Corrective Action Plans

Finding 524493 (2024-002)

Significant Deficiency 2024

OR

Reporting Special Tests & Provisions Student Financial Aid

Finding: 2024-002 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.007, 84.033, 84.063, and 84.268 Program Name: Student Financial Assistance Cluster Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for accurate report...

Finding: 2024-002 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.007, 84.033, 84.063, and 84.268 Program Name: Student Financial Assistance Cluster Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for accurate reporting of a student’s enrollment status and changes in those enrollment statuses, whether they report directly or via a third‐party servicer. The support provided by RCC for the student’s last date of attendance did not agree to the student’s withdrawal that had been submitted to NSLDS. Responsible Individuals: Danielle Crouch, Registrar and Analisa Gifford, Assistant Registrar Corrective Action Plan: During the 2023-2024 academic year, we were utilizing an outdated, homegrown Student Information System (SIS). A previously unidentified flaw in the system’s programming logic caused incorrect withdrawal dates to be populated in the National Student Clearinghouse (NSC) report. For the 2024-2025 academic year, we have transitioned to Jenzabar One, an industry-recognized SIS that includes built-in Enrollment Reporting functionality. To ensure accurate reporting moving forward, we are conducting audits of withdrawal dates at the end of each term. With the implementation of this new system and enhanced audit processes, this issue will be fully mitigated. Anticipated Completion Date: June 25, 2025

View Audit 343860

Finding 524490 (2024-001)

Significant Deficiency 2024

Hoke County, North Carolina

NC

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

Finding: 2024-001 Name of Contact Person: Diane Simmons, Program Integrity Supervisor Corrective Action/Management’s Response: Management agrees with the audit finding. The Program Integrity Investigator will ensure that all documentation and evidence relative to the case is scanned into NCFAST u...

Finding: 2024-001 Name of Contact Person: Diane Simmons, Program Integrity Supervisor Corrective Action/Management’s Response: Management agrees with the audit finding. The Program Integrity Investigator will ensure that all documentation and evidence relative to the case is scanned into NCFAST under the Program Integrity Investigative Case. The Invesitgator will complete the DSS-1682 and review for accuracy prior to submitting the form to the Program Integrity Supervisor for approval. The Program Integrity Supervisor will complete a second party review of all DSS-1682’s and documentation to ensure that investigations and forms are completed correctly and timely. The Program Integrity Investigator will enter the claim into NCFAST after approval by the Supervisor. The second party review results will be reviewed with Program Integrity Staff monthly. Remedial training will be conducted if any errors are found. Proposed Completion Date: the above mentioned procedures will be Implemented immediately.

View Audit 343849

Finding 524441 (2024-001)

Significant Deficiency 2024

McDaniel College and Subsidiary

MD

Questioned Costs Student Financial Aid Subrecipient Monitoring

Finding 2024-001 Condition Finding 2024-001 – Significant Deficiency – Return of Title IV Federal Program – Federal Pell Grant Program, Federal Direct Student Loan Program Federal Agency – U.S. Department of Education Pass- Through Entity – Not Applicable ALN Number – 84.063, 84.268 Federal Award Y...

Finding 2024-001 Condition Finding 2024-001 – Significant Deficiency – Return of Title IV Federal Program – Federal Pell Grant Program, Federal Direct Student Loan Program Federal Agency – U.S. Department of Education Pass- Through Entity – Not Applicable ALN Number – 84.063, 84.268 Federal Award Year – May 31, 2024 Criteria: The Uniform Guidance requires recipients of federal awards to administer its federal programs with an adequate system of internal controls over applicable compliance requirements. In addition, when a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period, Title IV regulations (34 CFR 668.22) require the College to determine, through a Return of Title IV Funds (R2T4) calculation, the amount of Title IV grant or loan assistance that the student earned as of the withdrawal date and return the unearned portion of the grant or loan to the Title IV programs as soon as possible but no later than 45 days after the withdrawal date. Corrective Action Plan Corrective Action Planned: {The College agrees with the finding and has taken immediate corrective action to address the finding related to R2T4 calculations. All R2T4 calculations for the related period have been recalculated and reviewed for accuracy. Any noted discrepancies related to the necessary return of funds have been addressed. Enhanced internal controls have been implemented to ensure that the dates entered in the Colleague system aligns with the academic calendar. The College will also institute an internal audit/compliance process for additional verification and monitoring. Identify the specific actions to be taken to eliminate or mitigate the recurrence of the finding. Name(s) of Contact Person(s) Responsible for Corrective Action: Kemia Himon, Financial Aid Director Anticipated Completion Date: 3.3.25

View Audit 343760 Questioned Costs: $1

Finding 524434 (2024-003)

Significant Deficiency 2024

Payne Theological Seminary

OH

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend that the Seminary review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend that the Seminary review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The seminary will update our current WISP to comply with all requirements and updated standards. Name(s) of the contact person(s) responsible for corrective action: Raymond Ingram Planned completion date for corrective action plan: April 2025

View Audit 343723

Finding 524433 (2024-002)

Significant Deficiency 2024

Payne Theological Seminary

OH

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend that the Seminary implemented a process to ensure credit balances are returned timely based on the regulations set forth by the Department of Education. Explanation of disagreement with audit finding: There is no disagreeme...

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend that the Seminary implemented a process to ensure credit balances are returned timely based on the regulations set forth by the Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through December 2024, Payne issues credits/refunds in two disbursements. In November 2024, the Business Office and Academic Services discussed moving to a single credit/refund disbursement in an effort to avoid potential delays in processing. A decision was made to approve the single credit/refund disbursement process effective Spring 2025. Financial Aid Services was notified and provided a new disbursement schedule. Communication of the change was sent to students November 30, 2024. Person responsible - Maryjo Lewis Planned completion date: The new process in effect beginning Spring 2025 term

View Audit 343723

Finding 524432 (2024-001)

Significant Deficiency 2024

Payne Theological Seminary

OH

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend the Seminary evaluate its procedures and policies around reporting Unsubsidized loan disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding:...

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend the Seminary evaluate its procedures and policies around reporting Unsubsidized loan disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Business Office will post the awarded funds to the accounts in SONIS on the date designated on the disbursement roster. Name(s) of the contact person(s) responsible for corrective action: Razieh Adinehzadeh Planned completion date for corrective action plan: Changes implemented in February 2025.

View Audit 343723

Finding 524384 (2024-001)

Significant Deficiency 2024

Haysville Usd No. 261

KS

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Condition: During our review of IDEA funds, we noted that sales tax was paid on multiple invoices. Criteria: When federal dollars are used to pay for items from a tax exempt entity, it is important to ensure the vendor is not charging the entity sales tax. Cause: The District paid sales tax on multi...

Condition: During our review of IDEA funds, we noted that sales tax was paid on multiple invoices. Criteria: When federal dollars are used to pay for items from a tax exempt entity, it is important to ensure the vendor is not charging the entity sales tax. Cause: The District paid sales tax on multiple invoices we found during our testing. Effect: Unallowable cost through IDEA. Perspective: The District should have controls in place and a review process to ensure sales tax is not being charged. Recommendation: We recommend the District go through and update (or establish) procedures to ensure sales tax is not being paid. Views of Responsible Officials and Planned Corrective Actions: Haysville USD 261 staff involved will work with the necessary parties to ensure policies and procedures are updated.

View Audit 343618 Questioned Costs: $1

Finding 524350 (2024-006)

Significant Deficiency 2024

Pitt County, North Carolina

NC

Significant Deficiency Internal Control / Segregation of Duties

Corrective Action/Management Response: We will get with MIS to see if they can reduce the amount of time the computer auto locks as well as doing checks to ensure all unattended computers are locked. Proposed Completion Date: 12/1/2024

View Audit 343583

Finding 524341 (2024-002)

Significant Deficiency 2024

Bryn Mawr College

PA

Student Financial Aid Special Tests & Provisions Reporting

The College acknowledges that, while student status change information was being sent to the NSC, it did not have an appropriate process in place to regularly review and reconcile the data received by the NSLDS and information for 2 students was not properly remitted. A correction was made to the e...

The College acknowledges that, while student status change information was being sent to the NSC, it did not have an appropriate process in place to regularly review and reconcile the data received by the NSLDS and information for 2 students was not properly remitted. A correction was made to the existing reconciliation report so that all statuses remitted to the NSLDS are captured accurately and can be reconciled by the Registrar’s Office to the College’s enrollment records. Additionally, the College will adopt a practice of manually updating the NSC after receiving each student status change notification throughout the semester. The Planned Corrective Action will be implemented immediately.

View Audit 343564

Finding 524320 (2024-011)

Significant Deficiency 2024

Northampton County

NC

Eligibility Significant Deficiency

Corrective Action Plan For the Year Ended June 30, 2024 Corrective Action: Proposed Completion Date: Finding 2024-011 Inaccurate Resources Entry Name of contact: Lisa Broady, Adult Medicaid Supervisor Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Question Cost...

Corrective Action Plan For the Year Ended June 30, 2024 Corrective Action: Proposed Completion Date: Finding 2024-011 Inaccurate Resources Entry Name of contact: Lisa Broady, Adult Medicaid Supervisor Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Question Costs (continued) Family and Children's Medicaid Supervisor will be meeting with staff on requesting information needed to determine eligibility for applications and/or redetermination. Supervisor will continue to check at least 10 records a month to ensure adequate and accurate information is being requested and information is being correctly documented. Supervisor will also implement refresher training through Learning Gateway and one on one if necessary. Adult Medicaid Supervisor will be meeting with staff to ensure that all required information has been requested and verified timely and correct documentation has been notated and updated to determine complete eligibility for all applications and/or redeterminations. Supervisor will continue to check 10 cases per month to ensure that caseworkers are following proper procedures when determining eligibility and case documentation indicates what actions were performed and the results of those actions by use of application/recerts templates. Supervisor will meet monthly with workers individually and unit as a whole if needed to track worker(s) and/or unit progress as well as to discuss what is working or not working. Supervisor will also implement refresher training for all caseworkers thru Learning Gateway and/or one on one training if needed. These procedures will be implemented November 2024 in addition to the hiring of a program manager to assist in any needed training for staff who may need additional help. Supervisor will be meeting with staff to ensure that all resources countable and/or noncountable have been verified, calculated and documented thoroughly and correctly in NC Fast and that both NC Fast and case files agree. Supervisor will implement checklists and/or templates for staff to use to ensure that they are following correct procedures when determining eligibility and to indicate what actions were performed and the results of those actions as well as to ensure that what is in NC Fast matches the verifications of items received from client and/or electronic verifications. These procedures will be implemented November 2024 in addition to the hiring of a program manager to assist in providing additional training for staff who may be needing additional help. 150

View Audit 343516

Finding 524319 (2024-010)

Significant Deficiency 2024

Northampton County

NC

Eligibility Significant Deficiency

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2024-009 Inaccurate Information Entry Name of contact: Correct...

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2024-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2024-010 Inadequate Request for Information Name of contact: Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Section III - Federal Award Findings and Question Costs Family and Children's Medicaid Supervisor will be randomly checking at least 10 cases a month to ensure if accurate information is being entered. Also, prior to submitting work, cases will be randomly check by supervisor and/or lead work to ensure the correct information is being entered. Supervisor will be implement refresher training in the Learning Gateway. Adult Medicaid Supervisor will be meeting with staff to put into place that prior to case termination, case be reviewed by supervisor and/or lead-worker to ensure that all proper procedures have been followed before terminating a case. Supervisor will also implement refresher training for all caseworkers thru Learning Gateway. Supervisor will continue to randomly check at least 10 cases to track any error trends and then discuss any errors or trends with worker and/or unit. These procedures will be implemented November 2024. Also a program manager will be hired in the month of November 2024 as an additional source in helping with reports and providing additional training to staff who may be needing additional help. Supervisor will be checking at least 10 records a month with focus on IV-D entry and documentation. Meeting with staff to ensure child support information is being obtained, documented and entered if needed. Supervisor will be implementing Learning Gateway training for the staff and/or one on one training. These procedures will be implemented in November 2024. Also, a Program Manager will be hired in November 2024 to assist with trainings and any other additional help staff may be needing. 149

View Audit 343516

Finding 524317 (2024-008)

Significant Deficiency 2024

Northampton County

NC

Eligibility Significant Deficiency

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2024-009 Inaccurate Information Entry Name of contact: Correct...

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2024-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2024-010 Inadequate Request for Information Name of contact: Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Felicia Bullock, Family and Children's Medicaid Supervisor, & Lisa Broady, Adult Medicaid Supervisor Section III - Federal Award Findings and Question Costs Family and Children's Medicaid Supervisor will be randomly checking at least 10 cases a month to ensure if accurate information is being entered. Also, prior to submitting work, cases will be randomly check by supervisor and/or lead work to ensure the correct information is being entered. Supervisor will be implement refresher training in the Learning Gateway. Adult Medicaid Supervisor will be meeting with staff to put into place that prior to case termination, case be reviewed by supervisor and/or lead-worker to ensure that all proper procedures have been followed before terminating a case. Supervisor will also implement refresher training for all caseworkers thru Learning Gateway. Supervisor will continue to randomly check at least 10 cases to track any error trends and then discuss any errors or trends with worker and/or unit. These procedures will be implemented November 2024. Also a program manager will be hired in the month of November 2024 as an additional source in helping with reports and providing additional training to staff who may be needing additional help. Supervisor will be checking at least 10 records a month with focus on IV-D entry and documentation. Meeting with staff to ensure child support information is being obtained, documented and entered if needed. Supervisor will be implementing Learning Gateway training for the staff and/or one on one training. These procedures will be implemented in November 2024. Also, a Program Manager will be hired in November 2024 to assist with trainings and any other additional help staff may be needing. 149

View Audit 343516

Finding 524285 (2024-005)

Significant Deficiency 2024

Cleveland County

NC

Eligibility Significant Deficiency

Finding 2024-005 Inadequate Request for Information Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-006 FNS Eligibility Determinations Name of Contact Person: Alice Wilson, FNS Program Administrator Corrective Action: Pro...

Finding 2024-005 Inadequate Request for Information Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-006 FNS Eligibility Determinations Name of Contact Person: Alice Wilson, FNS Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs (continued) The county will conduct refresher training on how and when to request information needed that includes when to request The Work Number, OVS,AVS, Property checks and Register of Deeds checks. The county will conduct a targeted second party of cases to check the effectiveness of the refresher training provided. 4/1/2025 Section IV - State Award Findings and Questioned Costs Corrective Action Plan for Finding 2024-002, 2024-003, 2024-004, 2024-005 also apply to State Award Findings. All FNS staff will attend a refresher training where sections 435, 505 and 510 will be reviewed. This training will be conducted by Supervision in FNS with the support of the FNS lead staff. This training will include an outline of the requirement for supporting documentation of eligibility and benefit determinations to include verifications used to support such determination at application and recertification where appropriate. All relatable NC FAST job aids will be reviewed with staff to ensure that functionality within the NCFAST system is followed. 3/1/2025

View Audit 343481

Finding 524284 (2024-004)

Significant Deficiency 2024

Cleveland County

NC

Eligibility Significant Deficiency

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action:...

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-004 Inaccurate Resources Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: The County recognizes that through our transition in software we have fully reconciled all fixed asset transactions. Going forward, County finance staff will thoroughly track and reconcile all fixed assets annually. Along with reconciliation, the process of purchasing and recoding asset transactions has been modified, to include various checks and balances. Completed 7/1/2024 Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings 4/1/2025 Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and continues to demonstrate the successfullness as the error for 2024 was one error. For the Year Ended June 30, 2024 Corrective Action Plan Staff will receive refresher training on updating the evidence dashboard at redetermination of eligibility that will be conducted by Supervision. The documentation template for Recertifications will also be updated to include a line item for caseworkers to document that the evidence dashboard has been updated. Lead staff will also complete two targeted Quality review checks on a case sampling to gauge if staff are appropriately updating the dashboard. 4/1/2025 All staff will receive refresher training on determining Household size and countable income, including checking the determinations tab on the activated PDC to ensure that all required income and household members are counted. Lead staff will conduct a targeted QC sample to track progress of lowering this error finding over the first quarter of 2025. 4/1/2025

View Audit 343481

Finding 524283 (2024-003)

Significant Deficiency 2024

Cleveland County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action:...

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-004 Inaccurate Resources Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: The County recognizes that through our transition in software we have fully reconciled all fixed asset transactions. Going forward, County finance staff will thoroughly track and reconcile all fixed assets annually. Along with reconciliation, the process of purchasing and recoding asset transactions has been modified, to include various checks and balances. Completed 7/1/2024 Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings 4/1/2025 Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and continues to demonstrate the successfullness as the error for 2024 was one error. For the Year Ended June 30, 2024 Corrective Action Plan Staff will receive refresher training on updating the evidence dashboard at redetermination of eligibility that will be conducted by Supervision. The documentation template for Recertifications will also be updated to include a line item for caseworkers to document that the evidence dashboard has been updated. Lead staff will also complete two targeted Quality review checks on a case sampling to gauge if staff are appropriately updating the dashboard. 4/1/2025 All staff will receive refresher training on determining Household size and countable income, including checking the determinations tab on the activated PDC to ensure that all required income and household members are counted. Lead staff will conduct a targeted QC sample to track progress of lowering this error finding over the first quarter of 2025. 4/1/2025

View Audit 343481

Finding 524282 (2024-002)

Significant Deficiency 2024

Cleveland County

NC

Eligibility Significant Deficiency

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action:...

Finding 2024-002 IV-D Cooperation with Child Support Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-003 Inaccurate Information Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-004 Inaccurate Resources Entry Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: The County recognizes that through our transition in software we have fully reconciled all fixed asset transactions. Going forward, County finance staff will thoroughly track and reconcile all fixed assets annually. Along with reconciliation, the process of purchasing and recoding asset transactions has been modified, to include various checks and balances. Completed 7/1/2024 Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings 4/1/2025 Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and continues to demonstrate the successfullness as the error for 2024 was one error. For the Year Ended June 30, 2024 Corrective Action Plan Staff will receive refresher training on updating the evidence dashboard at redetermination of eligibility that will be conducted by Supervision. The documentation template for Recertifications will also be updated to include a line item for caseworkers to document that the evidence dashboard has been updated. Lead staff will also complete two targeted Quality review checks on a case sampling to gauge if staff are appropriately updating the dashboard. 4/1/2025 All staff will receive refresher training on determining Household size and countable income, including checking the determinations tab on the activated PDC to ensure that all required income and household members are counted. Lead staff will conduct a targeted QC sample to track progress of lowering this error finding over the first quarter of 2025. 4/1/2025

View Audit 343481

Finding 524281 (2024-006)

Significant Deficiency 2024

Cleveland County

NC

Matching / Level of Effort / Earmarking Eligibility Significant Deficiency

Finding 2024-005 Inadequate Request for Information Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-006 FNS Eligibility Determinations Name of Contact Person: Alice Wilson, FNS Program Administrator Corrective Action: Pro...

Finding 2024-005 Inadequate Request for Information Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2024-006 FNS Eligibility Determinations Name of Contact Person: Alice Wilson, FNS Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs (continued) The county will conduct refresher training on how and when to request information needed that includes when to request The Work Number, OVS,AVS, Property checks and Register of Deeds checks. The county will conduct a targeted second party of cases to check the effectiveness of the refresher training provided. 4/1/2025 Section IV - State Award Findings and Questioned Costs Corrective Action Plan for Finding 2024-002, 2024-003, 2024-004, 2024-005 also apply to State Award Findings. All FNS staff will attend a refresher training where sections 435, 505 and 510 will be reviewed. This training will be conducted by Supervision in FNS with the support of the FNS lead staff. This training will include an outline of the requirement for supporting documentation of eligibility and benefit determinations to include verifications used to support such determination at application and recertification where appropriate. All relatable NC FAST job aids will be reviewed with staff to ensure that functionality within the NCFAST system is followed. 3/1/2025

View Audit 343481

Finding 524280 (2024-005)

Significant Deficiency 2024

Johnston County

NC

Eligibility Significant Deficiency

Corrective Action Plan For the Year Ended June 30, 2024 Finding: 2024-005 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to the State Award Findings. Section IV - State Award Findings and Quest...

Corrective Action Plan For the Year Ended June 30, 2024 Finding: 2024-005 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Finding 2024-001, 2024-002, 2024-003, and 2024-004 also apply to the State Award Findings. Section IV - State Award Findings and Question Costs Section III - Federal Award Findings and Question Costs (continued) Darren Phillips, Supervisor QA/PI The Eligibility Error case will be referred to Program Integrity as an Agency Error to redo the Client's budget and to see if any money is owed back to the County and State. We have developed a training slideshow for all FNS workers to cover all errors made on the audited cases. Training will be conducted by 2/28/2025. 236

View Audit 343473

Finding 524279 (2024-004)

Significant Deficiency 2024

Johnston County

NC

Eligibility Reporting Significant Deficiency

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of...

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers.This covers training for the use of OVS and the TWN and a reminder about the correct way to end-date income and add new income to NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers. A training slide shows that buildings are part of Real Property and must be added to a case. Corrective Action Plan Section III - Federal Award Findings and Question Costs Section II - Financial Statement Findings For the Year Ended June 30, 2024 Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers and a new system for tracking recertification cases has been implented in the three Recertification Units to alleviate worker errors when sending request for information to applicant/beneficiaries and completing recertifications in a timely manner. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide training to the caseworkers. Supervisors has been reminded to use the appropriate reports in NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. 235

View Audit 343473

Finding 524278 (2024-003)

Significant Deficiency 2024

Johnston County

NC

Eligibility Significant Deficiency

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of...

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers.This covers training for the use of OVS and the TWN and a reminder about the correct way to end-date income and add new income to NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers. A training slide shows that buildings are part of Real Property and must be added to a case. Corrective Action Plan Section III - Federal Award Findings and Question Costs Section II - Financial Statement Findings For the Year Ended June 30, 2024 Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers and a new system for tracking recertification cases has been implented in the three Recertification Units to alleviate worker errors when sending request for information to applicant/beneficiaries and completing recertifications in a timely manner. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide training to the caseworkers. Supervisors has been reminded to use the appropriate reports in NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. 235

View Audit 343473

Finding 524277 (2024-002)

Significant Deficiency 2024

Johnston County

NC

Eligibility Significant Deficiency

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of...

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers.This covers training for the use of OVS and the TWN and a reminder about the correct way to end-date income and add new income to NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers. A training slide shows that buildings are part of Real Property and must be added to a case. Corrective Action Plan Section III - Federal Award Findings and Question Costs Section II - Financial Statement Findings For the Year Ended June 30, 2024 Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers and a new system for tracking recertification cases has been implented in the three Recertification Units to alleviate worker errors when sending request for information to applicant/beneficiaries and completing recertifications in a timely manner. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide training to the caseworkers. Supervisors has been reminded to use the appropriate reports in NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. 235

View Audit 343473

Finding 524276 (2024-001)

Significant Deficiency 2024

Johnston County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of...

None Reported Finding: 2024-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-003 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2024-004 Name of contact person: Corrective Action: Proposed Completion Date: Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers.This covers training for the use of OVS and the TWN and a reminder about the correct way to end-date income and add new income to NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers. A training slide shows that buildings are part of Real Property and must be added to a case. Corrective Action Plan Section III - Federal Award Findings and Question Costs Section II - Financial Statement Findings For the Year Ended June 30, 2024 Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide to the caseworkers and a new system for tracking recertification cases has been implented in the three Recertification Units to alleviate worker errors when sending request for information to applicant/beneficiaries and completing recertifications in a timely manner. Training will be provided by 1/31/2025 for all Medicaid caseworkers. Darren Phillips, Supervisor QA/PI We have built a training slideshow to provide training to the caseworkers. Supervisors has been reminded to use the appropriate reports in NCFAST. Training will be provided by 1/31/2025 for all Medicaid caseworkers. 235

View Audit 343473

Finding 524274 (2024-001)

Significant Deficiency 2024

Lancaster Area Habitat for Humanity, Inc.

PA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.302

Anticipated Completion Date: January 31, 2025 Responsible Contact Person: Andrew Szalay The root of this “significant finding” has been among the Program staff capturing receipts for small expenditures, such as water and ice, and such, from convenient stores, during construction with Habitat volu...

Anticipated Completion Date: January 31, 2025 Responsible Contact Person: Andrew Szalay The root of this “significant finding” has been among the Program staff capturing receipts for small expenditures, such as water and ice, and such, from convenient stores, during construction with Habitat volunteers. These were all credit card receipts. In the fall of 2024, Habitat management have conducted two types of meetings to ensure source documentation is collected and submitted with financial records: 1. Individual conversations with every credit card holder about the importance of turning in receipts, no matter how small, documentation is critical. 2. Goup meeting with the “frequent offenders” and further emphasized the importance of turning in receipts. Credit card holders were warned that credit card privileges may be revoked if the problem continues. In addition, additional tools may be put into place to capture and retain documentation. This may include vendor apps and digital upload tools. Policies will also be reviewed to ensure practices and terms are consistent and clear for both credit card holders and other staff that submit expense reimbursement forms.

View Audit 343464 Questioned Costs: $1

Finding 524224 (2024-002)

Significant Deficiency 2024

Staywell Healthcare, Inc.

CT

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

2024.02 - Eligibility Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken 1) To ensure patient eligibility is properly assigned to patients, the Dir...

2024.02 - Eligibility Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken 1) To ensure patient eligibility is properly assigned to patients, the Director of Clinical Operations will perform random audits on a Monthly basis of patients that are assigned. 2) The Director of Clinical Operations will also ensure proper training to those that are assigning eligibility to ensure that proper documentation is obtained and properly stored. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Eric Newman, CFO at (203) 756-8021 x 3015. Sincerely yours, Eric Newman Chief Financial Officer

View Audit 343418

Finding 524220 (2024-001)

Significant Deficiency 2024

Staywell Healthcare, Inc.

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will ass...

SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will assign random audits on a Monthly basis of patients that are assigned a sliding fee. 2) Director of Program Management as well as Program Managers will monitor Phreesia dashboard to identify self-pay patients on the schedule and work to ensure that accounts are updated accordingly. a. For any accounts that need to be updated, they will inform the PSA who checked in the patient to make the updates as necessary and provide additional training if needed. b. Provide trainings to PSAs to ensure that they are offering the Sliding Fee Discount to all patients that may need to apply, and appropriately applying those slides. 3) If a Pt has had a visit and left prior to getting sliding fee information, PSAs are to call the patient to let them know that they may have to apply for a sliding fee (or receive insurance information over the phone). 4) Practice Managers will identify Self-pay accounts via Phreesia each morning that may need attention and send a list of accounts to the PSAs at the beginning of each day. PSA will then contact the patients to remind them to bring in proof of income to apply for the sliding fee if eligilble.

View Audit 343418

Corrective Action Plans

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