Corrective Action Plans

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Finding: 2021-011 Inaccurate Resource Calculation Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2021-012 Inadequate Request for Information Name of contact person: Corrective Action: Heather Starr Thomas, Medicaid Supervisor Files will be reviewed internally 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. All files will 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. Templates have been put in place to address request for information. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) 2/28/2022 Heather Starr Thomas, Medicaid Supervisor Files will 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. All files must 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. Resources have been readdressed at Unit Meeting. Templates have been put in place to address programs in which resources are countable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 128

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Proposed Completion Date: Finding: 2021-010 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: 2/28/2022 All workers have knowledge that Templates put in place are Mandatory. IV-D Referrals are addressed on template. All cases will be reviewed for IV-D Referrals or open/active I-VD cases. All children must have a referral if the parent is receiving Medical Benefits. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally 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. All files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The template that has been put in place for applications and recertification address all computer checks and documentation that is needed to accurately approve/deny/continue or terminate benefits. All other cases in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes are reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket or an 8020 to remove benefits client may not have been eligible for. OST has provided guidance on Changes in policy to remove a client that may continue during Covid that is not eligible for NC Medicaid. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 2/28/2022 127

Finding: 2021-009 IV-D Non-Cooperation Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs Referrals are being keyed to Child Support Enforcement Agency (IV-D) each case with dependent children must cooperate with IV-D unless there is good cause. County will review cases for a referral keyed or to ensure a new child support referral is keyed. On 11/15/2021 eligibility workers refreshed on IV-D policy and reviewed the job aid in NCFAST help for IVD referrals. Second Party reviews are reviewed internally to ensure proper information is in place and necessary procedures are followed after eligibility is determined and documented in case notes. Documentation will clearly state what actions were performed and the outcome of those actions. The County has developed a mandatory verification check list enforced 11/15/2021 to ensure all criteria has been meet according to policy of the state. Since template has been in place we have noticed a significant drop in IV-D referral issues in Second Party Reviews.CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694‐4193 Corrective Action Plan For the Year Ended June 30, 2021 Proposed Completion Date: Finding: 2021-010 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: 2/28/2022 All workers have knowledge that Templates put in place are Mandatory. IV-D Referrals are addressed on template. All cases will be reviewed for IV-D Referrals or open/active I-VD cases. All children must have a referral if the parent is receiving Medical Benefits. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally 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. All files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. The template that has been put in place for applications and recertification address all computer checks and documentation that is needed to accurately approve/deny/continue or terminate benefits. All other cases in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes are reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket or an 8020 to remove benefits client may not have been eligible for. OST has provided guidance on Changes in policy to remove a client that may continue during Covid that is not eligible for NC Medicaid. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 2/28/2022 127

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-03 (Single audit submission) Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Anticipated completion date: June 30, 2025

Audit Finding Reference: Federal Award Findings and Questioned Costs: 2021-02 (Reporting) Planned Corrective Action: The Kanawha Valley Collective, Inc. will implement enhanced reconciliation and documentation procedures that timely identify and allow for the correction of differences between the accounting recordkeeping and the grant reporting documentation. Name of Contact Person: Traci Strickland

Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately document and produce grant-specific totals for audit year 2021 program income. CUAHSI staff missed the NSF filing deadline for declaring federal fiscal year 2021 program income by one day (submitted November 16th, 2021). Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time beginning in 2023 and appropriate staff and policies are in place to ensure future compliance. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

ASEE is working with the Program directors to ensure that proper and sufficient documentation is stored and retained for all federal awards. In addition, the organization is providing the proper tools to assist the Program Directors store and retain all documents safely for a long time.

Assistance Listing Number 21.019 Noncompliance Over Major Federal Program Coronavirus Relief Fund Activities Allowed or Unallowed and Allowable Costs/Cost Principles Chairman Board of County Commissioners: Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended within the allowable period of performance. It should be noted that OMES did not review any of the submitted information to determine eligibility prior to sending reimbursements for items that have now been determined questionable. County Clerk: Documentation was scanned into the Purchase Order's images and once the Purchase Order was paid, the images were then deleted by the Board of County Commissioners secretary. Images were later recovered by the software system and since the incident, restrictions have been implemented to no longer allow deletions.

Recommendation: NCPE should have internal controls in place for the retention of federal program records. NCPE should also have procedures in place to allow for the review of an individual’s eligibility to receive a federal award. Response: NCPE’s Executive Committee hired a new manager in 2017 to create, track, and retain important records to comply with the terms and conditions of federal agreements. In addition to the application form completed by all interns, an award letter was introduced in 2019. The Award Letter is sent by the National Park Service (NPS) site supervisor to the successful candidate, with NCPE copied, to confirm their appointment and provide essential details about the internship like duration, rate of pay, location, paid time off, etc. This letter with the completed application form documents an intern's eligibility to participate in the program for a specific duration and rate of pay. For the current audit, applications or resumes were missing for 1 of the interns sampled and an award letter was missing for 1 intern. It was this lack of documentation that resulted in the questioned costs. Requiring a completed application has been a standard practice for several years but this wasn’t always the case when students applied directly to a site supervisor and not through the online application at PreserveNet (NCPE’s website for preservationists and preservation resources). Site supervisors are now regularly reminded about the program’s eligibility requirement, however, and management is confident that these interns, and all future interns, met the criteria for participation in the program. Nevertheless, in the future efforts will be intensified to improve record keeping. If NPS has any questions concerning these responses, please contact me or NCPE’s Treasurer, Doug Appler.

The Board of Commissioners has recently hired an Executive Director (ED) who will actively oversee all financial aspects of the agency. Additionally, it is the intent of the ED to hire a CPA as fee accountant, as soon as financially feasible, to keep finances current and accurate monthly. With the added assistance of the existing bookkeeper, all financial systems should be operable and accurate going forward. Planned Implementation Date of Corrective Action: December 31, 2024 Person Responsible for Corrective Action: Pat Croslan, Executive Director

2021-008- Special Tests and Provisions - Material Weakness Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: Management will establish procedures to ensure that tenant eligibility is correctly determined and that all the tenant lease files are properly maintained in accordance with the requirements of HUD handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs.

2021-004 Program concurs and working with MOF management to correct the finding On-going Glendalynn Ngirmeriil Executive Director Palau WIOA Office Contact: 680-488-2513 Email: gngirmeriil.wioa@gmail.com

FINDING 2021-003 – Material Weakness and Material Noncompliance – Eligibility Views of responsible officials and planned corrective actions: Management agrees with the finding and will implement a regular training program to review grant requirements and uniform guidance. Management will also implement the following policies: •Related party transaction involving staff, or an immediate relative of a staff member will require a majority approval of the board •Implementing an eligibility questionnaire/form that will be required for any assistance payouts. •Review grant requirements and uniform guidance with staff and implement a annual training/review program Timeline: Updated policies and reviews have been completed. Responsible parties: Linda Lauch

Finding: 2021-002 Personnel Responsible for Corrective Action: Rachel Webb, Controller at Urban Strategies, Inc. Anticipated Completion Date: June 30, 2023 Corrective Action Plan: Urban Strategies, Inc. acknowledges the lack of record retention after an employee left the organization. After a thorough review of allowable costs, all were deemed materially correct. Urban Strategies, Inc. communicated to the departments involved the necessary improvements to the internal controls that were agreed upon in order to prevent the deficiencies from occurring in the future. Urban Strategies, Inc. is refining procedures to ensure all reviews and communications are performed, reviewed and documented timely and accurately, as well as ensuring all review documentation is properly retained.

Finding: 2021-001 Personnel Responsible for Corrective Action: Rachel Webb, Controller at Urban Strategies, Inc. Anticipated Completion Date: June 30, 2023 Corrective Action Plan: Urban Strategies, Inc. acknowledges the lack of record retention after an employee left the organization. After a thorough review of allowable costs, all were deemed materially correct. Urban Strategies, Inc. communicated to the departments involved the necessary improvements to the internal controls that were agreed upon in order to prevent the deficiencies from occurring in the future. Urban Strategies, Inc. is refining procedures to ensure all reviews and communications are performed, reviewed and documented timely and accurately, as well as ensuring all review documentation is properly retained.

Corrective Action Planned: SSVF Policies and Procedure Guide will be updated at the agency CARF retreat to reflect the process of transactions related to SSVF and updated retention polices and documentation requirements. Contact Person: Cassandra Montgomery, Executive Director Anticipated Completion Date: All staff training was held on Wednesday, May 3, 2023 @11:00AM.

The County engaged an outside consultant to assist with compliance and reporting of the CSLFRF grant. Moving forward, management will ensure that a County employee, if working with a consultant or otherwise, be responsible for verifying compliance with all aspects of all federal grants.

Eligibility: The college noted the finding, and the program is working to gather all required documents from current and previous Upward Bound students. The program will use the college’s electronic filing system and the standards described in the Upward Bound grant application moving forward. September 30, 2022 Stevenson Kotton VPBAA Pam Kaios UB Director

2021-001 Condition: Deficiencies Noted in Maintenance of Tenant Files Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Mr. Damon Dunbar, Executive Director Timeframe: As of December 31, 2022

Finding No.: 2021-041 AL Program: 97.050 - Presidential Declared Disaster Assistance to Individuals and Households – Other Needs Area: Eligibility Questioned Costs: $2,430 Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: CNMI DOL agrees with this finding. The three remaining applicants noted above were indeed paid then later found to be ineligible for benefits. Currently, they are pending to undergo audit and potentially recollection should fault not reside with CNMI DOL. However, it is important to note that the amount of questioned costs indicated by the auditors in both Draft 2 of the Audit Report does not reflect the updated amount of $2,430. Proposed Completion Date: Ongoing

Finding No.: 2021-034 AL Program: 93.489/93.575/93.596 - CCDF Cluster Area: Eligibility Questioned Costs: $39,200 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: CCDF disagrees with this finding. Please refer to the documents submitted. Case ID 3170B: CW1-upon submission of the CCDF Waitlist application the CW1 was valid. Case ID 3242B: CW1-upon submission of the CCDF Waitlist application the CW1 was valid. Case ID 3097A: CW1-upon submission of the CCDF Waitlist application the CW1 was valid. Condition 2: CCDF agrees with this finding. This is correct that there were no dates indicated on the affidavits. The cases questioned happened during Covid-19 which applicants are sending their applications through email. (Please see documents submitted). As a policy, CCDF is already in practice of ensuring date is stated with the signature of the affiant and such affidavit is notarized. Condition 3: CCDF disagrees with this finding. 1040 tax forms are not required for the CCDF Renewal application, and it is only required for self-employed applicants. Please see the application checklist on the questioned cases. Condition 4: CCDF disagrees with this finding. At the time of the submission of the renewal application, the applicant had a valid CW1. The application was submitted on June 15, 2020, the CW1 that was submitted did not expire until September 9, 2020. All documents for verification are on file. Applicant was off island for medical purposes at the time of Certificate of Confirmation (renewal certificate) routing, upon her return she submitted a copy of her passport that indicated that she became a CW2 holder, CCDF then proceeded with termination because of her CW2 status. (Please refer to the documents submitted). Proposed Completion Date: Ongoing

Finding No.: 2021-029 AL Program: 21.023 - Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $4,252 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: The Office of Grants Management agrees with this finding. We were unable to locate these two folders due to the high volume of application files, moving between offices, and staff turnover experienced during the period of performance; however, we do have copies of the invoices, check payments, and lease agreements for these two cases. The CCERA Program does not exist anymore, it closed in December 2023 and all the documents were not fully digitized, making the retention of records partly difficult. OGM has learned that it would be more prudent to have a database software that could hold vital information for any large social assistance program. It is my understanding that the CCERA staff did verify that these clients are eligible to receive federal assistance and it was checked by their program officers and coordinators. Although, these particular files had case workers assigned to them, multiple staff had access to these folders as well. Proposed Completion Date: Ongoing

Finding No.: 2021-024 AL Program: 17.225 - Unemployment Insurance Area: Eligibility Questioned Costs: $1,131,117 Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: Condition 1: CNMI DOL agrees with audit findings for Condition 1 for all three Application IDs indicated, as upon further review, Social Security Cards were not on file for claims identified. However, per the Benefits Rights Information (BRI) Handbook, and PL 116-136 CARES Act, claimants were only required to provide their full social security number. For each claim, the full SSN of claimant is provided and self-certified, on both the Initial Application and in each Weekly Certification. Condition 2: CNMI DOL agrees with this finding. Notably, this issue was identified and addressed through Fiscal Year 2020’s Single Audit. OPC 590093 was initiated on July 31, 2020 to send a Letter of Determination via the HireMarianas Portal’s internal messaging system. Moreover, the OPC also requested for all future payments that a Letter of Determination be issued once a payment is generated per user. Condition 3: CNMI DOL agrees with this finding, with respect to the SAVE Verification being necessary. However, upon further examination: Application ID 398353: The applicant has a SAVE verification response uploaded to their HireMarianas Portal dated 05/23/2022. Moreover, upon a further review of the USCIS-SAVE Database, the other Application IDs identified did not have a SAVE Verification initiated upon initial clearance. CNMI DOL has initiated a SAVE Verification for the remaining 3 users. The results are as follows: Application ID 158179: This applicant is a Green Card holder and the SAVE response was returned immediately. A copy of the SAVE verification response for this user was uploaded to the applicant’s HireMarianas Portal on June 24, 2024. A Green Card holder meets the definition of a qualified alien. Application ID 111798: This applicant is a CW-1 VISA holder. A SAVE verification was initiated on June 24, 2024 with the WAC Number indicated on the I-797A (Notice of Action) Form for the relevant period in time. A response was returned on July 5, 2024 stating that the applicant is employment authorized. Application ID 399118: This applicant is a CW-1 VISA holder. A SAVE verification was initiated on June 24, 2024 with the WAC Number indicated on the I-797A (Notice of Action) Form for the relevant period in time. A response was returned on July 5, 2024 stating that the applicant is employment authorized. While CNMI DOL agrees with the fact that SAVE Verification was necessary prior to payment disbursement, it is important to note that all the indicated applicants were indeed qualified aliens per the PUA Program Guidelines   This issue was identified and addressed through Fiscal Year 2020’s Single Audit. OPC 590093 was initiated on July 31, 2020 to send a Letter of Determination via the HireMarianas Portal’s internal messaging system. Moreover, the OPC also requested for all future payments that a Letter of Determination be issued once a payment is generated per user. Condition 4: CNMI DOL agrees with this finding. Upon additional review of the current overpayment log, the Department was able to recollect a total of $19,354.17 from the applicants that were noted in the initial listing provided to the auditors. This leaves the updated remaining overpayment balance for FY 2021 at $1,128,975.35. Auditors were provided with the documentation to substantiate this on 06/24/2024. Recollection efforts are Ongoing. Proposed Completion Date: Ongoing

Finding No.: 2021-016 AL Program: 10.551/10.561 – SNAP Cluster Area: Special Tests and Provisions – ADP System for SNAP Questioned Costs: $1,421 Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: Condition 1: The CNMI-NAP disagrees with this finding. NAP staff has to guide the auditors during the time the audit is being performed to understand the history and process of files being audited. Case ID#B100092775 Variance of $69.00 caused by change in income guideline and benefit Level Effective October 1st 2020 Income level is 781.00 benefit for Saipan is $221. Corrective action taken by Eligibility worker processed income for household of 1 as SSI which gave household $41.00 benefit. Income should be counted as SSA which at the time the adjustment was made and increased the benefit amount for the household. Case ID#B100094249 Variance of $180.00 a change in income and benefit level. Household income was $108.00 which changed to $120.00 for a household of 4. Adjustment was made to reflect changes including benefit level. From $708.00 to $1,231.00. Case ID #B100095019 Variance of $69.00 Benefit level was $212.00, and household had $20.00 contribution as unearned income. Benefit issued was 295.00 new benefit level effective October 1st, 2021 adjusted benefit issuance at $364.00 (maximum benefit for household of one for zero income is $369.00). Case ID#B100095077 Variance of $180.00. Benefit for household of 3 was issued for 2020 benefit and income level. November Benefit effectuated new income and benefit level. Issued benefit is based by household and income of head of household. Case ID#B100094664 Variance of $69.00. Household is zero income maximum benefit level issued was $300.00 reflecting 2020 benefit level. On October 1st, 2021 eligibility system automatically adjust benefit to $369.00 as per new benefit level. Case ID#B10109695 variance of $126.00 household of 2 maximum benefit was $389.00 with ineligible household members earning SS benefits totaling at $167.00 (prorated income) benefit issued was $651.00. Increase in benefit and income level was automatically adjusted by the eligibility system. Case ID#B100093732 Variance of 272.00 household of 5 maximum Benefit level for zero income Household is $1,462.00 deduction of 25 percent for over issuance ($272.00) increase of benefit level automatically adjusted by Eligibility system and still taking offset of 25% for over issued benefits. Over issuance claim is already paid off. Condition 2: The CNMI-NAP disagrees with this finding. NAP staff has to guide the auditors during the time the audit is being performed to understand the history and process of files being audited. Case ID#B100081068 Questioned cost of $162.00. Head of household declared zero income. Benefit amount under issued in the amount of $229.00 by eligibility system for maximum level of benefits should be $1,231.00. Unable to do corrective action due to beyond 2 months from time the discrepancy was found: Corrective action for eligibility system to implement a system audit that will prevent future glitches that would create a loss for both the household and NAP program budget. Condition 3: The CNMI-NAP disagrees with this finding. NAP staff has to guide the auditors during the time the audit is being performed to understand the history and process of files being audited. Case ID#B100082118 questioned cost is $162.00 Questioned cost of $294.00. household had income from ineligible parents which is prorated towards the two eligible household members. Total prorated unearned income is $843.46 which was counted towards the household’s benefits. Then household became zero income due to Furlough from COVID-19 pandemic. We disagree with the findings. When the auditor reviewed the case files, there was a misunderstanding of changes in household composition and income which is also affected by the increase in income guidelines and benefit levels between the certification period. This created the variances that the auditor noted in the findings. *CNMI NAP recommends having NAP staff guide the auditor during time the audit is being performed to understand history and process of files being audited. CNMI-NAP recently hired a Certification Unit Supervisor who had been on board for close to three months. He had been actively working closely with the EWs and especially the Management Evaluation Unit (MEU) who oversees the program reviews and quality control. Mini Trainings and assessments of the Certification Unit are in the works. One training was done sometimes in April by the MEU to ensure compliance is met. More trainings and workshops are in being planned between the Certification Unit and Management Evaluation Unit for a better process and procedures Proposed Completion Date: Ongoing