Corrective Action Plans

Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the college update procedures around disbursements of credit balances and implement controls to ensure credit balances are being returned timely. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The College is in the process of developing a new procedure which will be implemented in January 2025. Name of the contact person responsible for corrective action: Jonathan Jett,Director of Financial Aid Planned completion date for corrective action plan: January 2025

Finding 2024-001 Finding Title: Student Financial Assistance Cluster Name of Contact Person: Traci Boeve, Director of Financial Aid Corrective Action: The Assistant Registrar and the Office of Financial Aid will continue to be included in the receipt of the graduation file. The Assistant Registrar will confirm in NSC (National Student Clearinghouse) the file was uploaded with no errors for campus level and program level reporting. The Office of Financial Aid will add to its current procedure by requesting an additional report from NSLDS to show graduates and withdrawal information reported at the program level. Anticipated Date of Completion: In place for 2024-2025 school year

2024-003 – Student Financial Assistance Cluster – (a) Federal Supplemental Educational Opportunity Grants (b) Federal Work-Study Program (c) Federal Perkins Loan (d) Federal Pell Grant Program (e) Federal Direct Student Loans (f) Teacher Education Assistance for College and Higher Education Grants (TEACH Grants) (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 (f) 84.379 – Year Ended June 30, 2024 Criteria: 34 CFR 685.203 states, "A first (second) (third) year student can receive up to $3,500 ($4,500) ($5,500) in subsidized loans in one academic year (34 CFR 685.203).” Condition: We tested 40 files, 37 of which were Federal Direct Loan recipients, and 1 student did not receive the full amount of her Federal Direct Subsidized Loans. Questioned Costs: $1,375 Cause and Effect: The result is a student received unsubsidized loans prior to receiving full subsidized loans. Recommendation: We recommend the College evaluate policies and procedures to ensure students receive the proper amount of Title IV aid. Views of Responsible Officials: Management agrees with this Single Audit Finding. All members of the Financial Aid Office staff will complete the loan learning track on the FSA training site. There will also be a refresher on steps to take prior to awarding a student to ensure the right credit hours are being used for Direct Loan recipients.

The College has established a policy of governing the Return of Title IV funds for its students in prison. The policy better defines withdrawals for this unique student population, and institutes regular meetings at critical dates throughout the semester between the Director of the Moreau College prison initiative, the Registrar, Finance, the Office of Financial Aid, and the Vice President for Enrollment and Student Engagement to ensure student withdrawals from both the prison program as well as the residential campus are known and recorded, and the Return of Title IV funds process can be completed within the required timeframe. Additionally, the College continues to invest in its Office of Financial Aid through hiring of additional support and enrolling its senior administrators in the NASFAA Certified Financial Aid Administrator Program.

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will ensure that the FEMA reimbursement requests have clear evidence of the individuals preparing and reviewing of the submission. Documentation will be maintained to evidence preparation and review process.

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that expenditures being charged to the program are specifically identified in the grant contract.

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance periods. Review of cost activity will occur in fiscal year 2025 to ensure policy is followed.

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has drafted the policy titled, Alameda Health System Reports Policies – SUD Program, to ensure earmarking requirements of the program and proper documentation is retained to evidence fulfilled requirements. The policy will be finalized in fiscal year 2025.

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System finalized the standard work procedures titled, Internal Controls for Proper Verification, which include procedures to ensure reported timesheet hours agree to hours on the time study and costs incurred are appropriately charged based on the contracts’ performance periods. Staff is implementing policy in fiscal year 2025.

FINDING 2024-003 Subject: COVID-19 - Education Stabilization Fund - Reporting Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation had not designed nor implemented a system of internal control to ensure that the annual Elementary and Secondary School Emergency Relief (ESSER) annual Data Collection reports (Reports) were complete and accurately submitted. The reports were prepared and submitted in JotForm, the online application used by the Indiana Department of Education to collect information, without an oversight or secondary review process in 2 place to prevent, or detect and correct, errors. During tie out of the Year 3 report, a variance between the underlying records and reported expenditures of $187,649 was noted due to the lack of effective controls surrounding annual data reporting. 84.425U expenditures submitted within the Year 3 report were overstated by $187,649. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will implement a formal review process over data reporting to ensure compliance with reporting requirements for federal awards. A Grant Coordinator has been hired and is already in place. Both the Grant Coordinator and Treasurer will review and sign off of required reporting and ensure it is completed in a timely manner. Responsible Party and Timeline for Completion: Andrew Grismore - Grant Coordinator and Moriah Crane - Treasurer will be responsible. These corrective measures are already in place.

FINDING 2024-002 Subject: COVID-19 - Education Stabilization Fund - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Education Stabilization Fund and Activities Allowed or Unallowed. FINDING 2024-002 (Continued) Context: During the testing of payroll disbursements charged to the Education Stabilization Fund grant awards during the audit period, the following exceptions were noted: • For 16 payroll disbursements, in a sample of 40, management was unable to provide an approved employee contract or hourly rate ordinance to support the selected employees' bi-weekly pay rate. • For one transaction selection, an employee received a $730.43 one-time payment for a Teacher Appreciation Grant (TAG) funded by the 84.425U award. The Teacher Appreciation Grant has its own fund and is a state/local grant received to reward high-performing, eligible certified staff. The selected employee is a noncertified employee and did not qualify for a TAG award. There was no documentation provided to support work performed under this award to support allowability of the cost incurred. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure records of approved contracts are maintained for all employees and that payroll charged to federal awards is reviewed each pay period for allowability. The HR Coordinator is currently storing each contract both by hard copy in the employee file and digitally in our software. The Deputy Treasurer/Payroll Coordinator reviewing the distribution report prior to payroll submission. The Treasurer is also reviewing and will sign off on the distribution report for each payroll. Responsible Party and Timeline for Completion: Kelli Kizzee - HR Coordinator, Jessica Elliot - Payroll Coordinator, Moriah Crane - Treasurer. The process is already in place.

FINDING 2024-004 Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other Identifying Numbers): H027A220084, H027A230084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Special Education Cluster and Activities Allowed or Unallowed. Context: During the testing of a sample of 40 payroll disbursements charged to the Special Education Cluster during the audit period, the following exceptions were noted: • For eight transactions selected, management was unable to provide an approved contract to support the selected employees' bi-weekly pay rate. • For two transactions selected, management was unable to provide approved timecards for the selected hourly employee and time period. • For seven transactions selected, management was unable to provide time and effort logs to support the allocation of one employee's salary between the federal grant and the Education fund. The lack of controls was systematic throughout the audit period. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will ensure records of approved contracts and approved timecards are maintained for all employees. Management will ensure payroll charged to federal awards is reviewed each pay period for allowability. The HR Coordinator is currently storing each contract both hard copy in the employee file and digitally in our software. The Deputy Treasurer/Payroll Coordinator will review the distribution report prior to payroll submission. As time cards are being approved in our software system, a print out of the approvals will be maintained for each payroll. The Treasurer will review and sign off on the distribution and approval report for each payroll. Responsible Party and Timeline for Completion: Kelli Kizzee - HR Coordinator, Jessica Elliot - Payroll Coordinator, Moriah Crane - Treasurer. The process is already except for the printed time card approval report which will be in place starting with the January 2025 payrolls.

Berkeley School District No. 87 CORRECTIVE ACTION PLAN FOR CURRENT YEAR FINDINGS Year ending June 30, 2024 Corrective Action Plan Finding No.: 2024-002 Condition: During our audit of the Child Nutrition Cluster, we identified that the client did not have adequate disbursement controls in place. Specifically, duplicate invoices on multiple occasions were entered into the client’s software system due to typographical errors, resulting in payments being made twice to each vendor for the same service. Plan: The District will implement stronger internal controls over the disbursement process. This includes establishing a review and approval process for all invoices before payment, implementing software controls to detect duplicate invoices, and/or providing training to staff on proper invoice processing procedures to minimize typographical errors. Anticipated Date of Completion: 06/30/2025 Name of Contact Person: Irene Daciuk Management Response: See above

Finding Number: 2024-002 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2025

Finding Number: 2024-003 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted, until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2025

Finding: 2024-001 Name of contact person: Jacob Joyner, Director of Financial Services Corrective Action: Housing staff is training additional staff to complete inspections and increasing management oversight of the program to ensure compliance with grant requirements.

Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 09/30/24

Recommendation: We recommend that the housing specialist complete the rent computation and review all support provided to the entity by the tenant to ensure all assets and income has been addressed on the rent computation form. We also recommend that a secondary person review the rent computation form for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to make the correction in the rent computation and return the amount overpaid by the grantor to HUD in FY2024-2025. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 10/04/2024

Recommendation: We recommend that the organization review the changes in income limits published by HUD during the tenant certification and recertification process to update form HUD-50059 income limits accordingly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Brad Hughes Planned completion date for corrective action plan: 09/30/24 2024

2024-002 Special Tests and Provisions – Selection from the Waiting List Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2023-003 from March 31, 2023 (initially occurred as Finding 2022-004 from March 31, 2022) Condition: 25 out of 250 new admissions were selected for testing. Exceptions were noted as follows: • 15 new admissions where the selection from the waiting list was not in compliance with the Authority’s administrative plan. The administrative plan states that that the waiting list should be organized by preference point and then by date and time of application (first come first serve basis). However, the applicants tested were ranked randomly through a lottery. Due to this issue, there were many applicants that were not ranked properly on the waiting list and were thus not admitted in proper sequence into the Section 8 program. • 4 new admissions where the Authority was unable to provide support that the applicants were properly selected from the waiting list (as the waiting list for the new admissions that were selected from was not retained). • 1 new admission where the Authority did not sign the lease agreement and the unit address and rent amount on the lease agreement did not agree to the Form 50058. • 1 new admission where the Authority could not provide the tenant’s voucher. Recommendation: The Authority should correct the deficiencies and ensure staff is aware of acceptable procedures as outlined in the Authority’s Administrative plan. In addition, the Authority should review staffing levels, skill sets and case load. Furthermore, the Authority should utilize an ongoing quality control review process to ensure proper procedures are being followed. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review process and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.

2024-001 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream – Vouchers CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding (the prior year finding was a significant deficiency) of 2023-002 from March 31, 2023 (initially occurred as Finding 2021-003, Significant Deficiency) Condition: Out of a total tenant population of approximately 1,775 tenants, 25 files were selected for testing. Exceptions were noted as follows: • 1 tenant file had the following errors: o Miscalculation of social security income reported on the form 50058 (used a prior year SSI instead of the current year). Correcting this error would decrease the HAP rent from $1,610 to $1,567. o One missing 214-affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o Two members of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificates, the two household members are U.S. citizens. o The 9886 form was not dated. Thus, we do not know if the 9886 form was signed within 15 month required timeframe. • 1 tenant file had the following errors: o Missing 214-affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. o The tenant did not sign and date the Form 9886. • 1 tenant file had the following errors and correcting the errors would increase the HAP rent from $1,130 to $1,159: o Miscalculation of social security income reported on the 50058. o Miscalculation of medical expense reported on the 50058. • 1 tenant file error where a member of the household over the age of 18 did not sign the Form 9886. • 1 tenant file error where social security income was calculated incorrectly. Correcting the income would decrease the HAP rent from $1,155 to $1,153. • 1 tenant file error where a member of the household over the age of 18 did not sign the 9886. • 1 tenant file error where the tenant dated the year on the 9886 form 2013 when it should be 2023. • 1 tenant file error where a member of the household over 18 years old did not sign Form 9886. • 1 tenant file error where the tenant’s wage income was miscalculated. However, correcting the error would have no effect on the HAP rent amount. • 1 tenant file error where there was no EIV form for the recertification period. • 1 tenant file error where tenant wage income was calculated incorrectly. Correcting these income issues would decrease the HAP rent from $1,207 to $896. • 1 tenant file had the following errors and correcting the errors would decrease the HAP rent from $1,378 to $1,030: o An incorrect utility allowance was reported on the Form 50058. o Income support was not reported correctly on the Form 50058. • 1 tenant file had the following errors: o A member of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificate, the household member is a U.S. citizen. o Support for tenant’s pension income was over 12 months old. • 1 tenant file error where child support income was calculated incorrectly. However, correcting the error would have no effect on the HAP rent amount. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.1 tenant file error where the Form 50058 reported an incorrect utility allowance, but correcting the allowance would not change the HAP rent amount.

Finding 2024-001 Eligibility Management agrees with the summarized findings. Management has reviewed the current policies and procedures to ensure that the steps to be performed are clearly stated for the underwriting and disbursement staff. Management has discussed the findings with staff members and will provide additional training as deemed necessary.

U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance - Reporting Finding 2024-006 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Per 2 CFR 200.334 the recipient must retain all Federal award records for three years from the date of submission of their final financial report. Condition: During the audit we tested 13 reports and noted the following: a) There were four (4) instances out of 13 reports tested where the submitted reports were unable to be provided, including the date of submission for the reports. b) There were 10 instances out of 13 reports tested where the County was unable to provide evidence the report was reviewed prior to submission. Questioned Costs: None. Effect: By not having the required documentation and underlying support, the County is not able to demonstrate compliance with the applicable requirements. Cause: The County did not have a formal policy to ensure documentation was retained to evidence review and submission of all reports. Recommendation: The County should consider creating a formalized policy to require all submitted reports and underlying data are retained in accordance with the Uniform Grant Guidance requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: See Corrective Action Plan prepared by the County. The Health Department will create and adopt a policy to ensure that federal award reports and data are retained in accordance with Uniform Guidance. The Health Department will also collaborate with NCDHHS to develop a procedure to address circumstances when the required report consists of answering a NCDHHS survey or form that does not have “save” or “download” capability, making it difficult to retain the required documentation. In addition, the Health Department will develop a standard operating procedure whereby program managers document that they have reviewed federal award reports prior to submission. While review of grant reports is common, the Health Department did not have adequate documentation to demonstrate completion of this step. Completion Date: April 30, 2025 Responsible Person(s): Jana Harrison, Business Operations Director

U.S. Department of Agriculture Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Material Weakness – Eligibility Finding 2024-003 Criteria: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: For the WIC program, we were unable to obtain evidence to corroborate the review of the Senior Quality Training Specialist eligibility determinations. Questioned Costs: None Effect: By not having the required documentation to support the review by the Senior Quality Training Specialist, the County is unable to support their assertion the cases are properly reviewed by an individual other than the preparer. Cause: County does not have a formal policy for documenting evidence of the review by the Senior Quality Training Specialist. Recommendation: We recommend the County implement a policy to ensure the review by the Senior Quality Training Specialist is properly documented and retained. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: See below Corrective Action Plan prepared by the County. Program leadership will collaborate The Total Quality Team i.e. Compliance Coordinator and Quality Assurance Coordinator to revise current internal monitoring policies and procedures. Internal monitoring tools will be created to align with state and federal guidelines. Following review with Total Quality, staff will be trained on revised monitoring processes, policy, and procedures. WIC Policy A-19 mandates the use of the State Agency's WIC program monitoring tool for conducting record audits. To ensure proper implementation, this policy will be reviewed with the Senior Quality and Training Specialist. The WIC Senior Quality Training Specialist and WIC leadership will maintain audit documentation in accordance with Policy A-13, Retention of Administrative Documents, established by Mecklenburg County Health Department. The following the phases of the corrective action plan will be completed by March 31st, 2025. Phase1: Review of Federal Guidelines Phase 2: Review Of State Guidelines Phase 3: Internal Policy Review Phase 4: Creation and Implementation of new internal monitoring processes. Phase 5: Staff Training Completion Date: March 31, 2025 Responsible Person(s): WIC Director, Ali Raza and Senior Quality and Training Specialist, Tamika Moore

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal Assistance Listing Number: 93.778 Material Weakness and Nonmaterial Noncompliance – Eligibility Finding 2024-001 – Repeat Finding Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NCFAST. We noted several errors related to the following compliance criteria: a) Self-attestation wages should be compared to information in NC FAST. b) All countable resources should be confirmed and recalculated and ensure they are computed accurately in NC FAST. c) An OVS inquiry must be completed and agreed to information reported in NC FAST. d) An ex parte review is required every six (6) to twelve (12) months. e) Forced eligibility cases should maintain the proper documentation within NC FAST to support the determination for the required forced eligibility. f) For Aged, Blind, or Disabled cases or MQB programs the Register of Deeds is required to be verified and documented in the case file g) The caseworker should prepare and submit a DMA-5097 form in the case of incompatible income verification and self-attestation income as described in the Eligibility Review Document. h) For countable earned and unearned income, income conversion and computation was done in accordance with policy manuals, and have to agree to amounts in NC FAST. Condition: The following are the results of nonmaterial noncompliance noted for each criteria listed above out of the 122 program participants selected for testing: a) There were four instances where the participants self-attest wages did not agree to the wages entered into NC FAST. b) There were three instances where the countable resources were inaccurate within NC FAST. c) There was one instance where the OVS query was not run at the time of the determination. d) There were two instances where the ex parte review was not completed timely. e)There were two instances where the support for the forced eligibility was not properly maintained in NC FAST. f) There was one instance where the Register of Deeds support was not maintained in NC FAST. g) There were five instances where the income was incompatible between the income verification and self-attestation income but no DMA-5097 was sent. h) There were two instances where countable income was not properly included in NC FAST. Lastly, there were 6 instances out of 60 program participants tested for control testing where the County did not remediate the errors identified within their internal review timely. Context: There were 14 out of 124 unique participants tested with the errors noted above. Questioned Costs: None noted. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk the County could provide funding to individuals who are not eligible. Cause: County oversight when performing reviews over applications. Additionally, the County does not have a formal process in place to ensure issues identified during the review process are appropriately corrected on a consistent and timely basis. Recommendation: Although these issues will occur from time to time considering the volume of case files, the County should review their processes to ensure proper supporting documentation of eligibility is maintained within each case file. Additionally, Mecklenburg County should consider implementing a formal policy for the requirements of having documentation corrected within a specific timeframe once identified. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: The County will take a multi-faceted approach to mitigating such errors in the future. Training: The Staff Development Unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine Medicaid eligibility and their supervisors and managers to address the specific errors identified. This training will be delivered by the end of January 2025. Responsible Individual(s): Staphon Snelling, Training and Development Manager Anticipated Completion Date: January 31, 2025 Process Improvement: The Economic Services Division (ESD) has trained new hires in one function of the Medicaid program, for example, processing applications or recertifications/changes. This has built a stronger foundation before they learn the second function of their assigned program. Our Supervisors and Quality and Training Specialists are working even more closely together to follow up on errors and help ensure identified challenges in training and mentoring are addressed before they are released from mentoring. Ex parte reviews are directly assigned for Family and Children’s Medicaid and for Adult Medicaid, renewals are placed into Current for workers to get next and work as soon as possible. Family and Children’s Medicaid will provide second-function training for current employees on recertifications. Adult Medicaid has 10 currently in mentoring for recertifications. Kim Konior is responsible for monitoring ex-parte review reports and MAGI cases are being assigned out by Supervisor Collin Smith and Jannicia Austin for Adult Medicaid. Each month the Medicaid managers Kim Konior and Lynn Martin review the progress and update the Assistant Division Director on the current status and plans to continually improve in this area. Supervisors will ensure that second party reviews are reviewed and corrected for any internal control and eligibility errors within 5 business days of receipt. Supervisors ensure that updates to the quality sampling tracking log are completed by the 20th day of the following month. Responsible Individual(s): Kim Konior and Lynn Martin Medicaid Program Managers and Staphon Snelling, Training and Development Manager Anticipated Completion Date: Will begin Family and Children’s Medicaid recertification training in third Quarter of FY25 (Jan 2025) and end by the end of 2nd quarter of FY 2025 (December 2025). Quality Sampling and Accountability: The Quality and Training Unit complete monthly quality sampling for Medicaid. Error trends are shared with the managers and their supervisors, who work collaboratively with Quality and Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward. Supervisors review specific quality sampling results with their staff. The supervisor when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process. Managers review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans. Supervisors, front line, and Managers have quality measure on their workplan to ensure timely response and accountability is held. All levels are to achieve an average quality score of 80% quarterly. Note that this error was found at a much higher rate last year. We are continuing to reinforce this importance and expect the improvement that we have achieved within one year will continue to grow as we keep reinforcing quality into our everyday work culture. Protocol for second party reviews provided 08/2024 in place for ESD. Cases will be checked by Quality and Training by the last day of each business month. Quality and Training will check and provide feedback to workers within 2 business days of the case being checked. Corrections of errors and rebuttals for QS errors should be submitted within 5 business days of feedback being provided and a response will be received within 3 business days of receipt. The Quality Assurance team in OSI/CFAS conduct an independent evaluation and review the second party review process at the divisional level to ensure review was accurate and errors were corrected timely. This team reports out to ESD Leadership quarterly on findings. Responsible Individual(s): Kim Konior and Lynn Martin, Medicaid Program Managers & Julio Rosales, Quality Assurance Supervisor, Staphon Snelling Training and Development Manager Anticipated Completion Date: Currently Ongoing