Audit 312326

FY End
2022-06-30
Total Expended
$13.16M
Findings
36
Programs
40
Organization: Surry County (NC)
Year: 2022 Accepted: 2023-06-23

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
421963 2022-003 Significant Deficiency - P
421964 2022-003 Significant Deficiency - P
421965 2022-001 - - E
421966 2022-001 - - E
421967 2022-002 Material Weakness - P
421968 2022-001 - - E
421969 2022-002 Material Weakness - P
421970 2022-001 - - E
421971 2022-002 Material Weakness - P
421972 2022-001 - - E
421973 2022-002 Material Weakness - P
421974 2022-001 - - E
421975 2022-002 Material Weakness - P
421976 2022-001 - - E
421977 2022-003 Significant Deficiency - P
421978 2022-003 Significant Deficiency - P
421979 2022-002 Material Weakness - P
421980 2022-002 Material Weakness - P
998405 2022-003 Significant Deficiency - P
998406 2022-003 Significant Deficiency - P
998407 2022-001 - - E
998408 2022-001 - - E
998409 2022-002 Material Weakness - P
998410 2022-001 - - E
998411 2022-002 Material Weakness - P
998412 2022-001 - - E
998413 2022-002 Material Weakness - P
998414 2022-001 - - E
998415 2022-002 Material Weakness - P
998416 2022-001 - - E
998417 2022-002 Material Weakness - P
998418 2022-001 - - E
998419 2022-003 Significant Deficiency - P
998420 2022-003 Significant Deficiency - P
998421 2022-002 Material Weakness - P
998422 2022-002 Material Weakness - P

Programs

ALN Program Spent Major Findings
21.027 Coronavirus State and Local Fiscal Recovery Funds $4.29M Yes 0
93.778 Medical Assistance Program $1.85M Yes 2
93.563 Child Support Enforcement $535,546 - 0
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $365,217 - 0
10.557 Special Supplemental Nutrition Program for Women, Infants, and Children $347,912 - 0
93.667 Social Services Block Grant $336,386 - 0
14.239 Home Investment Partnerships Program $320,894 - 0
16.838 Comprehensive Opioid Abuse Site-Based Program $193,219 - 0
93.268 Immunization Cooperative Agreements $124,047 - 0
93.044 Special Programs for the Aging_title Iii, Part B_grants for Supportive Services and Senior Centers $122,191 - 0
93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund $106,312 - 0
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $66,908 Yes 1
93.994 Maternal and Child Health Services Block Grant to the States $59,087 - 0
93.659 Adoption Assistance $55,315 - 0
97.042 Emergency Management Performance Grants $50,353 - 0
93.136 Injury Prevention and Control Research and State and Community Based Programs $48,164 - 0
93.217 Family Planning_services $45,405 - 0
93.658 Foster Care_title IV-E $44,216 - 0
20.106 Airport Improvement Program $43,723 Yes 0
93.767 Children's Health Insurance Program $43,518 - 0
90.404 2018 Hava Election Security Grants $41,232 - 0
16.922 Equitable Sharing Program $39,904 - 0
93.556 Promoting Safe and Stable Families $38,537 - 0
93.045 Special Programs for the Aging_title Iii, Part C_nutrition Services $37,349 - 0
93.069 Public Health Emergency Preparedness $35,478 - 0
93.991 Preventive Health and Health Services Block Grant $30,608 - 0
93.053 Nutrition Services Incentive Program $24,681 - 0
93.645 Stephanie Tubbs Jones Child Welfare Services Program $23,634 - 0
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $22,844 - 0
93.052 National Family Caregiver Support, Title Iii, Part E $14,842 - 0
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $11,050 - 0
97.067 Homeland Security Grant Program $9,829 - 0
93.674 John H. Chafee Foster Care Program for Successful Transition to Adulthood $9,166 - 0
93.568 Low-Income Home Energy Assistance $8,724 Yes 2
93.558 Temporary Assistance for Needy Families $8,053 - 0
93.324 State Health Insurance Assistance Program $6,216 - 0
93.436 Well-Integrated Screening and Evaluation for Women Across the Nation (wisewoman) $1,920 - 0
93.977 Preventive Health Services_sexually Transmitted Diseases Control Grants $100 - 0
93.116 Project Grants and Cooperative Agreements for Tuberculosis Control Programs $50 - 0
93.566 Refugee and Entrant Assistance_state Administered Programs $31 - 0

Contacts

Name Title Type
FMWCTM24C9J8 Laura Neely Auditee
3364018251 Daniel Mullinix Auditor
No contacts on file

Notes to SEFA

Title: Cluster of Programs Accounting Policies: Expenditures reported in the SEFSA are reported on the modified accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Surry County has elected not to use the 10-percent de minimis indirect cost rate as allowed under theUniform Guidance. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The following are clustered by the NC Department of Health and Human Services and are treated separately for state audit requirement purposes: Subsidized Child Care. Foster Care and Adoption
Title: Basis of Presentation Accounting Policies: Expenditures reported in the SEFSA are reported on the modified accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Surry County has elected not to use the 10-percent de minimis indirect cost rate as allowed under theUniform Guidance. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The accompanying Schedule of Expenditures of Federal and State Awards (SEFSA) includes the federal and State grant activity of Surry County under the programs of the federal government and the State of North Carolina for the year ended June 30, 2022. The information in this SEFSA is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the State Single Audit Implementation Act. Because the Schedule presents only a selected portion of the operations of Surry County, it is not intended to and does not present the financial position, changes in net position or cash flows of Surry County.

Finding Details

Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.?Condition: Second party reviews is a key internal control to assess the completeness and accuracy of the Medicaid and FNS case eligibility made by County staff. We selected forty second party reviews completed by the County for each program and noted that 2 cases for each program had errors that were identified by the reviewer with no subsequent correction made to case. So, it was total of 4 cases out of 80 cases. None of these errors were related to eligibility determination. These errors related todocumentation or required communications with the applicant.Questioned Costs: No questioned costs.Context: Of the second party reviews selected, corrections were not made to documentation 5% of thetime. These were not related to eligibility determination.Cause: The caseworker did not make corrections identified by the 2nd Party Review process thatrequired sending notices to the client or updating documentation in NCFAST. The 2nd Party Reviewprocess did not include follow-up to ensure corrections were made timely.Effect: The applicant may not receive important notifications from the County or the documentationmay be incomplete. Documentation should be complete and accurate.Identification of repeat finding: This is not a repeat finding.Recommendation: We would recommend the County review the 2nd Party Review process withsupervisors and case workers and the expectations related to correcting errors. The two errors thatwere uncorrected for the FNS program had to do with sending DSS-8569 to clients. Per the supervisor,this policy had changed during the year, so we would recommend having additional training on thispolicy.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action. Refer to corrective action plan on subsequent page 17.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.?Condition: Second party reviews is a key internal control to assess the completeness and accuracy of the Medicaid and FNS case eligibility made by County staff. We selected forty second party reviews completed by the County for each program and noted that 2 cases for each program had errors that were identified by the reviewer with no subsequent correction made to case. So, it was total of 4 cases out of 80 cases. None of these errors were related to eligibility determination. These errors related todocumentation or required communications with the applicant.Questioned Costs: No questioned costs.Context: Of the second party reviews selected, corrections were not made to documentation 5% of thetime. These were not related to eligibility determination.Cause: The caseworker did not make corrections identified by the 2nd Party Review process thatrequired sending notices to the client or updating documentation in NCFAST. The 2nd Party Reviewprocess did not include follow-up to ensure corrections were made timely.Effect: The applicant may not receive important notifications from the County or the documentationmay be incomplete. Documentation should be complete and accurate.Identification of repeat finding: This is not a repeat finding.Recommendation: We would recommend the County review the 2nd Party Review process withsupervisors and case workers and the expectations related to correcting errors. The two errors thatwere uncorrected for the FNS program had to do with sending DSS-8569 to clients. Per the supervisor,this policy had changed during the year, so we would recommend having additional training on thispolicy.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action. Refer to corrective action plan on subsequent page 17.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.?Condition: Second party reviews is a key internal control to assess the completeness and accuracy of the Medicaid and FNS case eligibility made by County staff. We selected forty second party reviews completed by the County for each program and noted that 2 cases for each program had errors that were identified by the reviewer with no subsequent correction made to case. So, it was total of 4 cases out of 80 cases. None of these errors were related to eligibility determination. These errors related todocumentation or required communications with the applicant.Questioned Costs: No questioned costs.Context: Of the second party reviews selected, corrections were not made to documentation 5% of thetime. These were not related to eligibility determination.Cause: The caseworker did not make corrections identified by the 2nd Party Review process thatrequired sending notices to the client or updating documentation in NCFAST. The 2nd Party Reviewprocess did not include follow-up to ensure corrections were made timely.Effect: The applicant may not receive important notifications from the County or the documentationmay be incomplete. Documentation should be complete and accurate.Identification of repeat finding: This is not a repeat finding.Recommendation: We would recommend the County review the 2nd Party Review process withsupervisors and case workers and the expectations related to correcting errors. The two errors thatwere uncorrected for the FNS program had to do with sending DSS-8569 to clients. Per the supervisor,this policy had changed during the year, so we would recommend having additional training on thispolicy.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action. Refer to corrective action plan on subsequent page 17.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.?Condition: Second party reviews is a key internal control to assess the completeness and accuracy of the Medicaid and FNS case eligibility made by County staff. We selected forty second party reviews completed by the County for each program and noted that 2 cases for each program had errors that were identified by the reviewer with no subsequent correction made to case. So, it was total of 4 cases out of 80 cases. None of these errors were related to eligibility determination. These errors related todocumentation or required communications with the applicant.Questioned Costs: No questioned costs.Context: Of the second party reviews selected, corrections were not made to documentation 5% of thetime. These were not related to eligibility determination.Cause: The caseworker did not make corrections identified by the 2nd Party Review process thatrequired sending notices to the client or updating documentation in NCFAST. The 2nd Party Reviewprocess did not include follow-up to ensure corrections were made timely.Effect: The applicant may not receive important notifications from the County or the documentationmay be incomplete. Documentation should be complete and accurate.Identification of repeat finding: This is not a repeat finding.Recommendation: We would recommend the County review the 2nd Party Review process withsupervisors and case workers and the expectations related to correcting errors. The two errors thatwere uncorrected for the FNS program had to do with sending DSS-8569 to clients. Per the supervisor,this policy had changed during the year, so we would recommend having additional training on thispolicy.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action. Refer to corrective action plan on subsequent page 17.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.?Condition: Second party reviews is a key internal control to assess the completeness and accuracy of the Medicaid and FNS case eligibility made by County staff. We selected forty second party reviews completed by the County for each program and noted that 2 cases for each program had errors that were identified by the reviewer with no subsequent correction made to case. So, it was total of 4 cases out of 80 cases. None of these errors were related to eligibility determination. These errors related todocumentation or required communications with the applicant.Questioned Costs: No questioned costs.Context: Of the second party reviews selected, corrections were not made to documentation 5% of thetime. These were not related to eligibility determination.Cause: The caseworker did not make corrections identified by the 2nd Party Review process thatrequired sending notices to the client or updating documentation in NCFAST. The 2nd Party Reviewprocess did not include follow-up to ensure corrections were made timely.Effect: The applicant may not receive important notifications from the County or the documentationmay be incomplete. Documentation should be complete and accurate.Identification of repeat finding: This is not a repeat finding.Recommendation: We would recommend the County review the 2nd Party Review process withsupervisors and case workers and the expectations related to correcting errors. The two errors thatwere uncorrected for the FNS program had to do with sending DSS-8569 to clients. Per the supervisor,this policy had changed during the year, so we would recommend having additional training on thispolicy.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action. Refer to corrective action plan on subsequent page 17.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.?Condition: Second party reviews is a key internal control to assess the completeness and accuracy of the Medicaid and FNS case eligibility made by County staff. We selected forty second party reviews completed by the County for each program and noted that 2 cases for each program had errors that were identified by the reviewer with no subsequent correction made to case. So, it was total of 4 cases out of 80 cases. None of these errors were related to eligibility determination. These errors related todocumentation or required communications with the applicant.Questioned Costs: No questioned costs.Context: Of the second party reviews selected, corrections were not made to documentation 5% of thetime. These were not related to eligibility determination.Cause: The caseworker did not make corrections identified by the 2nd Party Review process thatrequired sending notices to the client or updating documentation in NCFAST. The 2nd Party Reviewprocess did not include follow-up to ensure corrections were made timely.Effect: The applicant may not receive important notifications from the County or the documentationmay be incomplete. Documentation should be complete and accurate.Identification of repeat finding: This is not a repeat finding.Recommendation: We would recommend the County review the 2nd Party Review process withsupervisors and case workers and the expectations related to correcting errors. The two errors thatwere uncorrected for the FNS program had to do with sending DSS-8569 to clients. Per the supervisor,this policy had changed during the year, so we would recommend having additional training on thispolicy.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action. Refer to corrective action plan on subsequent page 17.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: The NC Department of Health and Human Services requires information used to determine eligibility (citizenship and income) be retained in some form.Condition: For three applications selected, there was no form of income verification documented. These three applicants received LIEAP benefit payments and LIEAP ARPA benefits with no income verification documentation even though the applicant?s file indicated online verification was performed. The caseworker did not run online verification (OVS) in NCFAST. In addition, there was conflicting applicant income information when compared to other program income determination for the applicants that received other benefits. Physical documentation for FY2022 applications was recently disposed of by the County (unable to verify income). Since documentation was not available, we were unable to determine whether or not the eligibility determination was correct. Questioned costs were estimated based upon the error of these three cases compared with our total LIEAP cases tested.Questioned Costs: $149,000. The applicants received a total of $1,942.74 (each received a total of $647.58, consisting of $300 for LIEAP and $347.58 for LIEAP ARPA automatic payment), which made up 11.8% of total LIEAP payments tested.Context: Surry County recipients were awarded $1,640,668 (paid to vendors) across three programs(LIEAP, CIP, and LIHWAP) of which $1,348,137 was for LIEAP (includes ARPA). We selected atotal of 40 applications over the three programs with these applications awarded $20,418 out of the$1,640,668 in total awards. 29 applications of the 40 were for LIEAP recipients who were awarded$17,489 and found 3 out of the 29 applications received assistance of $1,942.74 without having theappropriate income verification.Cause: There was higher volume of applicants due to funding increases. Documentation was notretained due to miscommunication between former employees regarding the requirement ofretaining documentation. In addition, those involved in the program?s eligibility determinationhad limited experience with NCFAST since these employees did not work with similar programswhere income verification was needed, other than the LIEAP program. Plus, a majority ofexpenditures occurs over a short time period, generally December through March depending onfunding availability for this program.Effect: Improper eligibility determinations may have occurred.Identification of Repeat Finding: This is not a repeat finding.Recommendation: We recommend additional training on income verification procedures and Countydocumentation retention policies for the program. Processes should be implemented to ensuredocumentation is retained in some form.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.?Condition: Second party reviews is a key internal control to assess the completeness and accuracy of the Medicaid and FNS case eligibility made by County staff. We selected forty second party reviews completed by the County for each program and noted that 2 cases for each program had errors that were identified by the reviewer with no subsequent correction made to case. So, it was total of 4 cases out of 80 cases. None of these errors were related to eligibility determination. These errors related todocumentation or required communications with the applicant.Questioned Costs: No questioned costs.Context: Of the second party reviews selected, corrections were not made to documentation 5% of thetime. These were not related to eligibility determination.Cause: The caseworker did not make corrections identified by the 2nd Party Review process thatrequired sending notices to the client or updating documentation in NCFAST. The 2nd Party Reviewprocess did not include follow-up to ensure corrections were made timely.Effect: The applicant may not receive important notifications from the County or the documentationmay be incomplete. Documentation should be complete and accurate.Identification of repeat finding: This is not a repeat finding.Recommendation: We would recommend the County review the 2nd Party Review process withsupervisors and case workers and the expectations related to correcting errors. The two errors thatwere uncorrected for the FNS program had to do with sending DSS-8569 to clients. Per the supervisor,this policy had changed during the year, so we would recommend having additional training on thispolicy.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action. Refer to corrective action plan on subsequent page 17.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.?Condition: Second party reviews is a key internal control to assess the completeness and accuracy of the Medicaid and FNS case eligibility made by County staff. We selected forty second party reviews completed by the County for each program and noted that 2 cases for each program had errors that were identified by the reviewer with no subsequent correction made to case. So, it was total of 4 cases out of 80 cases. None of these errors were related to eligibility determination. These errors related todocumentation or required communications with the applicant.Questioned Costs: No questioned costs.Context: Of the second party reviews selected, corrections were not made to documentation 5% of thetime. These were not related to eligibility determination.Cause: The caseworker did not make corrections identified by the 2nd Party Review process thatrequired sending notices to the client or updating documentation in NCFAST. The 2nd Party Reviewprocess did not include follow-up to ensure corrections were made timely.Effect: The applicant may not receive important notifications from the County or the documentationmay be incomplete. Documentation should be complete and accurate.Identification of repeat finding: This is not a repeat finding.Recommendation: We would recommend the County review the 2nd Party Review process withsupervisors and case workers and the expectations related to correcting errors. The two errors thatwere uncorrected for the FNS program had to do with sending DSS-8569 to clients. Per the supervisor,this policy had changed during the year, so we would recommend having additional training on thispolicy.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this findingand is taking coordinated effort and action. Refer to corrective action plan on subsequent page 17.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.
Criteria: Uniform Guidance 2 CFR ? 200.303 requires the non-Federal entity to ?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.? Reasonable assurance includes the County documenting a key control was implemented.Condition: The main internal control over the LIHEAP programs are supervisory review of income verification and eligibility determination and documentation. There was no documentation of second party reviews for the LIHEAP programs. In addition, the staffing levels for this program is low related to the number of clients being served.Questioned Costs: No questioned costs.Context: The LIEAP Programs typically consist of a high volume of applications in a short period of time (approximately 3 months) with a required application turnaround period (2 to 10 business days for each application). Since the program is performed under Adult Services, these County staff were not familiar with NCFAST. Applications within the LIHEAP programs require the use of NCFAST for online verification, documentation, application entry, and eligibility determination. Due to these factors, supervisory review is critical. There are time pressures on the supervisory level due to high volume and short time period and limited staffing level. Although the Adult Services Supervisor currently performs random second party reviews of workers? eligibility determinations, it was not documented. Surry County processed 2,365 applications during fiscal year end June 30, 2022. We tested 40 applications and determined that there were 3 applications that were approved without proper income verification and 3 applications with technical errors that did not affect eligibility. This indicates concerns that there could be pervasive errors in determining eligibility.Cause: The County does not have a formal documented review process for this program. Review documentation was not retained.Effect: We were unable to verify whether the second party review process was functioning as designed.Identification of repeat finding: This is not a repeat finding.Recommendation: We recommend the implementation of a formal and documented review process to include an appropriate number of reviews given the volume of applications processed for given time period as appropriate.Views of Responsible Officials and Planned Corrective Actions: The County agrees with this finding and is taking coordinated effort and action. Refer to corrective action plan on subsequent page 16.