Corrective Action Plans

Finding: The Office of Financial Management did not have adequate internal controls over and did not comply with requirements to ensure Coronavirus State and Local Fiscal Recovery Funds were used for only allowable activities. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $300,000,000 Status: Corrective action not taken Corrective Action: The Office does not concur with the audit finding. The state of Washington implemented internal controls and created Fund 706 to track the Coronavirus State and Local Fiscal Recovery Fund (SLFRF) expenditures. The state, through legislation, approved the transfer of $300 million from the SLFRF account to various state transportation accounts under the revenue loss provision. The Office reaffirms that all expenditures from the transportation accounts that received the SLFRF funds were used to maintain government services. The State Administrative and Accounting Manual requires all state agencies to establish internal controls over payments for goods and services, including ensuring payments are lawful and for proper purposes, reviewing payments to ensure they are supported, as well as documenting the review of all payments. State agencies continued to follow their established internal controls to ensure expenditures from the transportation accounts were proper and allowable for both non-SLFRF and SLFRF funds. The Office will continue to: • Work with the U.S. Treasury, through the audit resolution and management decision process, to ensure no questioned costs are required to be repaid. • Document all correspondence with the grantor during the audit resolution process. The conditions noted in this finding were previously reported in finding 2022-018. Completion Date: Not applicable Agency Contact: Sara Rupe Deputy Statewide Accounting Director PO Box 43127 Olympia, WA 98504-3127 (360) 974-9252 sara.rupe@ofm.wa.gov

A) The planned corrective action. The Settlement agrees with the finding. The Assistant Controller will prepare the form SF- 429 report and the Controller will review and approve the report for submission. SF-429 due date reminders are posted in preparer’s calendar and adherence to the due dates is monitored by the Controller. For FY24, the Assistant Controller is currently working on the completion and submission of the OLDC (Online Data Collection) form. Once completed, the required SF-429 report will be filed. B) The name(s) of the contact person(s) responsible for corrective action. Assistant Controller – Julia Kagan Controller – Robert Holczer C) The anticipated completion date for the corrective action. 5/15/24

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023

The party that was making sure of signatures and signatures of changes ended up in a backlog and lost time cards. If time cards are sent back for signatures a copy of the original will be kept until the signed ones come back, and follow up will be made on a timely basis.

FINDING 2023-007 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Summary of Finding: The School Corporation did not have effective internal controls in place to ensure the correct reporting requirements for the High School Graduation Rate were being followed and that documentation was retained for audit. There was no tangible evidence of a process in place over the Annual Report Card/High School Graduation Rate to ensure that mobility codes were entered correctly. Of the 11 students tested, documentation was not presented for 9 students that were removed from the high school graduation cohort. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. A reminder will go to the High School guidance counselor, secretary, and principal about getting withdrawal forms from students and placing the form in their permanent records. Anticipated Completion Date: April 1, 2024

FINDING 2023-004 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Summary of Finding: One person was primarily responsible for compiling and uploading student data, including poverty status for Real Time reports. There was no additional review or verification being done to ensure that the numbers being pre-populated on the grant applications were correct. There was no internal control in place, such as an oversight, review or approval process to ensure eligibility was properly determined. There was no October 1 Real Time report presented for audit for either fiscal year 2020-2021 or 2021- 2022, which would have been used to pull in enrollment and poverty information for the 2021-2022 and 2022-2023 grants, respectively. Therefore, we were unable to verify if the amounts reported in the grant application were correct. Additionally, we were unable to verify if the correct socioeconomic status was properly reported for any of the students. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Superintendent will retain the Real Time reports and other supporting documentation. Superintendent will also start verifying the numbers pre-populated on the grant application to ensure correct reporting. Another person will start reviewing the application prior to submission to IDOE. Anticipated Completion Date: April 1, 2024

FINDING 2023-002 Finding Subject: COVID 19 – Education Stabilization Fund - Reporting Summary of Finding: Material Weakness, Other Matters. Contact Person Responsible for Corrective Action: Steve Nauman, Treasurer Contact Phone Number and Email Address: Phone: 812-522-3340 Email: naumans@scsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The SCSC management team will design and implement a proper system of internal control, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place prior to filing required reports. Anticipated Completion Date: The projected date of completion is February 29, 2024.

Finding # 2023-022 Title of Finding Activities Allowed or Unallowed Contact Person Jody Johnson, Sarah Wills and Christine Miller Anticipated Completion Date FY 2024 Corrective Action planned to be taken: The Board has developed procedures to ensure that all purchase orders are approved before orders are placed, all expenditures are properly authorized by the respective program director and supporting documentation is adequately maintained. The Board is using a requisition form in Droplet to achieve this goal. All employees authorized to make or approve purchases have been trained on purchasing procedures outlined in the Purchasing Policies and Procedures Manual for Local Educational Agencies in the State of West Virginia by the WVDE Office of School Finance on 2/23/2024.

Department of Education, United States Department of Agriculture, Federal Aviation Administration 2023-004 R&D Cluster – Assistance Listing No. 84.334, 10.001, 20.109 Condition: MSU established a micro-purchase threshold of $75,000 for contracted services and was not able to provide documentation to support this threshold. Recommendation: We recommend the institution review and revise their current procurement policy and review requirements to ensure that their policy is meeting Federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Mississippi State University will make corrections to the Procurement and Contracts Manual to ensure compliance with 2 CFR 200.320. Name(s) of the contact person(s) responsible for corrective action: Jennifer Mayfield, Director of Procurement and Contracts and Jonathan Tucker, Director Sponsored Programs Planned completion date for corrective action plan: June 30, 2024 If the Department of Education, United States Department of Agriculture, or Federal Aviation Administration has questions regarding this plan, please call Jonathan Tucker at 662-325-1930.

Condition: The Commission did have required written policies in place during the year under audit or retained copies of grant agreements once they became the direct recipient of the grants. Planned Corrective Action: Management agrees with the finding as reported. To correct this finding, the Commission reviewed its policies and procedures and revised as needed to comply with federal regulations. The policies were presented and approved at the August 2023 board meeting. The Commission has sent revised policies to HUD for their review and approval. Contact person responsible for corrective action: Steve Raiche Anticipated Completion Date: 6/30/2024

FINDING 2023-003 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed nor implemented a system of internal control to ensure that the six Elementary and Secondary School Emergency Relief (ESSER) annual data reports required to be filed during the audit period were complete and accurate prior to submission. The Reports were prepared by one employee without an oversight or review process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Greg Walker, Superintendent Contact Phone Number and Email Address: 812-723-4717 and walkerg@paoli.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Superintendent will enter information into the annual data report required for ESSER and once completed the Corporation Treasurer will review the information entered for accuracy. The Corporation Treasurer will sign off that the information entered is correct and then the Superintendent will submit the data report. Anticipated Completion Date: Projected date of completion is April 2024.

FINDING 2023-010 Finding Subject: COVID -19 - Education Stabilization Fund – Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. Additionally, the ESSER I, Year 2, ESSER I, Year 3, ESSER II, Year 1, ESSER III, Year 1, and ESSER III, Year 2 reports were not supported by the School Corporation's records. Contact Person Responsible for Corrective Action: Todd Balmer, Assistant Superintendent/CFO and Allison Vanover, Corporation Treasurer Contact Phone Number and Email Address: 812-246-3375 tbalmer@scsc.school avanover@scsc.school Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We are currently meeting with a Grants Management Consultant that will be working with us on how to properly complete the ESSER reports to ensure submission moving forward is accurate. Prior to submission, the grants person will review to ensure the report is complete and the information is correct. We will also send the reports to the consultant for review. Anticipated Completion Date: April 2024

FINDING 2023-004 Finding Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Summary of Findings: The School Corporation was a member of the Clark County Joint Services Program (Cooperative) during fiscal year 2021-2022. The Cooperative did not have internal controls in place over payroll transactions to ensure expenditures were allowable and in conformance with the cost principles. The Treasurer reviewed a report which showed the total amount paid from each fund and account; however, a detailed payroll report was not reviewed which would have identified the employee being paid from the grant fund. For vendor disbursements, although the Deputy Treasurer matched the invoice to the purchase order and provided it to the Corporation Treasurer for review and signature of the accounts payable voucher prior to payment, the control was not effective and did not detect or allow correction of errors. In the initial sample of 6 vendor disbursements, one claim was unable to be provided. Contact Person Responsible for Corrective Action: Ashley Compton, Director of Special Education, Tamara Swarens, Director of Elementary Curriculum and Allison Vanover, Corporation Treasurer Contact Phone Number and Email Address: 812-246-3375 alcompton@scsc.school tswarens@scsc.school avanover@scsc.school Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Silver Creek School Corporation does not operate under the Special Education Coop any longer. The AP Specialist makes sure that there is an appropriate claim for each payment we make, there are two signatures on each claim and the claims are approved by the Treasurer. Check processing is completed by the Deputy Treasurer as the third check. The AP Specialist now scans each invoice to the FMS accounting system to ensure that we have all back up for the claims. With the new Directors of Curriculum and Special Education, we only reimburse for positions that are charged to the federal grant that have gone through a multi-step process to ensure that they get coded to the right place. The process is also reviewed at the time a request for reimbursement is made. Anticipated Completion Date: March 2024

FINDING 2023-002 Finding Subject: COVID-19 – Education Stabilization Fund – Reporting Summary of Finding: ESSER III, Year 2 report contained material errors in the amounts reported Contact Person Responsible for Corrective Action: Tanya Pearson Contact Phone Number and Email Address: 765-522-6218 tpearson@nputnam.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will have one person complete the ESSER report and one person review the ESSER report for accuracy. Anticipated Completion Date: Immediately with the next ESSER report submission

FINDING 2023-007 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Summary of Finding: There was a material weakness, in that the School Corporation had not properly designed or implemented a system of internal controls, including appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. During the audit period, the School Corporation submitted two Title I Applications using the prior year’s Real Time Report data. The October 2021 Real Time Report used for the 2022-2023 Title I Application was not available for review to ensure compliance with the grant’s eligibility requirement. Contact Person Responsible for Corrective Action: Amanda Knipper Contact Phone Number and Email Address: 574-457-3188 x 1376, aknipper@wawasee.k12.in.us Views of Responsible Officials: Management concurs with the finding. Description of Corrective Action Plan: The Real Time Report data is pulled by Data Exchange directly from the School Corporation’s student management software system. The School Corporation will put a system in place to ensure that all student data within the student software system is accurate to ensure correct reporting of the Real Time data. The Grant Coordinator will review the Real Time report before submission with the information housed in the student management software and a second person will review the data for accuracy. An internal sign-off form will be created and implemented to document the secondary review of the report data. The Superintendent and the Treasurer will both sign off on the data digitally during the certification period as determined by IDOE. Anticipated Completion Date: The projected date of completion is August 2024.

FINDING 2023-003 Finding Subject: Covid-19 Education Stabilization Fund- Reporting Summary of Finding: Annual Data Report The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. The School Corporation was required to submit six annual data reports during the audit period. None of the annual data reports were submitted. Upon inquiry of the School Corporation to determine why the reports were not submitted, the School Corporation explained they had interpreted the reports to be final reports submitted upon completion of the grant not annual reports of expenditures. Reimbursement Requests To gain an understanding of how the School Corporation spent their Education Stabilization Fund award, all reimbursement requests submitted to the Indiana Department of Education (IDOE) were requested. Five of the ten reimbursement requests submitted to IDOE could not be located. As such, we determined reimbursement requests for the audit period should be further tested. The School Corporation’s process was to complete reimbursement requests on a periodic basis to obtain reimbursement for expenditures paid. Although the reimbursement requests were prepared by the Treasurer utilizing various ledger reports and were reviewed by a second knowledgeable employee; the process did not prevent, or detect and correct, errors. Of the ten reimbursement requests received, as noted above, five could not be provided for audit. Therefore, we were unable to substantiate the expenses reimbursed by those requests or if the requests were mathematically accurate or fairly presented. The remaining five reimbursement requests were tested without issue. Contact Person Responsible for Corrective Action: Andrew Schoff, Business Manager Contact Phone Number: 219-767-2263 Ext 1003 SOUTH CENTRAL COMMUNITY SCHOOL CORPORATION 9808 S 600 W Union Mills, IN 46382 219-767-2263 or 219-733-2311 Fax 219-767-2260 INDIANA STATE BOARD OF ACCOUNTS 34 Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Beginning March 2024 the Business Manager will submit Annual Data Reports for any Federal Grant issued when stated in the Grant contract. The Annual Data Report will be reviewed by the Superintendent for accuracy. Also, the Business Manager will request reimbursement timelier for Federal Grants collecting supporting documentation to ensure correct amounts are being requested. Documentation will be maintained with a copy of the submitted reimbursement requests to provide support for the amounts being requested. Anticipated Completion Date: These corrective actions will go into effect immediately and will be utilized with the March 31, 2024 for any Federal Grant reimbursement.

FINDING 2023‐004 Finding Subject: COVID‐19 Education Stabilization Fund ‐ Reporting Summary of Finding: Federal reporting lacked internal controls, resulting in errors on federal reporting. Contact Person Responsible for Corrective Action: Jill C. Mires Contact Phone Number and Email Address: 812‐883‐4437, jmires@salemschools.us Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: Internal controls will be added to each federal report that is submitted. They will be reviewed by a second staff member, indicated by a signature and date. Accounting expense reports and any other supporting documentation used to complete the reports will be kept internally with the reports and used by the reviewer to verify the accuracy of the reports. Anticipated Completion Date: March 2024

FINDING 2023-004 Finding Subject: COVID 19 - Education Stabilization Fund - Reporting Summary of Finding: The School Corporation failed, due to the lack of internal controls, to ensure that the ESSER annual data reports were complete and accurate prior to submission and that the reports had sufficient oversight to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Carla Gambill Contact Phone Number and Email Address: 812-847-6020 ext. 1004 cgambill@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Director of School Finance will prepare the annual data reports to be reported to the IDOE by using records that accumulate or summarize the data. Prior to the submission of the reports, the Superintendent, or his or her designee, will review the records and annual data report. The Director of School Finance and the Superintendent, or his or her designee, will initial and date a hard copy of the report to ensure accuracy and completeness. Anticipated Completion Date: This Corrective Action Plan will be put in effect April 2024 or when the next annual data reports are prepared.

FINDING 2023-003 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. The October 1st Real Time Report of Pupil Enrollment (PE) was used by the Indiana Department of Education to pull data into the Title I application. These numbers were then used to calculate Percent Poverty which was used to rank schools for Title I eligibility. One person was primarily responsible for compiling and uploading student data, including poverty status for Real Time reports. There was no additional review or verification being done to ensure that the numbers being pre-populated on the grant applications were correct. There was no internal control in place, such as an oversight, review or approval process to ensure eligibility was properly determined. The Indiana Department of Education (IDOE) used the October 1 Real Time reports for fiscal years 2020- 2021 and 2021-2022, as provided by the School Corporation, to determine Title I Eligibility for the 2021- 2022 and 2022-2023 grant programs, respectively. There was no October 1 Real Time report presented for audit for fiscal year 2021-2022, which would have been used to pull in enrollment and poverty information for the 2022-2023 grant. Therefore, we were unable to verify if the amounts reported in the grant application were correct. Additionally, we were unable to verify if the correct socioeconomic status was properly reported for any of the students. Contact Person Responsible for Corrective Action: Nancy Schroeder Contact Phone Number and Email Address: 765-932-3901 schroedern@rushville.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: Eligibility – The Technology Director, Brevin Runnebohm will supply the Title I director with the official October 1 count each school year. This will be retained for audit and will be used by the Grant Coordinator, Nancy Schroeder, to determine the enrollment numbers in the Title I application have INDIANA STATE BOARD OF ACCOUNTS 45 been prepopulated correctly. The Grant Coordinator will sign off that she has reviewed this information and find it accurate. Anticipated Completion Date: 10/2024

FINDING 2023-005 Finding Subject:􀀃Title􀀃I􀀃Grants􀀃to􀀃Local􀀃Educational􀀃Agencies􀀃–􀀃Reporting􀀃 Summary of Finding: An􀀃effective􀀃internal􀀃control􀀃system􀀃was􀀃not􀀃in􀀃place􀀃at􀀃the􀀃School􀀃Corporation􀀃to􀀃ensure􀀃compliance􀀃with􀀃 requirements􀀃related􀀃to􀀃the􀀃grant􀀃agreement􀀃and􀀃the􀀃Reporting􀀃requirement.􀀃The􀀃School􀀃Corporation􀀃did􀀃not􀀃have􀀃 effective􀀃internal􀀃controls􀀃to􀀃ensure􀀃that􀀃reimbursement􀀃requests􀀃or􀀃final􀀃expenditure􀀃reports􀀃were􀀃properly􀀃 supported􀀃with􀀃documentation.􀀃 Contact Person Responsible for Corrective Action: Lela Simmons Contact Phone Number and Email Address: (219) 391- 4100, lesimmons@ecps.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Internal controls and policies will be put in place to ensure all Title cash request will have three approvals before submitting the request to the State. The Federal clerk will prepare the request, the federal director we do second approval. The CFO will do final approval after review all documentation associated with the cash request. All will sign document. All title state reporting and back up documentation will be reviewed by the CFO and signed. Anticipated Completion Date:􀀃We􀀃anticipate􀀃having􀀃the􀀃above􀀃corrective􀀃action􀀃plan􀀃in􀀃place􀀃by􀀃September 30, 2024.

FINDING 2023-005 Information on the federal program: Subject: Special Education Cluster (IDEA) - Reporting Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listings Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 19611-022-PN01, 20611-022-PN01, 21611-022-PN01, 22611-022-PN01, 22611-022-ARP, 23611-022-PN01, 20619-022-PN01, 21619-022-PN01, 22619-022-PN01, 22619-022-ARP, 23619-022-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness, Qualified Opinion Condition: The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the reporting requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that requests for reimbursement were submitted accurately and agreed to supporting documentation. There was a documented oversight, review, and approval process in place; however, the Cooperative did not adequately ensure that proper procedures were followed. Context: The School Corporation is a member of the Greene-Sullivan Special Education Cooperative (Cooperative). During fiscal year 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its members.  As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Reporting compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the reporting requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that requests for reimbursement were submitted accurately and agreed to supporting documentation. There was a documented oversight, review, and approval process in place; however, the Cooperative did not adequately ensure that proper procedures were followed. For fiscal year 2022, 51 Reimbursement Reports were tested. 14 Reimbursement Reports could not be traced to unit ledgers for expenditures, and 21 Reports did not have appropriate supporting documentation. For fiscal year 2023, 23 Reimbursement Reports were tested. Three Reimbursements Report did not agree to supporting documentation, and key line items could not be verified. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action: 1 – Greene Sullivan Special Education Cooperative will implement a procedure that includes the requirement of proper documentation for all reimbursement requests, such as the detailed history report for each request submitted. The Director will then review each request prior to submission. Responsible party and timeline for completion: Chris Stitzle, Superintendent – April 1, 2024

Corrective action plan: In December 2021, HHSC implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Medicaid provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in Medicaid. Of the Medicaid providers requested during the fiscal year 2023 Statewide Single Audit, 47 of 60 samples had been enrolled or revalidated through PEMS and the auditor received all requested documentation. The listed exceptions only apply to Medicaid long-term care (LTC) providers whose enrollment and/or revalidation have not yet been processed through PEMS. The LTC enrollment and revalidation process mirrors the sampled acute care providers which were found to be 100 percent compliant during this review, further supporting that the process is working. HHSC operated under the public health emergency (PHE) between March 30, 2020, and May 11, 2023. In response to the PHE, the Centers for Medicare and Medicaid Services waived exclusion check requirements for provider reenrollments and revalidations. HHSC is in the process of revalidating providers through PEMS; however, as a result of the PHE end date and provider revalidation requirements, the projected completion date for the required revalidation of all LTC providers is January 2027. HHSC continues efforts to enroll LTC providers through PEMS and expects to eliminate errors related to these documents once all LTC providers have revalidated. Implementation dates: December 2021, PEMS implementation January 2027, LTC provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management

Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Children’s Health Insurance Program (CHIP) provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in CHIP. Of the CHIP providers requested during the fiscal year 2023 Statewide Single Audit, 59 of 60 samples had been enrolled or revalidated through PEMS and the auditor received all requested documentation. The listed exceptions only apply to one CHIP provider. The provider enrolled with CHIP before the implementation of PEMS. HHSC operated under the public health emergency (PHE) between March 30, 2020, and May 11, 2023. In response to the public health emergency (PHE), the Centers for Medicare and Medicaid Services waived exclusion check requirements for provider reenrollments and revalidations. HHSC is in the process of revalidating providers through PEMS; however, as a result of the PHE end date and provider revalidation requirements, the projected completion date for the required revalidation of all CHIP providers is January 2027. HHSC continues efforts to enroll CHIP providers through PEMS and expects to eliminate errors related to these documents once all CHIP providers have revalidated. Implementation dates: December 2021, PEMS implementation January 2027, provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management

Corrective action plan: The HHSC Federal Funds Office will work with HHSC Accounting, Department of Family and Protective Services (DFPS), and Texas Workforce Commission (TWC) to strengthen oversight of the Social Services Block Grant (SSBG) post-expenditure report. As part of this oversight, HHSC will compile procedure documents, methodologies, data sources, and work documents from DFPS and TWC. The HHSC Federal Funds Office already has this documentation for HHSC. Implementation date: August 31, 2024 Responsible person: Racheal Kane, Director, Federal Funds

Corrective action plan: The Provider Finance Department (PFD) will take proactive measures to establish and enforce guidelines that guarantee documentation is retained for a minimum of three years from the date of submission of the final expenditure report for each grant. This approach aligns with our dedication to transparency, accountability, and responsible grant management. We will ensure that all the documentation is saved within our documentation repository for a minimum of three years from the date of submission. Implementation date: June 1, 2024 Responsible person: Stacy Kerns – Director, Business Operations and Support Services