Corrective Action Plans

Finding 1153983 (2023-016)

Material Weakness 2023

State of Illinois

IL

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

Finding Number: 2023-016 Finding Name: Improper TANF Beneficiary Payments Finding Condition(s): The Illinois Department of Human Services (IDHS) made improper payments to beneficiaries of the Temporary Assistance for Needy Families (TANF) program. In addition, the IDHS identified a system error in J...

Finding Number: 2023-016 Finding Name: Improper TANF Beneficiary Payments Finding Condition(s): The Illinois Department of Human Services (IDHS) made improper payments to beneficiaries of the Temporary Assistance for Needy Families (TANF) program. In addition, the IDHS identified a system error in June 2025 impacting beneficiaries whose benefit payments were calculated using diverted income. Name of Contact Person(s): Elizabth Lusk, Social Service Program Planner – Illinois Department of Human Services, Division of Family and Community Services Corrective Action(s): As of June 30, 2025, the IDHS’ Office of Policy and Program Integrity and the IDHS’ Office of Family Community Resource Centers discussed and formulated a plan to ensure payments are properly calculated and paid. Additionally, a training will be provided for caseworkers that pertains to reviewing the case summary for income errors or sanction errors, etc. Proposed Completion Date: June 30, 2026

View Audit 366965 Questioned Costs: $1

Finding 1153954 (2023-011)

Material Weakness 2023

State of Illinois

IL

Questioned Costs Eligibility Special Tests & Provisions § 200.303

Finding Number: 2023-011 Finding Name: Failure to Obtain Required Certifications for Child Care Providers Receiving American Rescue Plan Act Stabilization Funds Finding Condition(s): The Illinois Department of Human Services (IDHS) did not obtain the required certifications at the time of applicatio...

Finding Number: 2023-011 Finding Name: Failure to Obtain Required Certifications for Child Care Providers Receiving American Rescue Plan Act Stabilization Funds Finding Condition(s): The Illinois Department of Human Services (IDHS) did not obtain the required certifications at the time of application for certain providers of the Child Care Development Fund (CCDF) Cluster receiving American Rescue Plan Act (ARPA) stabilization funds. Name of Contact Person(s): Felicia Gray, Associate Director– Illinois Department of Human Services, Early Childhood Corrective Action(s): The IDHS’ Division of Early Childhood (DEC) has not received and does not anticipate receiving any new ARPA funding. For future consideration of funding, the IDHS will ensure that, in addition to meeting health and safety requirements, the providers will also complete certifications and attestations that verify that they meet the requirements and eligibility of the program. In addition, the DEC will train appropriate staff to review, identify, and implement any new Child Care grant/funding requirement(s). Proposed Completion Date: May 31, 2024 – Completed

View Audit 366965 Questioned Costs: $1

Finding 1153935 (2023-007)

Material Weakness 2023

State of Illinois

IL

Questioned Costs Matching / Level of Effort / Earmarking Eligibility § 200.303

Finding Number: 2023-007 Finding Name: Missing Documentation in Beneficiary Files Finding Condition(s): The Illinois Department of Human Services (IDHS) could not locate case file documentation supporting certain eligibility and special test requirements for beneficiaries of the Temporary Assistance...

Finding Number: 2023-007 Finding Name: Missing Documentation in Beneficiary Files Finding Condition(s): The Illinois Department of Human Services (IDHS) could not locate case file documentation supporting certain eligibility and special test requirements for beneficiaries of the Temporary Assistance for Needy Families (TANF) program. Furthermore, the IDHS does not have adequate resources to perform and document eligibility determinations and has not established appropriate monitoring procedures to ensure eligibility determinations are properly documented in accordance with program requirements. Name of Contact Person(s): Angela Imhoff, Acting Associate Director – Illinois Department of Human Services, Division of Family and Community Services Corrective Action(s): As of February 20, 2025, the IDHS’ Associate Director met with the regional administrators to discuss the ongoing importance of ensuring the Responsibility Service Plan (RSP) signatures are captured through the manual process. In addition, an enhancement request has been filed with a vendor that will allow telephonic signatures for the RSPs in the Integrated Eligibility System (IES). Additionally, as of February 20, 2025, the Associate Director discussed with the regional administrators the ongoing need to review the manual 1611 process throughout the regions. Finally, the IDHS will work toward automating the 1611 process in the IES in collaboration with an Illinois Department of Healthcare and Family Services child support system update. Proposed Completion Date: December 31, 2026

View Audit 366965 Questioned Costs: $1

Finding 576441 (2023-053)

Material Weakness 2023

State of Nevada

NV

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Finding 2023-053 Program Information Program Name: Children’s Health Insurance Program (CHIP) CFDA Number: 93.767 Summary of Finding Eligibility Material Weakness in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Plan DSS has enhanced internal...

Finding 2023-053 Program Information Program Name: Children’s Health Insurance Program (CHIP) CFDA Number: 93.767 Summary of Finding Eligibility Material Weakness in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Plan DSS has enhanced internal controls to ensure CHIP applications are accurately processed and properly documented. Procedures have been reinforced to require that all applications and supporting documentation are consistently reindexed to the correct case file when a pseudo-SSN is updated, that each application carries a clear date stamp, and that records are fully maintained in DIS. In addition, DSS relies on its Quality Control (QC) unit to conduct post-eligibility reviews, validate determinations, and identify corrective actions when necessary. Together, these measures ensure that applications are complete, accessible, and compliant with program requirements. Contact Person(s) Responsible Karen Stoycoff, Social Services Program Specialist Phone: 775-684-7436 Email: kstoycoff@dss.nv.gov Anticipated Completion Date September 30th, 2025.

View Audit 366218

Finding 576429 (2023-043)

Significant Deficiency 2023

State of Nevada

NV

Questioned Costs Eligibility Reporting

Finding 2023-043 Program Information Program Name: Low-Income Home Energy Assistance Covid-19 Low-Income Home Energy Assistance CFDA Number: 93.568 Summary of Finding Significant Deficiency in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Pla...

Finding 2023-043 Program Information Program Name: Low-Income Home Energy Assistance Covid-19 Low-Income Home Energy Assistance CFDA Number: 93.568 Summary of Finding Significant Deficiency in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Plan To address the issue of incorrect benefit calculations, DSS has reinforced internal controls requiring supervisory case reviews to verify the accuracy of income information and benefit amounts before case certification. EAP supervisory staff provide ongoing training to case management staff on reviewing documentation and applying program rules accurately. Cases identified with errors are corrected promptly, and trends from supervisory reviews are used to provide targeted staff training. These measures ensure benefit determinations are accurate and consistently applied. Contact Person(s) Responsible Maria Wortman-Meshberger, Social Services Chief III Phone: 775-684-0506 Email: mrwortman@dss.nv.gov Anticipated Completion Date Corrective action in place.

View Audit 366218 Questioned Costs: $1

Finding 576419 (2023-056)

Material Weakness 2023

State of Nevada

NV

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Finding 2023-056 Program Information Program Name: Children’s Health Insurance Program (CHIP), Medicaid Cluster: State Medicaid Fraud Control Units, State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, Medical Assistance Program (Medicaid; Title XIX) CFDA Num...

Finding 2023-056 Program Information Program Name: Children’s Health Insurance Program (CHIP), Medicaid Cluster: State Medicaid Fraud Control Units, State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, Medical Assistance Program (Medicaid; Title XIX) CFDA Number: 93.767/93.775/93.777/93.778 Summary of Finding Eligibility Material Weakness in Internal Control over Compliance Agency Response Agency agrees with the finding. Corrective Action Plan DSS has clarified its internal control framework to reflect that eligibility accuracy is verified through the Division’s Quality Control (QC) unit rather than a secondary supervisor review. The QC unit conducts ongoing post-eligibility case reviews to validate determinations, identify errors, and recommend corrective measures. To support this process, DSS has reinforced procedures requiring all applications and redeterminations to be properly filed, time-stamped, and maintained in DIS to ensure accessibility for QC review. These measures, combined with QC oversight, provide assurance that eligibility determinations are accurate, documented, and compliant with program requirements. Contact Person(s) Responsible Karen Stoycoff, Social Services Program Specialist Phone: 775-684-7436 Email: kstoycoff@dss.nv.gov Anticipated Completion Date September 30th, 2025.

View Audit 366218

Finding 576417 (2023-054)

Material Weakness 2023

State of Nevada

NV

Questioned Costs Reporting Eligibility

Finding 2023-054 Program Information Program Name: Children’s Health Insurance Program (CHIP), Medicaid Cluster: State Medicaid Fraud Control Units, State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, Medical Assistance Program (Medicaid; Title XIX) CFDA Num...

Finding 2023-054 Program Information Program Name: Children’s Health Insurance Program (CHIP), Medicaid Cluster: State Medicaid Fraud Control Units, State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, Medical Assistance Program (Medicaid; Title XIX) CFDA Number: 93.767/93.775/93.777/93.778 Summary of Finding Eligibility Material Weakness in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Plan DSS has reinforced internal controls to ensure applications are correctly indexed, date-stamped, and fully accessible in DIS with documented supervisory review. The Division has also implemented automation of the PARIS file to ensure quarterly residency verification is completed, with non-responding or out-of-state participants terminated. These controls are now in place and will be applied consistently going forward. Contact Person(s) Responsible Karen Stoycoff, Social Services Program Specialist Phone: 775-684-7436 Email: kstoycoff@dss.nv.gov Anticipated Completion Date September 30th, 2025.

View Audit 366218 Questioned Costs: $1

Finding 576417 (2023-054)

Material Weakness 2023

State of Nevada

NV

Questioned Costs Reporting Eligibility

Finding Number 2023-054 U.S. Department of Health and Human Services Children’s Health Insurance Program (CHIP), 93.767 Medicaid Cluster: State Medicaid Fraud Control Units, 93.775 State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, 93.777 Medical Assistance...

Finding Number 2023-054 U.S. Department of Health and Human Services Children’s Health Insurance Program (CHIP), 93.767 Medicaid Cluster: State Medicaid Fraud Control Units, 93.775 State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, 93.777 Medical Assistance Program (Medicaid; Title XIX), 93.778 Summary of Finding: PARIS data was not utilized by the Division of Health Care Financing and Policy (DHCFP) or the Division of Welfare and Suppor􀆟ve Services (DWSS) to monitor residency changes to determine when managed care benefits needed to be terminated because the beneficiary was a resident of another state for Medicaid purposes. DHCFP and DWSS did not have internal controls in place to effectively communicate the PARIS data between the two agencies to ensure managed care benefits were terminated when appropriate. Projected questioned costs are $11,108,851 for Medicaid and $139,223 for CHIP. We recommend DHCFP and DWSS implement internal controls to effectively communicate the PARIS data between each other and to ensure managed care benefits are terminated when appropriate. NVHA Response: The Nevada Health Authority agrees with this finding. Corrected Action Planned: The Division of Social Services (DSS) is in the process of automating the PARIS process. The automation is designed to streamline the quarterly PARIS process. Upon receipt of the file, the system generates initial requests for information to customers identified, requiring them to confirm Nevada residency. Customers are allowed 30 days to respond. Approximately five days after the initial request, reminder notices are issued by text message and email to customers who have not responded. Customers who fail to respond within the 30-day timeframe, or who confirm an out-ofstate address, will be terminated in accordance with policy, while those confirming Nevada residency will retain eligibility Anticipated Completion Date of Corrective Action Plan : September 2025

View Audit 366218 Questioned Costs: $1

Finding 576388 (2023-028)

Material Weakness 2023

State of Nevada

NV

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Audit Finding: 2023-028 Emergency Rental Assistance Program: 21.023 Special Tests and Provisions – ERA Funds Reallocation Material Weakness in Internal Control over Compliance and Material Noncompliance Summary: Supporting documentation for the application to receive reallocated funds was not mainta...

Audit Finding: 2023-028 Emergency Rental Assistance Program: 21.023 Special Tests and Provisions – ERA Funds Reallocation Material Weakness in Internal Control over Compliance and Material Noncompliance Summary: Supporting documentation for the application to receive reallocated funds was not maintained and there was not adequate segregation of duties in the preparation and review of the application. Recommendation: Enhance internal controls to ensure supporting documentation is maintained. Agency Response: The Nevada Housing Division (“Division”) does not agree with the finding. While the Division acknowledges the requirements outlined for audit in the Special Test, these do not align with the actual reallocation application which simply stated that the applicant must confirm a demonstrated need and submit monthly projections. The Division did provide these projections with its reallocation application along with households in the queue for emergency rental assistance and past monthly expenditures and households served in order to inform the projections. Corrective Action: In FY25, the Housing Division moved ERAP to the Grants Team for management, including the documentation of amounts being reported to the awarding agency. Additionally, the Division established an internal audit and compliance committee to enhance oversight of existing policies for assessing risk, monitoring, and sharing best practices across its business in January of 2024. The internal audit and compliance committee is responsible for reviewing internal controls and policies on an annual basis, following up on any audit findings and ensuring follow-through of corrective action plans. Finally, the Division received legislative approval for an Auditor 3 position that will commence in October 2025 to support fiscal and overall grant compliance. Adoption of Corrective Action: January 2024 Division Contact and Corrective Action Plan Lead: Christine Hess, Chief Financial Officer Nevada Housing Division 775-687-2249 chess@housing.nv.gov

View Audit 366218

Finding 576297 (2023-011)

Material Weakness 2023

Dakota County

MN

Eligibility Material Weakness Reporting § 200.303

U.S. Department of Health and Human Services Medical Assistance Program Assistance Listing Number: 93.778 Passed Through Minnesota Department of Human Services Pass Through Number: H55215048 Award Period: 2023 Recommendation: We recommend the County implement process and procedures to provide re...

U.S. Department of Health and Human Services Medical Assistance Program Assistance Listing Number: 93.778 Passed Through Minnesota Department of Human Services Pass Through Number: H55215048 Award Period: 2023 Recommendation: We recommend the County implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input or updated in MAXIS and issues are followed up in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will continue to train staff to ensure they are aware that review of casefiles needs to be documented by a signature for all applications, all information in casefiles needs to be accurately input into MAXIS for income and assets, and all applications should be processed in a timely and accurate manner. Name of the contact person responsible for corrective action: Tiffinie Miller, Deputy Director of Employment & Economic Assistance Planned completion date for corrective action plan: December 31, 2024

View Audit 366181

Finding 576290 (2023-006)

Material Weakness 2023

Dakota County

MN

Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.303

U.S. Department of Health and Human Services Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Passed Through Minnesota Department of Human Services Pass Through Number: H55214077 Award Period: 2023 Recommendation: We recommend the County implement process and procedures ...

U.S. Department of Health and Human Services Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Passed Through Minnesota Department of Human Services Pass Through Number: H55214077 Award Period: 2023 Recommendation: We recommend the County implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input or updated in MAXIS and issues are followed up in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will continue to train staff to ensure they are aware that review of casefiles needs to be documented by a signature for all applications, all information in casefiles needs to be accurately input into MAXIS for income and assets, and all applications should be processed in a timely and accurate manner. Name of the contact person responsible for corrective action: Tiffinie Miller, Deputy Director of Employment & Economic Assistance Planned completion date for corrective action plan: December 31, 2024

View Audit 366181

Finding 576289 (2023-008)

Material Weakness 2023

Dakota County

MN

Subrecipient Monitoring Eligibility Material Weakness § 200.303 § 200.331

U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Direct Payment Award Period: 2023 Recommendation: We recommend that the County establish clear policies and procedures for formal review and approval of subrecipient monitoring checklis...

U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Direct Payment Award Period: 2023 Recommendation: We recommend that the County establish clear policies and procedures for formal review and approval of subrecipient monitoring checklists. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County already had established policies, procedures, and checklists related to subrecipient monitoring, but the selected subrecipient relationship did not have adequate, formal documentation that monitoring checklists were completed. Going forward the County will continue to train staff to follow these policies. The County has also put more resources towards its finance department’s audit unit in 2024 and 2025 to follow-up on the proper implementation of corrective action plans related to audit findings. Name of the contact person responsible for corrective action: Will Wallo, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 366181

Finding 576276 (2023-007)

Material Weakness 2023

Dakota County

MN

Eligibility Material Weakness Reporting § 200.303

U.S. Department of Agriculture Supplemental Nutrition Assistance Program Cluster Assistance Listing Number: 10.561 Passed Through Minnesota Department of Human Services Pass Through Number: H55210010 Award Period: 2023 Recommendation: We recommend the County implement process and procedures to pr...

U.S. Department of Agriculture Supplemental Nutrition Assistance Program Cluster Assistance Listing Number: 10.561 Passed Through Minnesota Department of Human Services Pass Through Number: H55210010 Award Period: 2023 Recommendation: We recommend the County implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input or updated in MAXIS and issues are followed up in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will continue to train staff to ensure they are aware that review of casefiles needs to be documented by a signature for all applications, all information in casefiles needs to be accurately input into MAXIS for income and assets, and all applications should be processed in a timely and accurate manner. Name of the contact person responsible for corrective action: Tiffinie Miller, Deputy Director of Employment & Economic Assistance Planned completion date for corrective action plan: December 31, 2024

View Audit 366181

Finding 575372 (2023-008)

None 2023

Renville County

MN

Eligibility Internal Control / Segregation of Duties § 200.303

Medical Assitance Eligiblity 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The County acknowledges the finding and has implemented procedures to ensure AGI is calculated correctly. 3. Official Responsib...

Medical Assitance Eligiblity 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The County acknowledges the finding and has implemented procedures to ensure AGI is calculated correctly. 3. Official Responsible for Ensuring CAP: Lisa Herges, County Administrator, if the official responsible for ensuring corrective action of the compliance finding. 4. Planned Completion Date for CAP: December 31, 2025 5. Plan to Monitor Completion of CAP: The County Board will be monitoring this corrective action plan. Sincerely, Lisa Herges County Administrator

View Audit 365408

Finding 575276 (2023-005)

Significant Deficiency 2023

Standing Rock Sioux Tribe

ND

Eligibility Internal Control / Segregation of Duties § 200.303

Corrective Action Plan: ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future. Person(s) Responsible: Alv...

Corrective Action Plan: ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future. Person(s) Responsible: Alvonne Penola, Treatment Program Director Estimated Completion Date: Effective immediately

View Audit 365312

Finding 575273 (2023-004)

Material Weakness 2023

Standing Rock Sioux Tribe

ND

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Corrective Action Plan: ALN 93.575 and 93.596 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 and 93.596 (Provider files): In July 2025, the Program hired a Compliance ...

Corrective Action Plan: ALN 93.575 and 93.596 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 and 93.596 (Provider files): In July 2025, the Program hired a Compliance Specialist to review provider files for compliance. In addition, the Program hired an employee to assist with the demanding workload. ALN 93.568 (participant files): the identified items of non-compliance was a direct result of program personnel turnover, including the Director. The Director position was vacant for the entire fiscal year. The Program is now fully staffed and working on ensuring that all intake items are clearly documented/retained in the participant files. Person(s) Responsible: Jackie Brownotter, Child Care Assistance Program Director, Deanne Bear Catches, LIHEAP Director Estimated Completion Date: ALN 93.575 and 93.596 (CPR Certifications): October 2024, ALN 93.575 and93.596 (Provider files): Effective immediately ALN 93.568 (participant files): effectively immediately

View Audit 365312

Finding 573743 (2023-016)

Significant Deficiency 2023

Caswell County

NC

Allowable Costs / Cost Principles Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-016 Inaccurate Resource Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervis...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-016 Inaccurate Resource Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. Transfer of Asset policy and procedures will be reviewed with applicable caseworkers. TOA evaluation and clear documentation of Transfers and Resolutions must be documented. Help Desk tickets should be submitted timely if information or functionality is not working properly. 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. May 1, 2024 Section III - Federal Award Findings and Question Costs (continued) 141

View Audit 364406

Finding 573742 (2023-015)

Significant Deficiency 2023

Caswell County

NC

Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-015 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-015 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Section III - Federal Award Findings and Question Costs (continued) April 11, 2024 Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. CW must address all Household income and have clear documentation of request or findings. Training targeted to address error trend of Documentation of Vehicles and Rebuttals. Training targeted to address error trend of evaluation of 1/3 reduction. Information requested from OST to properly enter 1/3 reduction in NCFAST obtained. Training targeted for applicable staff to address Transfer of Asset requirements and how to address and clearly document transfers. Help Desk tickets should be submitted timely if information or functionality is not working properly. 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. 140

View Audit 364406

Finding 573741 (2023-014)

Significant Deficiency 2023

Caswell County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-014 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Super...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-014 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Section III - Federal Award Findings and Question Costs (continued) 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 accurate household members, online verifications, documented sources and verifications 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. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. 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. May 1, 2024 139

View Audit 364406

Finding 573740 (2023-013)

Significant Deficiency 2023

Caswell County

NC

Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-012 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: December 2025 Finding: 20...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-012 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: December 2025 Finding: 2023-013 IV-D Non-Cooperation Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor At the time the determinations under audit were completed this was a requirement. However, under current policy referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). Please see Administrative Letter 13/23 Due to CCU referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). 5/1/2024 Caseworkers will adhere to Continuous Coverage Unwinding (CCU) Period Policy. As noted in the response to Findings 2023-001 and 2023-006, County finance staff is diligently working to improve the timeliness of transaction processing and anticipates timely completion of the FY25 audit which will resolve this finding. Melissa Miller, Interim Finance Officer Section III - Federal Award Findings and Question Costs 138

View Audit 364406

Finding 573739 (2023-002)

Significant Deficiency 2023

Housing Authority of the City of Pueblo

CO

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2023-002 U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: For 5 participant files, the recertification / move-in checklists were not signed by Authority staff. Res...

Finding 2023-002 U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: For 5 participant files, the recertification / move-in checklists were not signed by Authority staff. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: In addition to accounting, we also had newer staff members in the compliance department after a leadership transition with the department manager. We have conducted thorough training and discussions to help identify solutions moving forward. We will establish internal controls to ensure that all recertification/move-in checklists are signed by Authority Staff. We will work with the department manager to ensure that the control processes are being followed. Anticipated Completion Date: January 2024

View Audit 364403

Finding 573738 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of Pueblo

CO

Allowable Costs / Cost Principles HUD Housing Programs Special Tests & Provisions

U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Nonco...

U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The Authority was not able to locate 1 of the 61 participant files selected for audit testing. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: During 2023, the Housing Choice Voucher Department moved physical locations from the 10th Floor of 1414 Santa Fe to 201 S Victoria. Also, during this time, all of the historical paper files were being scanned for digital storage. During this time, paperwork for one of the participants re-certification and inspection were misplaced and not able to be located during audit fieldwork. We do not anticipate this issue in the future since there will not be another office move, and all recertification paperwork moving forward is being scanned and attached in our software Anticipate Completion Date: January 2024

View Audit 364403

Finding 572978 (2023-001)

Significant Deficiency 2023

Park Shore East Cooperative

IL

Questioned Costs Internal Control / Segregation of Duties Eligibility

Finding No. 2023-01: Tenant income is to be reconciled to reports run by the Enterprise Income Verification system (EIV) Recommendation: Management should use the EIV system properly to verify tenant employment and income during recertifications and calculate subsidy payments correctly. Action Taken...

Finding No. 2023-01: Tenant income is to be reconciled to reports run by the Enterprise Income Verification system (EIV) Recommendation: Management should use the EIV system properly to verify tenant employment and income during recertifications and calculate subsidy payments correctly. Action Taken or Planned: Management is conducting proper reconciliation between EIV system and tenant declared income at recertification. Responsible Person: Monique Brown, Manager Completion Date: May 31, 2023

View Audit 363827 Questioned Costs: $1

Finding 572566 (2023-005)

Significant Deficiency 2023

Cherokee Boys Club, Inc.

NC

Eligibility

Finding 2023-005: Significant Deficiency - Eligibility Condition: The Club was unable to locate the initial program application documentation for one individual selected for testing. Corrective Action: The Club agrees with this finding and will establish a process for storing all past and present ...

Finding 2023-005: Significant Deficiency - Eligibility Condition: The Club was unable to locate the initial program application documentation for one individual selected for testing. Corrective Action: The Club agrees with this finding and will establish a process for storing all past and present student and staff files in a secure location to maintain all necessary applications and other documents related to enrollment and eligibility. Person Responsible For Corrective Action: Leslie McEntire, Childcare Manager Anticipated Completion Date: June 30, 2025

View Audit 363709

Finding 572326 (2023-059)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Special Tests & Provisions Eligibility Material Weakness

VIEWS OF RESPONSIBLE OFFICIALS ADSEF developed a collaborative agreement with ASUME to ensure the digital processing of referrals containing information about the absent parent. IMPLEMENTATION DATE August 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by i...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF developed a collaborative agreement with ASUME to ensure the digital processing of referrals containing information about the absent parent. IMPLEMENTATION DATE August 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Corrective Action Plans

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