring documentation of beneficiary status and the Patient Access Manager has developed a registration performance improvement plan. Anticipated Completion Date: June 30, 2024.

Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sonoran University will implement the corrective action suggestions outlined in the audit findings, including: • Expansion of vulnerability mitigation to include the prescribed penetration and exploitation operations. • Complete migration of Sonoran servers vendor-supported versions (as of this writing, only two systems remaining). • Implementation of a phishing campaign education initiative for Sonoran University Employees. • Update WISP documents to meet the prescribed documentation requirements. • Build University-consistent data retention strategy. Name of the contact person responsible for corrective action: • Paul Collins, Senior Director of IT, Sonoran University. Planned completion date for corrective action plan: • Completion of all items by September 30, 2024.

Management Response: The School will ensure that the Single Audit reporting package is completed and submitted within the timeline as required by Uniform Guidance. Anticipated Completion Date: March 31, 2025 Responsible Party: Maria Walking Eagle, Business Manager