Audit 314504

U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Fund AL #: 21.027 Finding: 2023-007 Untimely Adoption of Policy SIGNIFICANT DEFICENCY Criteria: Condition: Effect: Cause: Recommendation: Views of responsible officials and planned corrective actions: The County agrees with this finding. Please refer to the corrective action plan for details. In accordance with the U.S. Department of Treasury 31 CFR Part 35, Coronavirus State and Local Fiscal Recovery Funds Final Rule and the Uniform Guidance, General Financial Management Internal Controls, Eligible Projects Determination & Documentation Policy, Cost Principles/Allowable Costs Policy, Civil Rights Compliance / Nondiscrimination Policy, Records Retention Policy are required to be adopted as condition of receiving the funds. The County expended the funds without adopting the required policies of the federal award. The County could use the funds for unallowable costs that were prohibited by the Final Rule. County oversight of the new federal grant requirement to have the stated policies in place. The finance office should review the grant agreement and the Uniform Guidance more carefully to ensure all compliance requirements are meet.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-008 IV-D Cooperation with Child Support SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: The County agrees with the finding. In accordance with the Medicaid Manual MA-3365, all Medicaid cases should be evaluated and referred to the Child Support Enforcement Agency (IV-D). The Child Support Enforcement Agency (IV-D) can assist the family in obtaining financial and/or medical support or medical support payments from the child’s non-custodial parent. Cooperation requirement with Social Services and Child Support Agencies must be met or good cause for not cooperating must be established when determining Medicaid eligibility. There were 2 errors discovered during our procedures that referrals between DSS and Child Support Agencies were not properly made. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to North Carolina Families Accessing Services through Technology (NC FAST) and a participant could have been approved for benefits for which they were not eligible. This is a repeat finding from the immediate previous audit, 2022-004. Human error in reading the Automated Collection and Tracking System (ACTS) report and/or ineffective case review process. Files should be reviewed internally to ensure proper information is in place and necessary procedures are taken when determining eligibility. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-009 Inaccurate Information Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The County agrees with the finding. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Section III. Federal Award Findings and Questioned Costs (continued) In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. There was no known affect to eligibility and there were no known questioned costs. There were 11 errors discovered during our procedures that inaccurate information was entered when determining eligibility. This is a repeat finding from the immediate previous audit, 2022-005.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-010 Inaccurate Resources Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: There were 1 errors discovered during our procedures that resources in the county documentation and those same resources contained in NC FAST were not the same amounts or files containing resources were not properly documented to be considered countable or non-countable. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. In accordance with Medicaid Manual MA-2230, Medicaid for Aged, Blind and Disabled case records should contain documentation that verifications were done in preparation of the application and these items will agree to reports in the NC FAST system. In this process, the countable resources should be calculated correctly and agree back to the amounts in the NC FAST system. Any items discovered in the verification process should be considered countable or noncountable resources and explained within the documentation. Section III. Federal Award Findings and Questioned Costs (continued) Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. This is a repeat finding from the immediate previous audit, 2022-006. The County agrees with the finding. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-011 Untimely Review of SSI Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: Section III. Federal Award Findings and Questioned Costs (continued) The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. There was 2 applicant/beneficiary not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated, for which the recipient was not eligible. Any State communications related to applicants’ benefits received by any DSS department should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received. The County agrees with the finding. This is a repeat finding from the immediate previous audit, 2022-007. Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-012 Inadequate Request for Information SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. Electronic matches are required at applications and There were 7 errors discovered during our procedures that inadequate information was requested at applications and/or redeterminations. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. Section IV. State Award Findings and Questioned Costs This is a repeat finding from the immediate previous audit, 2022-008. SIGNIFICANT DEFICENCY: Finding 2023-008, 2023-009, 2023-010, 2023-011, 2023-012 also apply to State requirements and State Awards. Section III. Federal Award Findings and Questioned Costs (continued) Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The County agrees with the finding.

U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Fund AL #: 21.027 Finding: 2023-007 Untimely Adoption of Policy SIGNIFICANT DEFICENCY Criteria: Condition: Effect: Cause: Recommendation: Views of responsible officials and planned corrective actions: The County agrees with this finding. Please refer to the corrective action plan for details. In accordance with the U.S. Department of Treasury 31 CFR Part 35, Coronavirus State and Local Fiscal Recovery Funds Final Rule and the Uniform Guidance, General Financial Management Internal Controls, Eligible Projects Determination & Documentation Policy, Cost Principles/Allowable Costs Policy, Civil Rights Compliance / Nondiscrimination Policy, Records Retention Policy are required to be adopted as condition of receiving the funds. The County expended the funds without adopting the required policies of the federal award. The County could use the funds for unallowable costs that were prohibited by the Final Rule. County oversight of the new federal grant requirement to have the stated policies in place. The finance office should review the grant agreement and the Uniform Guidance more carefully to ensure all compliance requirements are meet.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-008 IV-D Cooperation with Child Support SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: The County agrees with the finding. In accordance with the Medicaid Manual MA-3365, all Medicaid cases should be evaluated and referred to the Child Support Enforcement Agency (IV-D). The Child Support Enforcement Agency (IV-D) can assist the family in obtaining financial and/or medical support or medical support payments from the child’s non-custodial parent. Cooperation requirement with Social Services and Child Support Agencies must be met or good cause for not cooperating must be established when determining Medicaid eligibility. There were 2 errors discovered during our procedures that referrals between DSS and Child Support Agencies were not properly made. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to North Carolina Families Accessing Services through Technology (NC FAST) and a participant could have been approved for benefits for which they were not eligible. This is a repeat finding from the immediate previous audit, 2022-004. Human error in reading the Automated Collection and Tracking System (ACTS) report and/or ineffective case review process. Files should be reviewed internally to ensure proper information is in place and necessary procedures are taken when determining eligibility. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-009 Inaccurate Information Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The County agrees with the finding. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Section III. Federal Award Findings and Questioned Costs (continued) In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. There was no known affect to eligibility and there were no known questioned costs. There were 11 errors discovered during our procedures that inaccurate information was entered when determining eligibility. This is a repeat finding from the immediate previous audit, 2022-005.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-010 Inaccurate Resources Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: There were 1 errors discovered during our procedures that resources in the county documentation and those same resources contained in NC FAST were not the same amounts or files containing resources were not properly documented to be considered countable or non-countable. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. In accordance with Medicaid Manual MA-2230, Medicaid for Aged, Blind and Disabled case records should contain documentation that verifications were done in preparation of the application and these items will agree to reports in the NC FAST system. In this process, the countable resources should be calculated correctly and agree back to the amounts in the NC FAST system. Any items discovered in the verification process should be considered countable or noncountable resources and explained within the documentation. Section III. Federal Award Findings and Questioned Costs (continued) Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. This is a repeat finding from the immediate previous audit, 2022-006. The County agrees with the finding. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-011 Untimely Review of SSI Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: Section III. Federal Award Findings and Questioned Costs (continued) The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. There was 2 applicant/beneficiary not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated, for which the recipient was not eligible. Any State communications related to applicants’ benefits received by any DSS department should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received. The County agrees with the finding. This is a repeat finding from the immediate previous audit, 2022-007. Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits.

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2023-012 Inadequate Request for Information SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Identification of a repeat finding: Recommendation: Views of responsible officials and planned corrective actions: Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. Electronic matches are required at applications and There were 7 errors discovered during our procedures that inadequate information was requested at applications and/or redeterminations. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 804,789 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to redetermine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. Section IV. State Award Findings and Questioned Costs This is a repeat finding from the immediate previous audit, 2022-008. SIGNIFICANT DEFICENCY: Finding 2023-008, 2023-009, 2023-010, 2023-011, 2023-012 also apply to State requirements and State Awards. Section III. Federal Award Findings and Questioned Costs (continued) Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The County agrees with the finding.