Audit 292856

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-002 IV-D Cooperation with Child Support SIGNIFICANT DEFICENCY Eligibility Criteria: Section III - Federal Award Findings and Questioned Costs The County's management and other users of the financial statements do not have accurate information for decisions-making and monitoring of the county's financial position and adherence to laws, regulations, and other requirements. Errors in financial reporting could occur and not be detected. County records were not reconciled properly. The County should review the ledger and financial documents regularly to ensure that necessary adjustments are made timely during the year. If information is required from outside parties, be sure to request this information in time to make an necessary adjustments. The County agrees with this finding. Please refer to the corrective action plan for details. Section II - Financial Statement Findings Management should have a system in place to verify that transactions are recorded in correctly, thereby reducing the likelihood of errors in financial reporting. Prior period adjustments were made to the General Fund that decreased fund balance by $13,188. These adjustment were to record a correction to forfeiture funds that were received which had been deposited into the Forfeiture - Treasury checking account, which should have been deposited into the Forfeiture - Department of Justice account. In accordance with the Medicaid Manual MA-3365, all Medicaid cases should be evaluated and referred to the Child Support Enforcement Agency (IV-D). The Child Support Enforcement Agency (IV-D) can assist the family in obtaining financial and/or medical support or medical support payments from the child’s non-custodial parent. Cooperation requirement with Social Services and Child Support Agencies must be met or good cause for not cooperating must be established when determining Medicaid eligibility. Condition: Questioned Cost: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-003 Inaccurate Resources Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Section III - Federal Award Findings and Questioned Costs (Continued) The County agrees with the finding. In accordance with Medicaid Manual MA-2230, Medicaid for Aged, Blind and Disabled case records should contain documentation that verifications were done in preparation of the application and these items will agree to reports in the NC FAST system. In this process, the countable resources should be calculated correctly and agree back to the amounts in the NC FAST system. Any items discovered in the verification process should be considered countable or noncountable resources and explained within the documentation. There were 6 errors discovered during our procedures that referrals between the County's Department of Social Services and Child Support Agencies were not properly made. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to North Carolina Families Accessing Services through Technology (NC FAST) and a participant could have been approved for benefits for which they were not eligible. Human error in reading the Automated Collection and Tracking System (ACTS) report and/or ineffective case review process. This is a repeat finding from the immediate previous audit, 2022-004. Files should be reviewed internally to ensure proper information is in place and necessary procedures are taken when determine eligibility. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit.

Condition: Questioned Cost: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-003 Inaccurate Resources Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Section III - Federal Award Findings and Questioned Costs (Continued) The County agrees with the finding. In accordance with Medicaid Manual MA-2230, Medicaid for Aged, Blind and Disabled case records should contain documentation that verifications were done in preparation of the application and these items will agree to reports in the NC FAST system. In this process, the countable resources should be calculated correctly and agree back to the amounts in the NC FAST system. Any items discovered in the verification process should be considered countable or noncountable resources and explained within the documentation. There were 6 errors discovered during our procedures that referrals between the County's Department of Social Services and Child Support Agencies were not properly made. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to North Carolina Families Accessing Services through Technology (NC FAST) and a participant could have been approved for benefits for which they were not eligible. Human error in reading the Automated Collection and Tracking System (ACTS) report and/or ineffective case review process. This is a repeat finding from the immediate previous audit, 2022-004. Files should be reviewed internally to ensure proper information is in place and necessary procedures are taken when determine eligibility. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. Condition: Questioned Cost: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-004 Inadequate Request for Information SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: There was no known affect to eligibility and there were no known questioned costs. This is a repeat finding from the immediate previous audit, 2022-005. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The County agrees with the finding. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. There were 3 errors discovered during our procedures that resources in the county documentation and those same resources contained in NC FAST were not the same amounts or files containing resources were not properly documented to be considered countable or non-countable.

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-004 Inadequate Request for Information SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: There was no known affect to eligibility and there were no known questioned costs. This is a repeat finding from the immediate previous audit, 2022-005. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The County agrees with the finding. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. There were 3 errors discovered during our procedures that resources in the county documentation and those same resources contained in NC FAST were not the same amounts or files containing resources were not properly documented to be considered countable or non-countable. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. Electronic matches are required at applications and redeterminations. There were 5 errors discovered during our procedures that inadequate information was requested at applications and/or redeterminations. There was no known affect to eligibility and there were no known questioned costs. Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-005 Inaccurate Information Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: There was no known affect to eligibility and there were no known questioned costs. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. There were 3 errors discovered during our procedures that inaccurate information was entered when determining eligibility. The County agrees with the finding. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Section III - Federal Award Findings and Questioned Costs (Continued) Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. This is a repeat finding from the immediate previous audit, 2022-006.

Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-005 Inaccurate Information Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: There was no known affect to eligibility and there were no known questioned costs. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. There were 3 errors discovered during our procedures that inaccurate information was entered when determining eligibility. The County agrees with the finding. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Section III - Federal Award Findings and Questioned Costs (Continued) Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. This is a repeat finding from the immediate previous audit, 2022-006. Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-006 Untimely Review of SSI Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: Section III - Federal Award Findings and Questioned Costs (Continued) There was 1 applicant/beneficiary was not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. There was no known affect to eligibility and there were no known questioned costs. The County agrees with the finding. This is a repeat finding from the immediate previous audit, 2022-007. In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions.

Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-006 Untimely Review of SSI Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: Section III - Federal Award Findings and Questioned Costs (Continued) There was 1 applicant/beneficiary was not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. There was no known affect to eligibility and there were no known questioned costs. The County agrees with the finding. This is a repeat finding from the immediate previous audit, 2022-007. In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Food and Nutrition Services (FNS) Cluster AL # 10.551 and 10.561 Finding: 2023-007 SIGNIFICANT DEFICENCY ELIGIBILITY Criteria: Any State communications related to applicants’ benefits received by any DSS department should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received. The County agrees with the finding. Section III - Federal Award Findings and Questioned Costs (Continued) We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible. Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits. This is a repeat finding from the immediate previous audit, 2022-008.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Food and Nutrition Services (FNS) Cluster AL # 10.551 and 10.561 Finding: 2023-007 SIGNIFICANT DEFICENCY ELIGIBILITY Criteria: Any State communications related to applicants’ benefits received by any DSS department should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received. The County agrees with the finding. Section III - Federal Award Findings and Questioned Costs (Continued) We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible. Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits. This is a repeat finding from the immediate previous audit, 2022-008. Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The State has provided policies and procedures to ensure that the County is meeting the federal guidance, relevant policies are: Food and Nutrition Services Policy 305 describes the verification sources and requirements and the FNS units primary responsibility for providing documentary evidence to support statements on applications and recertifications and procedures required if the statements by applicant/beneficiary are questionable. Food and Nutrition Services Policy 300 describes the sources of income countable and not countable to the household for determining financial eligibility. Food and Nutrition Services Policy 310 describes the procedures related to verifying changes in income (i.e. termination, end of contract, temporary, etc.). Due to the errors noted, eligibility cannot be sufficiently substantiated and there is a risk that the County could provide funding and/or benefits to individuals who are not program eligible. The County should provide training of management and staff on the program's eligibility requirements, proper case review process, and required verifications for eligibility. Also, the County should ensure that their formal internal review process is adequately completed to identify and correct errors in case reviews. The County agrees with the finding and is implementing actions to correct these issues, which are further discussed in the corrective action plan. There were a total of 6 errors found in our testing: 3 instances where verification of an expense used for a deduction of income was not included in the case file and 3 instances where earned income was incorrectly caclculated or verification of representative income was not completed or entered correctly in NCFAST. There was no known affect to eligibility and there were no known questioned costs. We examined 25 of 8,174 FNS recipients from the a report of all active FNS beneficiaries provided by Nash County's Department of Human Services. The finding is being reported with the financial statement audit as it relates to FNS administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible.

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-002 IV-D Cooperation with Child Support SIGNIFICANT DEFICENCY Eligibility Criteria: Section III - Federal Award Findings and Questioned Costs The County's management and other users of the financial statements do not have accurate information for decisions-making and monitoring of the county's financial position and adherence to laws, regulations, and other requirements. Errors in financial reporting could occur and not be detected. County records were not reconciled properly. The County should review the ledger and financial documents regularly to ensure that necessary adjustments are made timely during the year. If information is required from outside parties, be sure to request this information in time to make an necessary adjustments. The County agrees with this finding. Please refer to the corrective action plan for details. Section II - Financial Statement Findings Management should have a system in place to verify that transactions are recorded in correctly, thereby reducing the likelihood of errors in financial reporting. Prior period adjustments were made to the General Fund that decreased fund balance by $13,188. These adjustment were to record a correction to forfeiture funds that were received which had been deposited into the Forfeiture - Treasury checking account, which should have been deposited into the Forfeiture - Department of Justice account. In accordance with the Medicaid Manual MA-3365, all Medicaid cases should be evaluated and referred to the Child Support Enforcement Agency (IV-D). The Child Support Enforcement Agency (IV-D) can assist the family in obtaining financial and/or medical support or medical support payments from the child’s non-custodial parent. Cooperation requirement with Social Services and Child Support Agencies must be met or good cause for not cooperating must be established when determining Medicaid eligibility. Condition: Questioned Cost: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-003 Inaccurate Resources Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Section III - Federal Award Findings and Questioned Costs (Continued) The County agrees with the finding. In accordance with Medicaid Manual MA-2230, Medicaid for Aged, Blind and Disabled case records should contain documentation that verifications were done in preparation of the application and these items will agree to reports in the NC FAST system. In this process, the countable resources should be calculated correctly and agree back to the amounts in the NC FAST system. Any items discovered in the verification process should be considered countable or noncountable resources and explained within the documentation. There were 6 errors discovered during our procedures that referrals between the County's Department of Social Services and Child Support Agencies were not properly made. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to North Carolina Families Accessing Services through Technology (NC FAST) and a participant could have been approved for benefits for which they were not eligible. Human error in reading the Automated Collection and Tracking System (ACTS) report and/or ineffective case review process. This is a repeat finding from the immediate previous audit, 2022-004. Files should be reviewed internally to ensure proper information is in place and necessary procedures are taken when determine eligibility. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit.

Condition: Questioned Cost: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-003 Inaccurate Resources Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Section III - Federal Award Findings and Questioned Costs (Continued) The County agrees with the finding. In accordance with Medicaid Manual MA-2230, Medicaid for Aged, Blind and Disabled case records should contain documentation that verifications were done in preparation of the application and these items will agree to reports in the NC FAST system. In this process, the countable resources should be calculated correctly and agree back to the amounts in the NC FAST system. Any items discovered in the verification process should be considered countable or noncountable resources and explained within the documentation. There were 6 errors discovered during our procedures that referrals between the County's Department of Social Services and Child Support Agencies were not properly made. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to North Carolina Families Accessing Services through Technology (NC FAST) and a participant could have been approved for benefits for which they were not eligible. Human error in reading the Automated Collection and Tracking System (ACTS) report and/or ineffective case review process. This is a repeat finding from the immediate previous audit, 2022-004. Files should be reviewed internally to ensure proper information is in place and necessary procedures are taken when determine eligibility. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. Condition: Questioned Cost: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-004 Inadequate Request for Information SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: There was no known affect to eligibility and there were no known questioned costs. This is a repeat finding from the immediate previous audit, 2022-005. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The County agrees with the finding. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. There were 3 errors discovered during our procedures that resources in the county documentation and those same resources contained in NC FAST were not the same amounts or files containing resources were not properly documented to be considered countable or non-countable.

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-004 Inadequate Request for Information SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: There was no known affect to eligibility and there were no known questioned costs. This is a repeat finding from the immediate previous audit, 2022-005. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The County agrees with the finding. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. There were 3 errors discovered during our procedures that resources in the county documentation and those same resources contained in NC FAST were not the same amounts or files containing resources were not properly documented to be considered countable or non-countable. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. Electronic matches are required at applications and redeterminations. There were 5 errors discovered during our procedures that inadequate information was requested at applications and/or redeterminations. There was no known affect to eligibility and there were no known questioned costs. Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-005 Inaccurate Information Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: There was no known affect to eligibility and there were no known questioned costs. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. There were 3 errors discovered during our procedures that inaccurate information was entered when determining eligibility. The County agrees with the finding. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Section III - Federal Award Findings and Questioned Costs (Continued) Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. This is a repeat finding from the immediate previous audit, 2022-006.

Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-005 Inaccurate Information Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: There was no known affect to eligibility and there were no known questioned costs. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. There were 3 errors discovered during our procedures that inaccurate information was entered when determining eligibility. The County agrees with the finding. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Section III - Federal Award Findings and Questioned Costs (Continued) Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. This is a repeat finding from the immediate previous audit, 2022-006. Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-006 Untimely Review of SSI Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: Section III - Federal Award Findings and Questioned Costs (Continued) There was 1 applicant/beneficiary was not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. There was no known affect to eligibility and there were no known questioned costs. The County agrees with the finding. This is a repeat finding from the immediate previous audit, 2022-007. In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions.

Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medicaid Assistance Program (Medicaid; Title XIX) AL # 93.778 Finding: 2023-006 Untimely Review of SSI Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Cost: Section III - Federal Award Findings and Questioned Costs (Continued) There was 1 applicant/beneficiary was not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. There was no known affect to eligibility and there were no known questioned costs. The County agrees with the finding. This is a repeat finding from the immediate previous audit, 2022-007. In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Food and Nutrition Services (FNS) Cluster AL # 10.551 and 10.561 Finding: 2023-007 SIGNIFICANT DEFICENCY ELIGIBILITY Criteria: Any State communications related to applicants’ benefits received by any DSS department should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received. The County agrees with the finding. Section III - Federal Award Findings and Questioned Costs (Continued) We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible. Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits. This is a repeat finding from the immediate previous audit, 2022-008.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Food and Nutrition Services (FNS) Cluster AL # 10.551 and 10.561 Finding: 2023-007 SIGNIFICANT DEFICENCY ELIGIBILITY Criteria: Any State communications related to applicants’ benefits received by any DSS department should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received. The County agrees with the finding. Section III - Federal Award Findings and Questioned Costs (Continued) We examined 60 cases from of a total of 552,116 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible. Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits. This is a repeat finding from the immediate previous audit, 2022-008. Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The State has provided policies and procedures to ensure that the County is meeting the federal guidance, relevant policies are: Food and Nutrition Services Policy 305 describes the verification sources and requirements and the FNS units primary responsibility for providing documentary evidence to support statements on applications and recertifications and procedures required if the statements by applicant/beneficiary are questionable. Food and Nutrition Services Policy 300 describes the sources of income countable and not countable to the household for determining financial eligibility. Food and Nutrition Services Policy 310 describes the procedures related to verifying changes in income (i.e. termination, end of contract, temporary, etc.). Due to the errors noted, eligibility cannot be sufficiently substantiated and there is a risk that the County could provide funding and/or benefits to individuals who are not program eligible. The County should provide training of management and staff on the program's eligibility requirements, proper case review process, and required verifications for eligibility. Also, the County should ensure that their formal internal review process is adequately completed to identify and correct errors in case reviews. The County agrees with the finding and is implementing actions to correct these issues, which are further discussed in the corrective action plan. There were a total of 6 errors found in our testing: 3 instances where verification of an expense used for a deduction of income was not included in the case file and 3 instances where earned income was incorrectly caclculated or verification of representative income was not completed or entered correctly in NCFAST. There was no known affect to eligibility and there were no known questioned costs. We examined 25 of 8,174 FNS recipients from the a report of all active FNS beneficiaries provided by Nash County's Department of Human Services. The finding is being reported with the financial statement audit as it relates to FNS administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible.