Corrective Action Plans

Finding 2022-003 Name of Contact Person: Alice Wilson, Economic Program Administrator Corrective Action: The county will conduct refresher training for staff on how to correctly add/remove household members to a case. The county will conduct a targeted second party of cases to check for the effectivemness of the refresher training. This area will continue to be a part of the second party checks conducted by lead staff and supervision in the county. Proposed Completion Date: January 31, 2023.

Finding 2022-002 Name of Contact Person: Alice Wilson, Economic Services Program Administrator Corrective Action: County will conduct a refresher training to all staff on when/how to complete the IVD referral. The county has added a section for IVD referrals to the casenote template for all staff to complete when evaluating applications and recertifications for eligibility. The casenote template serves as a checklist for staff to ensure that all areas of eligibility as well as post eligibilty items are addressed. The county will complete a targeted second party to check for effectiveness of refresher training in the IVD referral area. This area will continue to be a part of the second party checks conducted by lead and supervision in the county. This is a repeat finding from previous year however the total number of findings for this review was lower than previous. Proposed Completion Date: January 31, 2023.

Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of the finding: Management did not retain evidence to support their review over the patient data submitted to Sponsor for the per diem billings from February 1, 2022 to December 31, 2022 was complete and accurate. Corrective action plan: The current attestation memo control will be replaced as follows: There are two categories of study activity that required review and approval by the appropriate individual (i.e., Principal Investigator, Clinical Research Manager (CRM) or a delegate): (1) at the time of enrollment to assure that the study participant met sponsor-defined eligibility requirements and (2) subsequent study activities that may include but are not limited to a study visit, data collection, follow-up phone call, questionnaire completion, laboratory testing, biospecimen collection, or some combination of these. Verification of eligibility at the time of enrollment will continue to be reviewed and approved by the study PI, CRM, or appropriate delegate per sponsor requirements. Documentation is maintained in study-specific binders, per FDA audit standards and internationally-accepted Good Clinical Practice principles to assure that only patients meeting the sponsor?s defined eligibility criteria are enrolled into the study. Review of study activities subsequent to the study participant enrollment will be conducted monthly by the CRM or their delegate. Sponsored Programs Administration (SPA) will prepare and send each CRM a Transaction Report downloaded from the institutional clinical trial management system for each federally funded study, at least quarterly, that includes a listing of study visits associated with enrolled study participants that occurred within the defined period of time. The CRM/delegate will review the report detail provided and, upon approval, sign, and date the report. To assure that the information in the report is consistent with what was submitted to third parties which generates reimbursement, the CRM/delegate will conduct an audit of a sample of patients from a random selection of studies included in the Transaction Report. Each sample will be verified against documentation maintained in the study binder. Audit results affirming document review will be recorded in an audit tracking log which will be retained with the study activity report in their Clinical Trial Office (CTO) file as evidence of their review of study activity for federally funded fixed fee/per patient studies. For those federally funded fixed fee/per patient studies that do not utilize the standard institutional clinical trial management system, a similar study activity report downloaded from the clinical trial management system utilized for the study will be used for review, signed and dated upon approval and kept in the CTO files as evidence of review. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: September 1, 2023 and going forward.

Finding 2022-103 - Improve Eligibility Screening and Documentation (Significant Deficiency) FAL Number: 10.557 Program Title: Special Supplemental Nutrition Program for Women, Infants, and Children Condition and Context: For two of 40 selected participants, the rights and obligations form was unsigned. Recommendation: The auditors recommended that Pinal County devote the necessary resources to the department to ensure all eligibility screenings are being performed and the rights and obligations form is signed prior to participants receiving benefits. Contact Name: Merissa Mendoza, Interim Director and Public Health Manager Corrective Action Planned: Each WIC staff member receives a minimum of 10 chart audits annually, resulting in roughly 160 chart audits completed by WIC management yearly. Additionally, each WIC staff member is observed with a minimum 6 certification appointments annually via their WIC Supervisor and/or Nutrition Specialist Senior. Staff will continue to follow AZ WIC Policy and Procedure when assessing clients for income eligibility. Any identified deficiencies in staff education or training will be identified and corrected by supervisory staff. Anticipated Completion Date: December 31, 2023

Name of Contact Person: Billie Culp, Economic Services Program Manager, 704-216-8350 Corrective Action/Management Response: The Department concurs with the following finding: 1) Failure to properly determine income for five (5) applicants. 2) Failing to ensure the client?s signature was provided authorizing the application. All staff responsible for working LIEAP applications will receive training that covers program specific information, income calculations, dictation requirements, notices and NCFAST procedures. Proposed Completion Date: November 28, 2022

Reference Number: 2022-001 Description: Medicaid Bus Logs Corrective Action Plan: The District will ensure that information from the bus logs is accurately included in the data used to calculate the transportation ratio. Anticipated Corrective Action Plan Completion Date: January 2023 Contact Information: For additional information regarding this finding please contact Erica Pickett, Director of Business Services, at 608-877-5011.

Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program Name: HIV Emergency Relief Project Grants ? Grantor: Department of Health and Human Services (HHS) ? Federal award identification number: Not Applicable Views of responsible officials and planned corrective actions: Management agrees with the finding. Management will develop internal controls to implement effective internal controls regarding 1) Review and retention of income and residency verification at program Intakes, and 2) Real time documentation of participants? income and residency eligibility at the required frequency (typically during 6 month Reassessments) with accepted supporting documentation for each participant. 3) This documentation will be entered into our EMR (EPIC) for each patient, outlining our eligibility verifications done at Intakes, Reassessments or Reassessment Attempts, along with screen shots from ePACES and/or other eligibility documents used. This will enable our program team and our funders and auditors to be able to more easily review our documented ongoing program eligibility for each patient. This will also improve our quality controls and will enable program staff to more effectively monitor annual eligibility checks. Contact person: Diane Tider Expected Completion Date: Implementing immediately 10/2/23

Contact Name: Barbara Staggs, CFO Contact Phone Number: 870-863-8194 Audit Period Ending: June 30, 2022 Audit Firm: FORVIS, LLP Federal Program: Child and Adult Food Care Program, Assistance Listing No. 10.558 Federal Agency: U.S. Department of Health and Human Services Management concurs with findings and plans to implement the recommendations above. Starting in July 2023, SADCCF's Quality Assurance will conduct a review of every eligibility form completed during the year to ensure that it was completed correctly. The form will then be traced to the USDA attendance sheet to make sure that the status (free, reduced or paid) is recorded correctly on the sheet to ensure that the billing for each child is correct.

Contact Name: Barbara Staggs, CFO Contact Phone Number: 870-863-8194 Audit Period Ending: June 30, 2022 Audit Firm: FORVIS, LLP Federal Program: Child and Adult Food Care Program, Assistance Listing No. 10.558 Federal Agency: U.S. Department of Health and Human Services Management concurs with findings and plans to implement the recommendations above. Starting in July 2023, the SADCCF Training Department will schedule Mandatory New hire and Refresher Trainings and document completion with a certificate, sign in sheet and agenda detailing the material covered during the training. The Training Department along with HR will also add USDA as a required training in the training database for each employee working for SADCCF's children and adult programs. This will enable HR to print a list by employee of needed trainings and this list will be reviewed quarterly to make sure all employees required to have the USDA training have received it.

FISCAL YEAR OF FINDING: 2022 AUDITOR FINDING: 2022-005 Eligibility. We noted the following issues in the 40 cases tested: 1. Four instances in which income was incorrectly calculated based on information maintained in case file. 2. One instance in which there was inadequate documentation to support eligibility determination within the case file. 3. One instance in which the Colorado Works Referral form was not processed timely. 4. Two instances in which the County' eligibility authorization notes for the period selected did not agree to CHATS. Recommendation: We recommend that the County continue to strengthen the internal controls surrounding the eligibility process, specifically continuing the use and monitoring of case reviews to help identify potential areas for additional training. CLIENT PLANNED ACTION: Jefferson County agrees with the findings. There continues to be improvement each year in the overall findings, which demonstrates that the strategies previously implemented had the desired impact. However, the continued findings require additional action steps. Jefferson County will continue and implement the following actions to address and prevent future errors. ? The CCAP supervisor will continue reviewing available reports in CHATS to target untimely closures and follow up on potential erroneous case closures. Reports include the RE301, RE224, and RE115. Any case needing action will be assigned for completion within 5 business days and reviewed to ensure corrections were completed. ? Monthly case reviews will continue, at three levels, to assess case and payment accuracy. o The Jeffco Human Services Internal Quality Assurance (IQA) team will review 1% of the caseload monthly, utilizing the state mandated list. o The State Program Integrity Office will review cases monthly to monitor case and payment accuracy. o CCAP Supervisor and/or Lead Worker will review cases as follows: - The CCAP Supervisor will complete a minimum of two case reviews per worker per month. The number and type of review may be adjusted based on individual staff performance. Income and parent fee calculations will be targeted using the primary activity report in CHATS. The Lead Worker will fulfill this function if the Supervisor is out of the office. - 5% of all applications and redeterminations will be reviewed by the CCAP Supervisor or Lead Worker prior to approval. Jefferson County?s Internal Auditor has also been trained on the eligibility process and may review cases prior to approval to support the team. Eligibility Specialists will utilize a pre-authorization checklist when submitting the selected cases for review. The checklist was developed and implemented to assist workers in accurately entering and checking their data entry and eligibility determination. New CCAP Eligibility Specialists will have 100% of cases reviewed prior to approval until accuracy rates reach 95%, at which point preauthorization reviews will be reduced incrementally based on performance. o All responses to IQA or State Program Integrity regarding corrections or resolutions to cases will be documented and provided to the CCAP Supervisor/Program Manager within 2-5 business days, depending on the identified deadline, and will include screen shots verifying corrections prior to submittal. o Monthly meetings between the Division Director, Program Integrity Manager, Program Integrity Supervisor, Quality Assurance Supervisor, CCAP Program Manager, and CCAP Supervisor will continue in order to discuss performance and progress related to quality assurance and program integrity. Prior to the meeting, the Internal Quality Assurance (IQA) team will provide monthly reports for review and analysis. During the meetings, data and trends will be reviewed utilizing the aforementioned reports, which include error type, accuracy, and error increase/reduction over the year. In addition, training needs for staff will be discussed based on the supervisory, Internal Quality Assurance (IQA), and State level review findings and monitoring strategies will be developed to address areas of concern. ? Monthly review data is incorporated into all individual and leadership performance milestones. Milestones are the county?s employee performance management system. Continued errors or lack of progress and improvement will be addressed via the county Employee Relations coaching and disciplinary framework. ? Effective January 1, 2023, Jefferson County launched an updated model for service delivery and workload management utilizing an internal system, GenApp. The utilization of GenApp: o Improved document storage, o Increased oversight related to workload and timeliness as all pending actions can be viewed by type, date received and due date, o Simplified workload coverage due to employee leave or vacancies, o Removed inconsistencies in customer service, o Improved available reports. ? The Colorado Works Referral inbox has been prioritized by the CCAP Supervisor/Lead Worker for review and timely completion. ? Supplementary income training will be developed and delivered starting in October 2023 and continue on a quarterly basis to provide a review of income rules, calculation, common errors, and answer questions. CLIENT RESPONSIBLE PARTY: Tara Noble (Program Manager) and Monie Salgado (CCAP Supervisor) COMPLETION DATE: October 2023

AUDITOR FINDING: 2022-006 Eligibility. We noted the following issues in the 25 cases tested: 1. One instance in which JCHS could not provide copy of the participant's Colorado Works Individualized Plan (IP), however case comments indicated an IP was completed. 2. One instance in which the Initial Assessment was not completed timely. 3. One instance in which JCHS did not properly cure the sanction after the client began complying with Colorado Works eligibility requirements. 4. One instance in which case comments were missing to support action of JCHS eligibility technician. CLIENT PLANNED ACTION: Jefferson County agrees with the findings and has taken or plans to take the following steps to address the errors. The findings were caused by workers on both the eligibility and workforce teams so varying measures will be implemented based on the finding and responsible team. Jefferson County will continue and implement the following actions to address and prevent future findings. ? Eligibility Team Actions o Beginning in August 2023, new processes were implemented for Colorado Works, which will improve timeliness, customer service, and increase staff program knowledge: - Prioritizing Colorado Works applications for interview scheduling within 3 business days, - Restructuring teams to create an intake and ongoing team to better meet timeliness measures, - Offering Colorado Works training in the fall of 2023, - Completed hiring for all vacant positions. o Additional training will be provided by the end of October 2023 to include: - Continue to emphasize the importance of clearing the compliance screen in CBMS when processing new applications during new worker training, - Providing a training alert requiring that all staff who process Colorado Works cases check the compliance screen as part of the intake process, - Provide coaching to the eligibility worker who processed the case. o The sanction that was improperly advanced was reversed and appropriate case note entered on August 31, 2023. ? Workforce Development Team Actions o In addition to the State and Internal Quality Assurance reviews, Colorado Works Supervisors and/or Lead Workers will review cases as follows: - Complete a minimum of two case reviews per worker per month. The number and type of review may be adjusted based on individual staff performance. The Lead Worker will fulfill this function if the Supervisor is out of the office or as needed to the team. Areas of focus will include but are not limited to timely case comments, active Individual Plans, and CBMS data entry. o Updated standards implemented in July 2022 requiring documents be uploaded into the document storage system, GenApp, within 7 days. o Training delivered during new employee onboarding and starting in May 2023, offered on a quarterly basis for document uploading and best practices. o Finding related to missing case note was corrected on August 23, 2023. CLIENT RESPONSIBLE PARTY: CW Eligibility Team: Amy Brown (Program Manager), Stephanie Reese (Program Manager) and Jennifer Martinez (Quality Assurance & Systems Administrator) CW Workforce Development Team: Tara Noble (Program Manager), Kathryn Boyd-Cordova (CW Supervisor), and Erin Encinias (CW Supervisor) COMPLETION DATE: September 2023

Oversight Agency for Audit, Retired Steelworkers Housing and Health Development Corporation respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: January 1, 2022 through December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III ? FINDINGS AND QUESTIONED COSTS ? MAJOR FEDERAL AWARD PROGRAMS AND FINANCIAL STATMENT AUDITS FINDING No. 2022-001: Section 236 Mortgage Restructuring Note, CFDA 14.103 Recommendation: The Project should implement procedures to ensure the Project verifies tenant eligibility through the EIV system in a timely manner. Also, the Project should contact its local HUD office EIV coordinator for guidance on generating reports for tenant occupying the Project?s section 236 units. Action Taken: Managers have been trained that EIV income reports must be pulled timely and reviewed and action taken if needed. Alerts have been turned on in One Site to remind managers to pull EIV 90 day reports.

2022-002 Noncompliance;Activities Allowed/Unallowed; Allowable Costs/Activities; Eligibility A. Comments on Findings and Recommendations: We concur with the auditor?s suggestions regarding lack of controls and adequate supporting documentation over gift cards and attribute the deficiencies to an error in determination of gift cards and proper treatment, as a result of turnover in program management. B. Actions Taken or Planned: Current management continues to evaluate process and procedures to ensure accurate recording, tracking, reporting and monitoring of program expenses, in order to provide adequate documentation to support compliance with grant requirements . Changes have been initiated to improve processes and documentation over assistance payments, including gift cards. Anticipated completion date: In Process Contact information for this finding: Vicky Pritchett, Finance Director, 573-324-2231

Incorrect and Late Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Upon the current finding of incorrect enrollment reporting to NSLDS, the Western Seminary Financial Aid office will seek to make three changes to its operational practices; integrating NSLDS reporting into a master calendar, institute standard practices in pulling withdraw data and create a training emphasis around proper withdraw practices. Person Responsible for Corrective Action Plan: Matthew Jolley, Director of Financial Aid Anticipated Date of Completion: 06/2023

CORRECTIVE ACTION PLAN November 4, 2022 Health Resources and Services Administration Tri-County Community Health Council, Inc. (d/b/a CommWell Health) respectfully submits the following corrective action plan for the year ended March 31, 2022. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: March 31, 2022 The findings from the March 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS ? FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance listing number 93.224/93.527) Finding 2022-001 - Special Tests and Provisions SIGNIFICANT DEFICIENCY Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken CommWell Health concurs with the recommendation and has designed a series of enhancements to existing registration orientation and ongoing training. Additional training time will be dedicated with current front desk registration colleagues to ensure that they can determine household income from the documentation given to them by patients. This education will be completed by December 31, 2022. New hire orientation training will include a thorough review of the Front Desk Handbook and slide fee procedures. Post-test will be given to each front desk colleague upon completion of education. Scores of at least 90% will required or training and testing will be repeated. In addition, CommWell Health is moving to a new electronic health record (EHR), EPIC, beginning November 7, 2022. This system has much better controls built in to help ensure that slide fee is documented correctly. EPIC also does not have many of the system limitations our previous EHR had. Audits of 100% of slide fee records will be done every day by designated colleagues to ensure slide fee documentation is correct. Supervisors will review daily audit findings and ensure additional training is given accordingly. Corrective action will be taken on any errors noted during audits. Finance staff will conduct random internal audits of slide fee records each month to evaluate for compliance with applicable requirements. Results of internal audits will be reviewed monthly in Utilization Review Committee. If the Health Resources and Services Administration has questions regarding this plan, please call Cheryl Stanley, Chief Financial Officer, at 910-567-7008.

Condition: All AmeriCorps participants did not undergo the correct eligibility testing before starting the program. Response: Management identified accountability issues with the implementation of the AmeriCorps grant. The supervisor immediately responsibility for the recruiting, determining eligibility, retaining records, and supervision of the AmeriCorps members, was terminated for cause. Management self-reported issues of noncompliance with the AmeriCorps grant to Volunteer Louisiana as it began to correct the issues. Management has hired a new supervisor for the grant. Management has also initiated a new plan with multiple checks and balances to ensure that all new AmeriCorps members complete the required components of the process prior to beginning service with the program. Management will complete all of the required steps outlined by Volunteer Louisiana in compliance with the terms of the grant. Implementation Date: December 1, 2022 Contact: Jayne Wright-Velez, Executive Director

Dear Cognizant or Oversight Agency for Audit: The Women's Home respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Doeren Mayhew, 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, 2022, is numbered consistently with the number assigned in the schedule. Federal Award Finding 2022-001. Corrective Action Plan: The initial chart creation checklist will be modified to include the TDHCA-Housing Stability Services Program Intake Form; TDHCA-Housing Stability Services Program Intake Form will be added to the intake paperwork packets to be completed upon client entry into the program; New staff will be trained on completion of intake paperwork including TDHCA-Housing Stability Services Program Intake Form as part of their orientation process; Regular chart audits will be conducted to review all documents and re-certify as necessary; A copy of each completed TDHCA-Housing Stability Services Program Intake Form will be submitted monthly to the Grant Compliance Specialist to review prior to monthly report submission to the state; Grant Compliance Specialist will send the Program Managers a list of clients in need of re-certification monthly; Compliance team to meet with program team twice a year to provide updates on compliance requirements. Corrective Action Steps Taken: The program team has received training on completion of the TDHCA-Housing Stability Services Program Intake Form; The program team has completed an audit of all open charts and are in the process of certifying or re-certifying all open clients to ensure compliance. Contact Person Responsible for Corrective Action: Ms. Anna Coffey, Chief Executive Officer. Anticipated Completion Date: It is expected that all processes listed above will be implemented by May 31, 2023. Many processes are ongoing and will be conducted throughout the length of grant. Respectfully submitted, Ms. Anna Coffey, Chief Executive Officer

Finding 2022-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

District Response and Corrective Action Plan: The district will perform the sampling prior to November 15th to meet the reporting deadline.

PRPHA has a provider with vast experience in this program and is currently serving other government authorities in the mainland that are entitled with this program. We have assured that they are following the regulations that are set forth by the Treasury Department. However, because of the short period of time that we have had this program in Puerto Rico we have had to adapt the practices that have been adopted in the other agencies as the formal procedures as a start up implementation. We are establishing more procedures as the program evolves in the island. This is an on going action plan.

Reinforcement of the required documentation is being done frequently with the occupancy officers to request all the required documents in the kit provided to them as part of the procedures. The agency is providing continous training to the employees in order to streamline the processes, avoid missing documents and ensure rent calculations are accurate. New procedures were revised as of 2020 when PRPHA started as new Section 8 receiving agency and is in the process of updating the current documentation.

Reinforcement of the required documentation is being done frequently with the occupancy officers to request all the required documents in the kit provided to them as part of the procedures. The agency is providing continous training to the employees in order to streamline the processes, avoid missing documents and ensure rent calculations are accurate. New procedures were revised as of 2020 when PRPHA started as new Section 8 receiving agency and is in the process of updating the current documentation.

Finding: 2022-007 Untimely Review of SSI Termination Name of contact person: Virginia Ewuell, & Angel Joyner/Adult Medicaid Supervisors Corrective Action: Automatic verification will be made available to caseworkers on the computer. The caseworker will verify their manual calculations with the automated calculations. The automated verification will also check the calculated family?s income against the State-provided income standard. A printout of the verifications will accompany the caseworker?s records in the file to be reviewed by a supervisor. "Proposed Completion Date: Training and corrections will be completed by January15, 2023. Case record reviews are currently being conducted and will be ongoing. "

Finding: 2022-006 Inadequate Request for Information Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, and Angel Joyner/ Medicaid Supervisors Corrective Action: Files will be reviewed internally by the Medicaid Supervisors and Quality Control workers to ensure that the proper requests are made for information needed. Workers have been given an agency/State approved checklist that included everything that is needed for a case to be dispositioned. This checklist should eliminate the inadequate request for information. Case notes will be documented using an agency/State approved narrative template that will include everything that should be requested for a case. "Proposed Completion Date: Training and corrections will be completed by January15, 2023. Case record reviews are currently being conducted and will be ongoing. "

Finding: 2022-005 Inaccurate Resource Calculation Name of contact person: Veronica Lyons, Tina Radford, Virginia Ewuell, and Angel Joyner/ Medicaid Supervisors Corrective Action:Files will be reviewed internally by Medicaid Supervisors and Quality Control workers to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. The workers have also been provided an agency/State approved checklist that includes everything that should be included in a case. All files will include online verifications, documented resources of income and those amounts will match information in NCFAST. The workers have been provided an agency/State approved automated budget that will be completed and compared to the information in NCFAST. The results found or documentation made in case notes will clearly indicate what actions were performed and the results of those actions. Workers have been provided a agency/State approved documentation template to use for each case. "Proposed Completion Date: Training and corrections will be completed by January15, 2023. Case record reviews are currently being conducted and will be ongoing. "