Audit 343481

FY End
2024-06-30
Total Expended
$19.83M
Findings
10
Programs
35
Organization: Cleveland County (NC)
Year: 2024 Accepted: 2025-02-24

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
524281 2024-006 Significant Deficiency - E
524282 2024-002 Significant Deficiency Yes E
524283 2024-003 Significant Deficiency Yes E
524284 2024-004 Significant Deficiency Yes E
524285 2024-005 Significant Deficiency Yes E
1100723 2024-006 Significant Deficiency - E
1100724 2024-002 Significant Deficiency Yes E
1100725 2024-003 Significant Deficiency Yes E
1100726 2024-004 Significant Deficiency Yes E
1100727 2024-005 Significant Deficiency Yes E

Programs

ALN Program Spent Major Findings
21.027 Coronavirus State and Local Fiscal Recovery Funds $6.20M Yes 0
93.778 Medical Assistance Program $3.92M Yes 4
93.563 Child Support Services $1.81M Yes 0
93.658 Foster Care Title IV-E $1.70M - 0
93.558 Temporary Assistance for Needy Families $1.45M Yes 0
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $1.29M Yes 1
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $769,957 - 0
93.667 Social Services Block Grant $503,409 Yes 0
93.045 Special Programs for the Aging, Title Iii, Part C, Nutrition Services $374,610 - 0
93.767 Children's Health Insurance Program $284,845 - 0
93.044 Special Programs for the Aging, Title Iii, Part B, Grants for Supportive Services and Senior Centers $254,315 - 0
93.268 Immunization Cooperative Agreements $232,534 - 0
93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund $184,197 - 0
93.568 Low-Income Home Energy Assistance $138,099 - 0
93.659 Adoption Assistance $98,651 - 0
16.710 Public Safety Partnership and Community Policing Grants $92,139 - 0
93.217 Family Planning Services $84,250 - 0
93.994 Maternal and Child Health Services Block Grant to the States $77,040 - 0
16.738 Edward Byrne Memorial Justice Assistance Grant Program $49,756 - 0
93.967 Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health $36,251 - 0
93.556 Marylee Allen Promoting Safe and Stable Families Program $35,583 - 0
97.042 Emergency Management Performance Grants $35,000 - 0
93.069 Public Health Emergency Preparedness $31,298 - 0
93.991 Preventive Health and Health Services Block Grant $30,431 - 0
93.940 Hiv Prevention Activities Health Department Based $28,000 - 0
93.645 Stephanie Tubbs Jones Child Welfare Services Program $24,978 - 0
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $24,492 - 0
93.674 John H. Chafee Foster Care Program for Successful Transition to Adulthood $23,850 - 0
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $22,800 - 0
93.053 Nutrition Services Incentive Program $22,251 - 0
93.436 Well-Integrated Screening and Evaluation for Women Across the Nation (wisewoman) $1,350 - 0
93.917 Hiv Care Formula Grants $507 - 0
93.977 Sexually Transmitted Diseases (std) Prevention and Control Grants $100 - 0
93.116 Project Grants and Cooperative Agreements for Tuberculosis Control Programs $50 - 0
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $14 - 0

Contacts

Name Title Type
MXEZRW9DKR86 Phillip Steffen Auditee
7044844840 Alan Thompson Auditor
No contacts on file

Notes to SEFA

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 Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. De Minimis Rate Used: N Rate Explanation: N/A

Finding Details

US Department of Health and Human Service Passed through the NC Dept of Health and Human Services Food and Nutrition Services (FNS) Cluster Finding 2024-006 FNS Eligibility Determinations SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Recommendation: Views of responsible officials and planned corrective actions: Section III - Federal Award Findings and Questioned Costs (continued) AL No.: 10.551 and 10.561 Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The State has provided policies and procedures to ensure that the County is meeting the federal guidance, relevant policies are: Food and Nutrition Services Policy 305 describes the verification sources and requirements and the FNS units primary responsibility for providing documentary evidence to support statements on applications and recertifications and procedures required if the statements by applicant/beneficiary are questionable. Food and Nutrition Services Policy 300 describes the sources of income countable and not countable to the household for determining financial eligibility. Food and Nutrition Services Policy 310 describes the procedures related to verifying changes in income (i.e. termination, end of contract, temporary, etc.). There were a total of 8 errors found in our testing: 5 instances where there was an inadequate request for information from the client or verification from electronic sources; 3 instances where income was incorrectly caclculated or incorrect amount was entered in NCFAST. Of these 8 errors, 1 of these could potentially be an eligibility error. Due to the nature of the populations provided from which the samples were chosen, we are unable to calculate questioned costs for the above mentioned potential eligibility issue. We examined 25 of 29,653 FNS cases from a report of all active FNS beneficiaries provided by the County's Department of Social Services. The finding is being reported with the financial statement audit as it relates to FNS administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. The County should provide training of management and staff on the program's eligibility requirements, proper case review process, and required verifications for eligibility. Also, the County should ensure that their formal internal review process is adequately completed to identify and correct errors in case reviews. The County agrees with the finding. See Corrective Action Plan in the following section.
Passed through the NC Dept of Health and Human Services Medical Assistance Program (Medicaid; Title XIX) Finding 2024-002 IV-D Cooperation with Child Support SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: Section III - Federal Award Findings and Questioned Costs AL No.: 93.778 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 was 1 error 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 a total of 1,459,263 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine 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. This is a repeat finding from the immediate previous audit, 2023-003. 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. The County agrees with the finding. See Corrective Action Plan in the following section.
US Department of Health and Human Service Passed through the NC Dept of Health and Human Services Medical Assistance Program (Medicaid; Title XIX) Finding 2024-003 Inaccurate Information Entry SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: 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. This is a repeat finding from the immediate previous audit, 2023-004. There was no known affect to eligibility and there were no known questioned costs. The County agrees with the finding. See Corrective Action Plan in the following section. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. There were 2 errors discovered during our procedures where income or household size was incorrectly calculated or inaccurate information was entered into the case file. AL No.: 93.778 We examined 60 cases from a total of 1,459,263 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine 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.
US Department of Health and Human Service Passed through the NC Dept of Health and Human Services Medical Assistance Program (Medicaid; Title XIX) Finding 2024-004 Inaccurate Resources Entry SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: Section III - Federal Award Findings and Questioned Costs (continued) 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. AL No.: 93.778 There were 6 errors discovered during our procedures where resources were imcorrectly calculated or were not properly documented in the case file. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from a total of 1,459,263 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine 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. 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. See Corrective Action Plan in the following section.
US Department of Health and Human Service Passed through the NC Dept of Health and Human Services Medical Assistance Program (Medicaid; Title XIX) Finding 2024-005 Inadequate Request for Information SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: This is a repeat finding from the immediate previous audit, 2023-006. 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. See Corrective Action Plan in the following section. Section III - Federal Award Findings and Questioned Costs (continued) AL No.: 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 redeterminations. There were 13 errors discovered during our procedures where required information needed for eligibility determinations were not requested or not requested timely at applications 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 1,459,263 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine 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.
US Department of Health and Human Service Passed through the NC Dept of Health and Human Services Food and Nutrition Services (FNS) Cluster Finding 2024-006 FNS Eligibility Determinations SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Recommendation: Views of responsible officials and planned corrective actions: Section III - Federal Award Findings and Questioned Costs (continued) AL No.: 10.551 and 10.561 Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The State has provided policies and procedures to ensure that the County is meeting the federal guidance, relevant policies are: Food and Nutrition Services Policy 305 describes the verification sources and requirements and the FNS units primary responsibility for providing documentary evidence to support statements on applications and recertifications and procedures required if the statements by applicant/beneficiary are questionable. Food and Nutrition Services Policy 300 describes the sources of income countable and not countable to the household for determining financial eligibility. Food and Nutrition Services Policy 310 describes the procedures related to verifying changes in income (i.e. termination, end of contract, temporary, etc.). There were a total of 8 errors found in our testing: 5 instances where there was an inadequate request for information from the client or verification from electronic sources; 3 instances where income was incorrectly caclculated or incorrect amount was entered in NCFAST. Of these 8 errors, 1 of these could potentially be an eligibility error. Due to the nature of the populations provided from which the samples were chosen, we are unable to calculate questioned costs for the above mentioned potential eligibility issue. We examined 25 of 29,653 FNS cases from a report of all active FNS beneficiaries provided by the County's Department of Social Services. The finding is being reported with the financial statement audit as it relates to FNS administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. The County should provide training of management and staff on the program's eligibility requirements, proper case review process, and required verifications for eligibility. Also, the County should ensure that their formal internal review process is adequately completed to identify and correct errors in case reviews. The County agrees with the finding. See Corrective Action Plan in the following section.
Passed through the NC Dept of Health and Human Services Medical Assistance Program (Medicaid; Title XIX) Finding 2024-002 IV-D Cooperation with Child Support SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: Section III - Federal Award Findings and Questioned Costs AL No.: 93.778 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 was 1 error 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 a total of 1,459,263 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine 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. This is a repeat finding from the immediate previous audit, 2023-003. 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. The County agrees with the finding. See Corrective Action Plan in the following section.
US Department of Health and Human Service Passed through the NC Dept of Health and Human Services Medical Assistance Program (Medicaid; Title XIX) Finding 2024-003 Inaccurate Information Entry SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: 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. This is a repeat finding from the immediate previous audit, 2023-004. There was no known affect to eligibility and there were no known questioned costs. The County agrees with the finding. See Corrective Action Plan in the following section. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. There were 2 errors discovered during our procedures where income or household size was incorrectly calculated or inaccurate information was entered into the case file. AL No.: 93.778 We examined 60 cases from a total of 1,459,263 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine 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.
US Department of Health and Human Service Passed through the NC Dept of Health and Human Services Medical Assistance Program (Medicaid; Title XIX) Finding 2024-004 Inaccurate Resources Entry SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: Section III - Federal Award Findings and Questioned Costs (continued) 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. AL No.: 93.778 There were 6 errors discovered during our procedures where resources were imcorrectly calculated or were not properly documented in the case file. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from a total of 1,459,263 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine 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. 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. See Corrective Action Plan in the following section.
US Department of Health and Human Service Passed through the NC Dept of Health and Human Services Medical Assistance Program (Medicaid; Title XIX) Finding 2024-005 Inadequate Request for Information SIGNIFICANT DEFICIENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: This is a repeat finding from the immediate previous audit, 2023-006. 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. See Corrective Action Plan in the following section. Section III - Federal Award Findings and Questioned Costs (continued) AL No.: 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 redeterminations. There were 13 errors discovered during our procedures where required information needed for eligibility determinations were not requested or not requested timely at applications 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 1,459,263 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine 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.