Corrective Action Plans

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Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on completing complete and thorough case documentation. Caseworkers will receive additional training on inputting the correct evidence into NCFAST, including inc...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on completing complete and thorough case documentation. Caseworkers will receive additional training on inputting the correct evidence into NCFAST, including income evidence. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 31, 2026
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers will receive additional training on obtaining adequate verifications for income. Caseworkers will receive additional training on completing complete and thorough case documentation. Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 30, 2026
Program(s): Supplemental Nutrition Assistance Program (SNAP) 10.561 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following instance of noncompliance in the sample of sixty case files tested: • One MAXIS case ...
Program(s): Supplemental Nutrition Assistance Program (SNAP) 10.561 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following instance of noncompliance in the sample of sixty case files tested: • One MAXIS case file did not have a re-determination of eligibility performed within the 12-month period. • One MAXIS case file did not have documentation of income verification. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered and the information required by the contract is retained in the County’s records. Hennepin County Employee Responsible for the CAP: Jennifer Frey, Human Services Area Manager for SNAP Planned Completion Date for CAP: December 1st, 2026
Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP progr...
Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP program period each year.
The Authority will establish controls to ensure all certifications are completed timely and in accordance with requirements.
The Authority will establish controls to ensure all certifications are completed timely and in accordance with requirements.
Finding Reference Number: 2025-001 for U.S. Department of Housing and Urban Development: Assistance Listing 14.195 Project-Based Rental Assistance (PBRA) View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor complia...
Finding Reference Number: 2025-001 for U.S. Department of Housing and Urban Development: Assistance Listing 14.195 Project-Based Rental Assistance (PBRA) View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Contact Person Responsible: Flynann Skeen, President/Executive Director, Equality Community Housing Corporation Joshua Allen, President, J. Allen Management Co. Inc. Completion Date: Open
Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J....
Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Taken and Planned 1. Resolution of the two identified cases. The Hospital reviewed and resolved the two patient accounts identified in the audit sample in which an incorrect sliding fee discount percentage was applied: • In the first case, the discount applied resulted in a charge to the patient below the amount that corresponded under the correct Federal Poverty Guidelines discount tier, and a lower amount was collected from the patient. Management evaluated the account and determined not to retroactively bill the patient for the remaining difference, consistent with the Hospital’s mission and its policy of not creating barriers to care for patients eligible under the Sliding Fee Discount Program. • In the second case, the Hospital billed and collected from the patient an amount higher than the amount that corresponded under the correct discount tier. This case was resolved and the amount collected in excess of the correctly discounted amount was returned to the patient by check no. 95274, issued on May 29, 2026. Documentation of the refund is retained in the patient’s account file. 2. Questioned cost. The known questioned cost of $245.97 has been repaid and offset by the Hospital. Supporting documentation of the resolution is available for review by the awarding agency. 3. Current Federal Poverty Guidelines implementation. The Sliding Fee Discount Schedule will be updated to the current Federal Poverty Guidelines (FPG) issued annually by HHS, and a standing procedure will be established requiring that the updated schedule be approved and incorporated into the Hospital’s billing system (eClinicalWorks) within thirty (30) days of the annual publication of the FPG. 4. Review of sliding fee determinations. The review process over sliding fee discount determinations, which had previously been performed by the Billing Department and was later delegated to the information management staff, has been returned to the Billing Department to ensure that discounts are properly applied to patients in accordance with the Sliding Fee Discount Program policies and the updated fee schedule. 5. Strengthened internal controls. A secondary review control will be implemented under which a quarterly sample of new and renewed SFDP eligibility determinations will be re-verified by the Billing Department against the current FPG schedule, income documentation, and household size, with the results documented in a monitoring log subject to review by the Chief Financial Officer. 6. Training. Formal training on the SFDP policy, the current FPG schedule, and the related documentation requirements will be provided to all registration, billing, and eligibility staff, with attendance documented. Refresher training will be provided annually upon each FPG update. Anticipated Completion Date Items 1 and 2 – Completed. Items 3 through 6 – October 31, 2026.
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF THE TREASURY, COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS (CSLFRF) – FEDERAL ALN 21.027 AND U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT, ECONOMIC DEVELOPMENT INITIATIVE, COMMUNITY PROJECT FUNDING, AND...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF THE TREASURY, COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS (CSLFRF) – FEDERAL ALN 21.027 AND U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT, ECONOMIC DEVELOPMENT INITIATIVE, COMMUNITY PROJECT FUNDING, AND MISCELLANEOUS GRANTS – FEDERAL ALN 14.251 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires City of Farmington, Minnesota (the City) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the Economic Development Initiative and CSLFRF federal programs. During our audit, we noted the City did not have sufficient controls in place within these programs to ensure compliance with federal requirements related to assuring that the City was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The City performed the required suspension and debarment verifications; however, documentation was not retained for two of the three vendors tested. To strengthen internal controls going forward, the City has implemented an updated procedure requiring staff to consistently retain documentation of suspension/debarment checks at the time of procurement for all federally funded contracts. This includes either (1) a SAM.gov screen print; (2) a copy of the contractor’s certification; or (3) a retained record of the method used. The Finance Director has reinforced this requirement with the responsible staff to ensure consistent and complete documentation going forward. Official Responsible – Kim Sommerland, Finance Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The City agrees documentation was not retained for two vendors. Plan to Monitor – The Finance Director will oversee compliance with the updated procedures and will conduct periodic spot checks to ensure documentation is consistently retained for all federally funded procurements.
2025-006: STUDENT MEAL APPLICATIONS Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Non...
2025-006: STUDENT MEAL APPLICATIONS Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: E. Eligibility Condition: During our testing of eligibility determinations under the Child Nutrition Cluster, we selected 40 student meal applications for review. Of the 40 applications tested, two applications were incorrectly classified based on the information provided on the applications. Specifically, one application was approved as free when it should have been approved as reduced, and one application was approved as reduced when it should have been approved as paid based on applicable eligibility guidelines. Action planned in response to finding: The District will ensure nutrition applications are reviewed to determine they meet the appropriate classification criteria. In addition, applications will be reviewed and approved by someone other than the initial individual that is recording the classification type. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Edward Dickie, Business Manager.
June 25, 2026 Dear Cognizant or Oversight Agency for Audit: DePelchin Children’s Center (DePelchin) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, S...
June 25, 2026 Dear Cognizant or Oversight Agency for Audit: DePelchin Children’s Center (DePelchin) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed below from the Schedule of Findings and Questioned Costs (the schedule) for the year ended December 31, 2025 is numbered consistently with the number assigned in the schedule. Federal Award Finding 2025-001 Corrective Action Plan: DePelchin has implemented an internal review process whereby a grant specialist on the evaluation team conducts a monthly review of all enrollments to verify that eligibility requirements, including priority characteristics and service area criteria, have been met. Program staff, evaluation staff, and data team members have been provided additional training on the applicable eligibility requirements and documentation standards. Additionally, DePelchin has implemented an annual cross-functional review process involving program leadership, evaluation staff, and fiscal representatives to review eligibility requirements and key contract provisions prior to the start of each fiscal year. This review is intended to ensure that any changes in program requirements are identified, communicated, and incorporated into program operations in a timely manner. Based on these corrective actions and enhanced monitoring procedures, DePelchin believes the risk of similar eligibility documentation issues has been substantially mitigated. Contact Person Responsible for Corrective Action: Mr. Brian Pate, Senior VP and CFO Anticipated Completion Date: The corrective action plan is anticipated to be completed by October 31, 2026. Respectfully submitted, Mr. Brian Pate Senior VP and CFO
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for rev...
Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for review at the time of audit. Method of Implementation: The district will improve the filing and retention of payroll timesheets and resolutions authorizing payroll expenses for federal programs. All payroll documentation will be properly maintained and made readily available for review at the time of audit.
Agency: Colorado Coalition for the Homeless Audit Period: 2025 Audit Finding Number: 2025-001 Audit Finding Title Sliding Fee Health Center Cluster Department of Health and Human Services Assistance Listing Number 93.224 Behavioral Health Services, 93.527 Bridge Access Program Award Numbers: 4 H8NCS...
Agency: Colorado Coalition for the Homeless Audit Period: 2025 Audit Finding Number: 2025-001 Audit Finding Title Sliding Fee Health Center Cluster Department of Health and Human Services Assistance Listing Number 93.224 Behavioral Health Services, 93.527 Bridge Access Program Award Numbers: 4 H8NCS53841-01-02 and 5 H80CS00040-24-00 Award Years: January 1, 2023-December 31, 2025 Criteria or Specific Requirement: Special Tests and Provision: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition: The Organization has a policy that includes homelessness when applying the sliding fee discount in addition to income and household size. The Health Center Compliance Manual only identifies income and household size as determining factors for the sliding fee program. Documentation to support income or household size were not maintained adequately for some patients who received sliding fee discount adjustments. Cause: The Organization's sliding fee discount policy includes homelessness, which is not specifically listed as an applicable determining factor for the sliding fee discount. The Health Center Compliance Manual specifically identifies income and household size as determining factors for the sliding fee program. Additionally, the Organization's controls did not clearly document eligibility for all patients with the sliding fee discount policy. Effect or potential effect: Other adjustments were not distinct from sliding fee adjustments applied to patient charges and, therefore, all patients received a full discount for services. Questioned Costs: None Context: A sample of 25 patients out of a population of 13,454 patients were tested.  Four of the patients sampled lacked appropriate documentation of income and/or household size. Seven of the patients sampled between 100% and 200% of the FPL were adjusted to no patient responsibility under the sliding fee discount program based on their homelessness status as identified in the Organization’s policy. The sampling methodology used is not and is not intended to be statistically valid. Identification as a repeat finding: Not a repeat finding. Recommendation: The Organization should revise its sliding fee discount policy to focus only on income and household size and further eliminate homelessness as a factor. Furthermore, the Organization should implement a process to review sliding fee discount eligibility to ensure compliance with its revised policy. Other adjustments should also be captured separately from sliding fee adjustments within the Organization's billing system. Views of responsible officials and planned corrective actions: The Organization agrees with the finding. Specific steps to be taken to correct the situation (including a timetable for performance of the CAP) or reason why corrective action is not necessary (including disagreement with the finding) NextGen, the electronic health record and practice management system CCH utilizes for revenue cycle operations has been reconfigured to separate the sliding fee adjustments from other adjustments. This was identified and corrected before the audit was completed on April 21, 2026. CCH will revise and update the Sliding Fee Discount Program policy to clarify that the only two factors for application of the sliding fee discount are family size and income. The Sliding Fee Discount Policy will no longer include ‘homelessness’ as a factor for this particular discount. CCH will review the sliding fee discount process regularly to ensure compliance with the revised policy. Additionally, appropriate documentation of self-attestation of income and family size will be collected as required. CCH will also revise and update existing policies related to Billing and Collections and for Waiving or Reducing Fees Beyond the Sliding Fee Scale to define the other discounts CCH provides to clients including those who do not provide complete data for sliding fee discount eligibility determination Finally, appropriate staff will receive updated training on the updated policies. Anticipated completion date The billing system change occurred on April 21, 2026. The policy revisions will be completed and approved by the Board by October 31, 2026 Training on the updated policies will be implemented upon final approval by the Board and be completed by November 30, 2026. Name(s) and title(s) of contact person(s) responsible for corrective action Billing system changes: Rob Plimpton, Controller /Kathy Hatfield, Interim Revenue Cycle Director Policies and Training: Andrew RobGrimm, Chief Integrated Health Operations Officer
A 100% review of applications was completed on October 10, 2025. The Food Service Supervisor will run an original direct certification before school starts and import that into Linq system. A 100% verification is completed in the fall. Each month a new direct certification is ran to catch any change...
A 100% review of applications was completed on October 10, 2025. The Food Service Supervisor will run an original direct certification before school starts and import that into Linq system. A 100% verification is completed in the fall. Each month a new direct certification is ran to catch any changes.
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.
Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit i...
Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: In September 2025, the Organization began its transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. This went live in December 2025. We included mandatory eligibility fields and document upload requirements before service can begin. We developed SOPs to include a standardized eligibility checklist to be completed for all new and returning participants. Staff were trained on Pantry Soft usage, eligibility requirements and document retention stands. The Executive Team performed spot checks on these records but will begin documenting this procedure.
View of Responsible Officials and Corrective Actions: We agree with the auditor's recommendation. Although the referenced invoices were reviewed by the CEO from the vendor for eligibility and reasonableness upon receipt of the automatic e-mailed invoice, there was no procedure to print and retain th...
View of Responsible Officials and Corrective Actions: We agree with the auditor's recommendation. Although the referenced invoices were reviewed by the CEO from the vendor for eligibility and reasonableness upon receipt of the automatic e-mailed invoice, there was no procedure to print and retain this documentation in the accounting files for Instacart invoices. Effective June 1, 2026, each month the Director of Finance will compare a checklist of all credit charges to the physical copies prior to filing and obtain any missing invoices as part of the monthly closing process.
See pdf of corrective action plan
See pdf of corrective action plan
Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should provide training and education to front desk staff related to the EMR and the process for collecting and retaining family size and income information in addition to inputting it into the electronic medical record...
Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should provide training and education to front desk staff related to the EMR and the process for collecting and retaining family size and income information in addition to inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information and has been obtained and charges are appropriately billed in accordance with the Organization's policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the finding. To address this issue, the Organization will reinforce procedures requiring current incomeand family size documentation prior to determining sliding fee eligibility, provide additionalstaff training, and will review electronic medical record system settings to ensure properdocumentation and application of discounts. Management will conduct periodic reviews tomonitor compliance with sliding fee discount requirements. Name(s) of the contact person(s) responsible for corrective action: Chief Operations Officer or their designee. Planned completion date for corrective action plan: September 1, 2026
Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically tes...
Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule •Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement an additional review of all sliding fee applications received and provide additional training for intake staff. Name(s) of the contact person(s) responsible for corrective action: Jennifer Smith Planned completion date for corrective action plan: 6/29/2026
During the 2025 audit, the auditors discovered that a secondary review of eligibility determinations did not occur in a timely manner. The lack of internal control opened the possibility that an individual was incorrectly determined to be eligible to receive benefits and this error would not have be...
During the 2025 audit, the auditors discovered that a secondary review of eligibility determinations did not occur in a timely manner. The lack of internal control opened the possibility that an individual was incorrectly determined to be eligible to receive benefits and this error would not have been identified or corrected in a timely manner. Federal Regulations establish requirements for internal control over compliance with Federal program requirements. 2 CFR Section 200.303 requires non-Federal entities to establish and maintain effective internal control over Federal awards that provides reasonable assurance the entity is managing the award in compliance with Federal statutes, regulations, and the terms and conditions of the award. These requirements include the design, implementation, and operation of control activities to ensure compliance with applicable compliance requirements, including eligibility. As eligibility is a key compliance requirement identified in the OMB Compliance Supplement, the County is required to implement a review process and system of internal controls that allows management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, errors or noncompliance in eligibility determinations on a timely basis. The Department of Human Services (DHS) has implemented a monthly review process to audit a random sample of the IV-E cases. The review includes verification of timely and accurate determinations, client information, supporting documentation, and system entries, with results documented and approved by the reviewer. DHS Division leadership will monitor compliance to ensure the reviews are conducted each month. DHS believes this additional review procedure will provide the needed internal controls over IV-E determination.
Finding #2025-007 14.239 HOME Investment Partnerships (HOME) Program Eligibility Views of Responsible Officials and Planned Corrective Action Management’s Position: #1 Management concurs and acknowledges that approving the matter without a more thorough evaluation was an oversight. #2 Management dis...
Finding #2025-007 14.239 HOME Investment Partnerships (HOME) Program Eligibility Views of Responsible Officials and Planned Corrective Action Management’s Position: #1 Management concurs and acknowledges that approving the matter without a more thorough evaluation was an oversight. #2 Management disagrees. HOME maximum subsidy per 3-bedroom unit is $338,419.00. Total HOME investment is $112,500.00. Corrective Actions: Corrective actions include strengthening internal controls and oversight. Management will implement a more comprehensive review process moving forward. This process will include additional supervisory review, verification of supporting documentation, confirmation of regulatory and policy compliance, and consultation with appropriate program and legal staff, when necessary, before approvals are granted. Management will also establish review checklists and documentation standards to ensure that all relevant factors are consistently evaluated and adequately documented. Moving forward, the Community Development Division will undergo a more rigorous evaluation process standardized review checklists and documentation requirements will be implemented to promote consistency, accountability, and proper recordkeeping. Management will monitor compliance with these enhanced procedures to reduce the risk of future deficiencies, oversights and ensure approvals are supported by adequate due diligence. Responsible Party: Jo Lyn Terlaje, Community Development Manager Anticipated Date of Completion: Final approval checklists will be implemented by August 1, 2026.
Name of Contact Person: Jill Sampson, DSS Director Corrective Action: Training will take place to reiterate the importance of properly recording the required telephonic signature and date. After reviewing the findings listed, the availability of time reserve and how to record it as well the steps fo...
Name of Contact Person: Jill Sampson, DSS Director Corrective Action: Training will take place to reiterate the importance of properly recording the required telephonic signature and date. After reviewing the findings listed, the availability of time reserve and how to record it as well the steps following its expiration will also be discussed. All will be addressed in the upcoming training. Proposed Completion Date: April 7, 2026.
Name of Contact Person: Jill Sampson, DSS Director Corrective Action- Internal Control Error: The Auditor Report for Bladen County disclosed finding(s) of non-compliance with laws and regulations. The audit shows that we have repetitive errors from the previous year. We take these results very serio...
Name of Contact Person: Jill Sampson, DSS Director Corrective Action- Internal Control Error: The Auditor Report for Bladen County disclosed finding(s) of non-compliance with laws and regulations. The audit shows that we have repetitive errors from the previous year. We take these results very seriously and are committed to implementing lasting improvements. Bladen County Department of Social Services is focused on establishing protocols that will build a standard of confidence for our Income Maintenance case workers. It has been and will remain our constant goal to strengthen our Medicaid programs through knowledge and training to eradicate errors. Bladen County DSS will implement the following program policy and procedures to improve proficiency in service delivery. We do recognize that we fell short of expectations on this audit, particularly with the repeat error findings. The nucleus of the Plan of Correction will have a framework that will involve both Income Maintenance staff and Managers to set a groundwork that will empower the Medicaid teams to meet state expectations and improved audit outcomes in the future. The Second-Party Audits completed each month by Medicaid Supervisors will track our performance and upon completion of the second party of cases training will be completed to address the errors found. Staff will be given a test that will measure our performance improvement to assure accuracy on case work. Areas Needing Correction: Internal Control Errors • Failure to comply with policy requirement: Three (3) instances of failure to complete at least one compliance component. All identified missing or incomplete verification of facts or were improperly forced. • Inaccurate Resource Calculation: Three (3) instances of inaccurate resource calculations in NC FAST. The values entered in NC FAST evidence and used in the eligibility determination did not match the supporting documentation or was lacking any substantiating documentation. • Inaccurate Budget Calculation: Six (6) instances of inaccurate budget calculations in NC FAST. The values entered in NC FAST evidence and used in the eligibility determination did not match the supporting documentation or was lacking any substantiating documentation. • Failure to document/correct system issues: Four (4) instances of system errors found that were not addressed or corrected. Cases contained benefit histories that were not representative of the benefit that was issued. Goal for Correction: • Work Number Usage Administrative Letter No: 02-19 The Work Number Procedures • The Work Number (TWN) - Job Aid dated 09/21/2023; The Work Number (Fact Sheet) Dated 09/25/2023. • Manual Calculations of Income F/C MA 3300; MA 2250 • MAF-MIC-HSF Budgeting – MA 3305 • Financial Resources MA 2230 • Evidence Dashboard Relationships - Job Aid dated11/27/2018 • Acceptable use of Medical Forced Eligibility– Last updated 03/01/2023. • NC FAST Mandatory Evidence and Verifications • Adding Evidence to Case (Job Aid) • Online Verifications (Job Aid) • MA 3515 Bladen County DSS is committed to using tools listed in this Plan of Correction to assist in recognizing any areas of concern for the Medicaid Teams. Bladen County DSS is eager to assist workers to become the most efficient and productive in their daily work routine, to reach the best desired outcome for both the clients served, as well as the overall audited scores. • Training has been completed for the Medicaid staff on February 23, 2026 (Adult Department) and February 24, 2026 (Family and Children Medicaid Department). See list of Medicaid policy, Administrative letter and NC FAST job aids that were addressed during the meeting. • Medicaid Program Checklist- each Medicaid team will have a checklist that will be utilized on each application/ recertification completed. This tool will be used to ensure Income Maintenance workers have completed all necessary actions to application/recertifications. This tool will also be used in auditing each case during the second party review of the case. *Note: Item Number 18 from the Medicaid Eligibility Testing Attribute has been updated to include The Work Number for household members age 14 and above. These tools are included in the Second Party review of the record and if the worker does not complete the tool a point is deducted as being in error. • Second Party Review of Records – Will be completed monthly by the Supervisor and Lead Worker for the specific program. Each Income Maintenance worker will be monitored by monthly review of three applications and three recertifications. Any errors that are determined during the second party review will be addressed with the worker, who will be given 3 days to make the correction to the file, refute the error finding by discussing manual policy with the Supervisor/Lead worker, workers will need the policy name and section number. This internal audit will assist in determining areas of training that staff need for overall improvement in job performance. • Medicaid Spreadsheet Internal Report Card – has been created for the Medicaid team monthly utilizing the individual scores received from the Second Party review of cases. This will be the benchmark set at 96.8% for Eligibility errors and 90% for technical errors. • Monthly Audits completed by Bladen County Finance Office will continue to be completed. Each worker is given their individual errors discovered by this audit. The worker will be coached concerning the errors found and will be required to make corrections to the case. The worker will also sign the audit form indicating that the information was reviewed with them and the date recorded. • Medicaid Spreadsheet Internal Report Card reviewed by County Boards – The Medicaid Second Party Spreadsheet (Internal Accuracy Report Card) for the Adult Medicaid and the Family and Children Medicaid Department will be reviewed monthly by the Bladen County Health and Human Services Advisory Committee. A formal presentation will be sent to the committee each month via computer. This information will be sent out in the format of spreadsheets; the spreadsheets will indicate each worker (using an alphabet identification) and will indicate if the employee met the benchmark goal of 96.8% eligibility and 90% technical error rate each month. This chart will give a three-month snapshot (window of time) for notifications of error trends identified by the audits. This report will be discussed quarterly at the Health and Human Service Advisory Committee meeting offering each committee member the opportunity to address their concerns about audit scores during that quarter. • All Medicaid Program teams will staff all pending applications (by date priority) with the IMC, Supervisor, and/or Lead worker. This will help to eliminate any questions that the IMC may have in response to completion of the application. • Second Party review of cases will be completed monthly by Supervisor and Lead worker in the Medicaid programs. Upon completion of the entire team’s second party reviews, training will be created based on the errors found at the second party of work. Once the training has been completed, workers will be given a test to determine their understanding of policy, job aid and forms reviewed in the training. A test score of 90% accuracy must be maintained by each staff member to receive a passing score. A score below 90% will require additional training. • A training outline form will be utilized during training so that staff have the opportunity to give feedback as to what they feel they need additional training in. • Newly hired staff within the first (1) year of employment will receive quarterly job performance evaluations. • Newly hired and all active Income Maintenance staff will take and pass (score of 70% or above) the NC FAST Core Functions Certification and Level 1 Training Program. • Newly hired staff will be required to have work reviewed 100%. • Warning System for Persistent Errors – Implementation of a warning system for caseworkers who persistently make errors, despite corrective actions and counseling. First Warning:  When an employee repeatedly makes errors despite individual counseling and corrective actions, they will receive a First Warning.  The employee's supervisor will meet with them to discuss the errors and reinforce the importance of adhering to policies and procedures.  As per Bladen County DSS policy, employees will be given three workdays to make necessary corrections.  The First Warning will be documented in the employee's personnel file. Second Warning:  Within three months, If the employee continues to make errors after receiving a First Warning, they will be issued a Second Warning.  The supervisor will conduct another meeting with the employee to address the persistent issues.  During this meeting, a performance improvement plan will be established, outlining specific areas for improvement and a timeline for achieving them.  The Second Warning will be documented in the personnel file. • Demotion in Position – If the employee's errors persist even after receiving the Second Warning and failing to meet the goals of the Plan of Correction, they will face demotion in position. The demotion will involve a change in job responsibilities or a transfer to a lower-level position if available within the organization. This action will be taken after thorough evaluation and consultation with Human Resources. • Termination – If, despite previous warnings, the employee continues to make errors that significantly impact their performance and the effectiveness of DSS, the last step is termination. Termination is the last resort and will be considered only after the employee has received a First Warning, a Second Warning, and a demotion in position. The decision to terminate will be made in consultation with Human Resources and higher-level management. • Proposed Completion Date: This Plan of Correction will become effective April 1, 2026. The Bladen County Department of Social Services Economic Services Division for the Medicaid Programs will take an active role in ensuring work is monitored and that staff receive training throughout the year, to minimize the error rate from the Single County Audit.
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