Corrective Action Plans

Finding 522670 (2024-001)

Significant Deficiency 2024

CA

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Moving to Work Demonstration Program to ensure that established internal control policies are being followed on a timely basis. James Wi...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Moving to Work Demonstration Program to ensure that established internal control policies are being followed on a timely basis. James Williams, Executive Director, will be responsible to implement this corrective action by June 30, 2025.

View Audit 341981

Finding 522666 (2024-001)

Significant Deficiency 2024

The Dowling Park Apartments, Inc.

FL

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

U.S. Department of Housing and Urban Development The Dowling Park Apartments, Inc. HUD Project No. 063-11059 respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 through June 30, 2024 The findings from the schedule of findings and que...

U.S. Department of Housing and Urban Development The Dowling Park Apartments, Inc. HUD Project No. 063-11059 respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 through June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY U.S. Department of Housing and Urban Development 2024-001 Section 223(d) Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects – Assistance Listing No. 14.155 Recommendation: Recommend Project Management reviews its internal control policies over the recording of transactions to ensure that all transactions are used for their intended purpose. Explanation of disagreement with audit finding: There was no disagreement with the audit finding. Action taken in response to finding: Management agreed that funds were erroneously used for HUD related operational expenditures and were replenished to the reserve account when the error was discovered by accounting staff. Procedures were changed to include all accounting personnel in communications regarding reserve funded projects. The contact person responsible for corrective action: Michael Willis, CFO of Advent Christian Village Planned completion date for corrective action plan: August 2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Michael Willis, at (386)-658-5450.

View Audit 341951 Questioned Costs: $1

Finding 522650 (2024-001)

Significant Deficiency 2024

Flathead Valley Community College

MT

Special Tests & Provisions Student Financial Aid Significant Deficiency

Finding: 2024-01 Federal Agency Name: Department of Education Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Award Numbers: P007A232416, Po33A232416, R063P232851, P268K242851 Program Name: Student Financial Aid Cluster Finding Summary: In the current fiscal year, the College failed...

Finding: 2024-01 Federal Agency Name: Department of Education Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Award Numbers: P007A232416, Po33A232416, R063P232851, P268K242851 Program Name: Student Financial Aid Cluster Finding Summary: In the current fiscal year, the College failed to initiate the notification process timely across 265 out of the 984 students (27%). The issue was discovered internally and corrected by the College, notifying those students during the fiscal year, however it was outside of the 30-day requirement. Corrective Action: The process has been reviewed and updated to correct this issue.  A task was implemented in PowerFAIDS that is assigned to the Student Financial Aid Director, and disbursement notifications will be emailed weekly.  If the email fails, a printed letter will be sent to the address on file.  A report was created and will be checked monthly to ensure all students have received notices. At this point, if the College determines someone did not receive the notification, the notification can be sent then and be in the 30-day regulation Responsible Individual: Crystal Morris, Director, Financial Aid Anticipated Completion Date: January 2025

View Audit 341896

Finding 522616 (2024-005)

Material Weakness 2024

Raymond #14 School District

WI

Cash Management Reporting Significant Deficiency

Corrective Action Plan: The District will monitor expenditures related to Federal grants in order to appropriately record these expenditures. The District will compare recorded expenditures to grant claims prior to claim submission to ensure that the claims match the accounting records. Anticipate...

Corrective Action Plan: The District will monitor expenditures related to Federal grants in order to appropriately record these expenditures. The District will compare recorded expenditures to grant claims prior to claim submission to ensure that the claims match the accounting records. Anticipated Corrective Action Plan Completion Date: 6/30/2025 Contact Information: For additional information regarding this finding, please contact Patti Hoppus, District Bookkeeper at 262-835-2929.

View Audit 341853

Finding 522612 (2024-004)

Significant Deficiency 2024

Oklahoma State University

OK

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.308

OSU OKC and OSU Tulsa: The key personnel listed on the GAN will be responsible for completing the post-award training. Key personnel will also reconcile their federal grant budget on a monthly basis and a copy will be submitted to the Office of Institutional Grants and Compliance. The Director of ...

OSU OKC and OSU Tulsa: The key personnel listed on the GAN will be responsible for completing the post-award training. Key personnel will also reconcile their federal grant budget on a monthly basis and a copy will be submitted to the Office of Institutional Grants and Compliance. The Director of Grants and Compliance will verify the purchases using the approved grant budget. Signed time and effort reports will also be submitted to the grants office at this time. OSU IT: A new PI will be appointed to the grant and ensure accurate reporting of time and effort. OSU IT will also implement a comprehensive training program for PI and grant-related staff, establish a monitoring system to ensure ongoing compliance, and designate a compliance officer to oversee this process. Will also implement a digital tracking system to streamline the reporting process and reduce the risk of errors.

View Audit 341848

Finding 522609 (2024-003)

Significant Deficiency 2024

Oklahoma State University

OK

Matching / Level of Effort / Earmarking Student Financial Aid Reporting § 200.303

OSU CHS will have a second person verify the data entered into NSLDS and document that it has been verified.

View Audit 341848

Finding 522608 (2024-002)

Significant Deficiency 2024

Oklahoma State University

OK

Questioned Costs Student Financial Aid Significant Deficiency § 200.303

OSU OKC Financial Aid and Registrar worked together in December 2023 to develop a timeline for updating SOATBRK in Banner. This Banner screen records the number of days in a break that is used for the R2T4 calculation. In addition, the Registrar will reach out to Financial Aid at the time they are...

OSU OKC Financial Aid and Registrar worked together in December 2023 to develop a timeline for updating SOATBRK in Banner. This Banner screen records the number of days in a break that is used for the R2T4 calculation. In addition, the Registrar will reach out to Financial Aid at the time they are building terms for the next academic year. This will serve as a backup to ensure the process is not missed.

View Audit 341848 Questioned Costs: $1

Finding 522597 (2024-003)

Significant Deficiency 2024

Pershing County, Nevada

NV

Reporting Significant Deficiency

Finding 2024-003 Finding Summary: Current obligation information was not reported correctly to the federal awarding agency Responsible Individual: Lacey Donaldson, Clerk-Treasurer Corrective Action Plan: Internal controls will be put in place to ensure Project and Expenditure Reports were pr...

Finding 2024-003 Finding Summary: Current obligation information was not reported correctly to the federal awarding agency Responsible Individual: Lacey Donaldson, Clerk-Treasurer Corrective Action Plan: Internal controls will be put in place to ensure Project and Expenditure Reports were prepared in accordance with governing requirements. Anticipated Date of Correction Action Plan: Correction will be made on the next annual report due in April of 2025.

View Audit 341826

Finding 522588 (2024-001)

Significant Deficiency 2024

Housing for Rockdale Elders, Inc.

MA

Questioned Costs HUD Housing Programs Special Tests & Provisions

Management agrees with the finding and is in the process of revising internal controls to address this issue.

View Audit 341811 Questioned Costs: $1

Finding 522542 (2024-002)

Significant Deficiency 2024

Capital Area Food Bank, Inc.,

DC

Questioned Costs Eligibility Subrecipient Monitoring

Finding 2024-002: Eligibility – Significant Deficiency in Internal Control over Compliance, Other Matter Compliance Finding Condition: During eligibility testing, we found instances of non-compliance, as follows: TEFAP – We noted that for one out of 20 participants sampled for TEFAP, an ineligible c...

Finding 2024-002: Eligibility – Significant Deficiency in Internal Control over Compliance, Other Matter Compliance Finding Condition: During eligibility testing, we found instances of non-compliance, as follows: TEFAP – We noted that for one out of 20 participants sampled for TEFAP, an ineligible community partner organization was able to order approximately 100 pounds of TEFAP food from CAFB’s website. CSFP – We noted that for one out of 40 individual participants sampled for CSFP, one participant’s original enrollment documents supporting eligibility was missing. The organization did have the participant’s re-enrollment documents for the subsequent fiscal year. This is related to a person being eligible to receive food. Views of Responsible Officials and Planned Corrective Actions: The Organization's investigation into the root causes of the two incidents revealed clerical errors. For the TEFAP incident, a mistake in the partner organization's profile allowed access to USDA food via our online ordering portal. Regarding the CSFP participant, the initial eligibility documents were misplaced, but subsequent reauthorization documents were available. The Organization’s planned corrective actions with respect to the two instances include the following: TEFAP partner eligibility:  Review and enhance existing procedures for establishing partner organization profiles; and  Establish a periodic reconciliation of partner organization’s authorized to access TEFAP commodities in the online ordering portal with a listing of authorized TEFAP partners CSFP eligibility:  Review and enhance existing procedures for filing individual eligibility documents; and  Continued internal reviews by the Organization’s compliance department covering the filing of individual eligibility documents Anticipated Completion Date: March 2025

View Audit 341804 Questioned Costs: $1

Finding 522423 (2024-001)

Significant Deficiency 2024

Albuquerque Housing Authority

NM

HUD Housing Programs Significant Deficiency

2024-001-(2023-004) MISSING REQUIRED DOCUMENTATION FROM PUBLIC HOUSING FILES (SIGNIFICANT DEFICINCY) AHA has implemented a training program for staff and is hiring a new position Compliance technical review. Responsible Party: Anticipated Completion Date: Finance Director February 2025

View Audit 341712

Finding 522420 (2024-001)

None 2024

Food for Kids, Inc.

TX

Subrecipient Monitoring Cash Management Significant Deficiency

From the desk of Rev. Vickie Keys, Executive Director. Date: January 20, 2025. Re: Lost Monitoring Visit form - Audit Finding Reference: 2024-001. The following corrective action plan will be implemented February 1, 2025 to ensure monitoring view forms are not misplaced. Step 1: The Director of Oper...

From the desk of Rev. Vickie Keys, Executive Director. Date: January 20, 2025. Re: Lost Monitoring Visit form - Audit Finding Reference: 2024-001. The following corrective action plan will be implemented February 1, 2025 to ensure monitoring view forms are not misplaced. Step 1: The Director of Operation will make monitoring visit assignments for the month. Step 2: Each Compliance Officer is to submit the monitoring form to the Director of Operation no later than the last day of the month the visit was due to be performed. Step 3: The Director of Operation will follow up with each Compliance Officer to ensure forms were received, review the form, and enter the date the visit was completed into the data base to ensure visits are made as TDA requires. Step 4: The Executive Director will review the final report of all visits conducted for the month to sensure forms are accounted for. Step 5: The Director of Operation and the Office Clerk will perform random binder checks to see if forms are filed correctly. Step 6: The Director of Operation will oversee the labiling and thinning process of forms and binders before sending boxes to storage. This will ensure stored files can be easily located. The Executive Director has final responsibility for the implementation and maintenance of this procedure.

View Audit 341706

Finding 522353 (2024-002)

Significant Deficiency 2024

Catskill Central School District

NY

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring

U.S. Department of Education Passed-Through Entity: New York State Department of Education Finding 2024-002 (Significant Deficiency) COVID-19 - Education Stabilization Fund: ARP Homeless II (Assistance Listing# 84.425U) ARP Leaming Loss (Assistance Listing# 84.425U) ESSER II (Assistance Listing# 84....

U.S. Department of Education Passed-Through Entity: New York State Department of Education Finding 2024-002 (Significant Deficiency) COVID-19 - Education Stabilization Fund: ARP Homeless II (Assistance Listing# 84.425U) ARP Leaming Loss (Assistance Listing# 84.425U) ESSER II (Assistance Listing# 84.425D) ARP Summer Enrichment (Assistance Listing# 84.425U) ARP Comprehensive After School (Assistance Listing# 84.425U) ARP ESSER III (Assistance Listing# 84.425U) Compliance Requirements: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Criteria - Expenditures must be used to prevent, prepare for, and respond to COVID-19. These programs are authorized, as applicable, by the Coronavirus Response and Relief Supplemental Appropriations (CRRSA) Act, 2021, Pub. L. No. 116-260 (December 27, 2020), and the American Rescue Plan (ARP) Act of 2021, Pub. L. No. 117-2 (March 11, 2021). The regulations in 34 CRF Part 76 (State Administration), 2 CFR Part 200 (Uniform Administrative Requirements, Cost Principles, and Audit Requirement for Federal Award and 31 CFR Part 205 (Cash Management Improvement Act) apply to these programs. The School District must: (a) 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. These internal controls should be in compliance with guidance in "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control Integrated Framework", issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). (b) Comply with the U.S. Constitution, Federal statues, regulations, and the terms and conditions of the Federal awards. (c) Evaluate and monitor the non-Federal entity's compliance with statutes, regulations and the terms and conditions of Federal awards. ( d) Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings. (e) Take reasonable measures to safeguard protected personally identifiable information and other information the Federal awarding agency or pass-through entity designates as sensitive or the non-Federal entity considers sensitive consistent with applicable Federal, State, local and tribal laws regarding privacy and responsibility over confidentiality. Condition/Context - We haphazardly sampled five COVID-19 - Education Stabilization Fund (ESF) expenditures. Our audit procedures found one disbursement where management overrode documented internal control procedures. We viewed invoices, purchase orders, and payment support and noted the disbursement was processed and paid without proper documentation to support the payment made and the payment was processed without the internal claims auditor's review prior to payment. Cause - Management override of established controls. Effect - Revenues and expenditures for one of the ESF grants were overstated prior to adjustment. Adjustment resulted in recording a receivable from the vendor and an offsetting liability to the passthrough agency providing the grant funding. Questioned Costs - None. The improper payment was subsequently adjusted out of expenditures. Recommendation - We recommend that the School District ensures that only disbursements that have been processed and approved by the internal claims auditor to be paid. Management Response - School District management concurs with the finding and will take corrective action. Corrective Action - The Business Office will review and adhere to all cash disbursements procedures and protocols. Completion Date - Effective immediately. Respectfully Submitted, Dr. Brett Miller, Assistant Supt. for Business

View Audit 341608

Finding 522325 (2024-001)

Significant Deficiency 2024

Alliance for Strategic Growth, Inc.

IN

Allowable Costs / Cost Principles Significant Deficiency

Corrective Action Plan for Current Year Finding Alliance for Strategic Growth, Inc. submits the following corrective action plan for the identified finding for the audit period July 1, 2023 through June 30, 2024. Finding 2024-001: Cost Allocation During the year ended June 30, 2024, the organizat...

Corrective Action Plan for Current Year Finding Alliance for Strategic Growth, Inc. submits the following corrective action plan for the identified finding for the audit period July 1, 2023 through June 30, 2024. Finding 2024-001: Cost Allocation During the year ended June 30, 2024, the organization did not allocate indirect expenses to all programs that benefitted from such expenses in accordance with its cost allocation plan and negotiated indirect cost rate agreement. Objective: To ensure compliance with the allowable cost requirements of grant awards by properly allocating indirect expenses to all benefiting programs in accordance with the negotiated indirect cost rate agreement and the organization's cost allocation plan. Corrective Action: Step 1: Implement Allocation System • • Responsible Party: Vice President (VP) of Fiscal Services • • Timeline: By January 31, 2025 • • Details: Implemented a cost allocation system to properly allocate its indirect expenses to all programs following its indirect cost rate agreement and cost allocation plan. Step 2: Monitor and Review • • Responsible Party: Chief Executive Officer (CEO), Chief Administrative Officer (CAO), and VP of Fiscal Services • • Timeline: Ongoing, with regular reviews • • Details: Establish a regular review process to monitor the pooled expense accounts and cost allocation to ensure the costs are properly allocated to all programs. Step 3: Report and Document • • Responsible Party: VP of Fiscal Services • • Timeline: Ongoing, with regular reports • • Details: Document all steps taken to address the finding process. Prepare quarterly reports on the status of indirect cost allocation, maintain records of the allocation, and present them to CEO and CAO. Expected Outcomes: • • Full compliance with the allowable cost requirements of grant awards. • • Accurate and equitable allocation of indirect expenses to all benefiting programs. • • Improved internal controls and accountability. _________________________________ Shauna Jester, VP of Fiscal Services

View Audit 341590

Finding 522305 (2024-002)

Significant Deficiency 2024

School District of the City of Hazel Park

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.303

See Corrective Action Plan for Chart/Table

View Audit 341580

Finding 522254 (2024-002)

Significant Deficiency 2024

The Open Door/cape Ann Food Pantry, Inc.

MA

Significant Deficiency Internal Control / Segregation of Duties

Item # 2024-002 Prepaid Expenses (Significant Deficiency in Internal Control) Criteria: Under U.S. GAAP, expenses prepaid during the fiscal year should be recorded as an asset on the statement of financial position and amortized through the remainder of the fiscal year to ensure that they are prope...

Item # 2024-002 Prepaid Expenses (Significant Deficiency in Internal Control) Criteria: Under U.S. GAAP, expenses prepaid during the fiscal year should be recorded as an asset on the statement of financial position and amortized through the remainder of the fiscal year to ensure that they are properly stated under the accrual basis of accounting. Condition: During the year under audit, the Organization did not properly reconcile the ending balance of prepaid expenses in the general ledger. Cause: Management did not take the necessary measures to reconcile prepaid expense amounts through the fiscal year to the general ledger to ensure that the ending balance of prepaid expenses was properly stated. Effect: Failure to update internal controls to comply with the requirements of U.S. GAAP could result in material misstatements of prepaid expense balances. Recommendation: The Organization should strengthen its internal control practices by updating its policies and procedures to comply with U.S. GAAP. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout fiscal year 2025 to be in full compliance with U.S. GAAP and the Uniform Guidance. This exercise is anticipated to be complete by the end of fiscal year 2025.

View Audit 341522

Finding 522253 (2024-001)

Significant Deficiency 2024

The Open Door/cape Ann Food Pantry, Inc.

MA

Significant Deficiency Internal Control / Segregation of Duties

Item # 2024-001 Valuation of Pledge Receivables (Significant Deficiency in Internal Control) Criteria: Under U.S. GAAP, long term pledge receivables are required to be discounted to net present value to ensure that they are properly stated under the accrual basis of accounting. Condition: During ...

Item # 2024-001 Valuation of Pledge Receivables (Significant Deficiency in Internal Control) Criteria: Under U.S. GAAP, long term pledge receivables are required to be discounted to net present value to ensure that they are properly stated under the accrual basis of accounting. Condition: During the year under audit, the Organization did not record the appropriate discount for long term pledge receivables. Cause: Management did not follow the requirements under U.S. GAAP for long term pledge receivables and did not take the necessary measures to ensure that the ending balance of long term pledge receivables was properly stated. Effect: Failure to update internal controls to comply with the requirements of U.S. GAAP could result in material misstatements of receivable balances. Recommendation: The Organization should strengthen its internal control practices by updating its policies and procedures to comply with U.S. GAAP. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout fiscal year 2025 to be in full compliance with U.S. GAAP and the Uniform Guidance. This exercise is anticipated to be complete by the end of fiscal year 2025.

View Audit 341522

Finding 522248 (2024-005)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

Finding 522247 (2024-004)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

Finding 522246 (2024-003)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Trai...

For the Year Ended June 30, 2024 Corrective Action Plan Finding 2024-003 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-004 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-005 Name of contact person: Corrective Action: Adult - Training to be provided to all Adult Medicaid workers to include adequate request for info: Property Checks, Vehicle Rebuttals, Resolution of Vehicles, 1/3 Reduction evaluation, policy section MA-2261and FL2; MA-2270, SA-3200. Targeted second parties will be completed for all workers for error trends. Family and Children's - Training to be provided to all caseworkers to include TWN and OVS learning gateway webinars, along with a review of Magi Budgeting (Household Composition, Income Determination & Introduction to Magi Budgeting). Reminding caseworkers on the importance of documentation and if notes are not documented it didn’t happen, including detailing information out, the documentation template needs to be completed on each case. Target checks on correct income, household composition and completed documentation will be completed monthly. Section III - Federal Award Findings and Questioned Costs (continued) Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Goldie Davis - Adult Medicaid Supervisor Training to be provided to all Adult Medicaid workers to include resource entry/documentation: Policy Section MA-2230, Liquid Resources, Life Insurance CV, Property tax value, and Vehicle tax values. Documentation Long-term care/Private Living Arrangement (PLA) template provided to workers and will be implemented at the county level to be required for all case files. PLA will implement a check list to be attached to all case files as a requirement. Targeted second parties will be completed for all workers for error trends. 12/2/2024 Angel Carpenter –Family and Children's Medicaid Supervisor Medicaid caseworkers will receive refresher training to include how to process an IV-D referral at the request of the Child Support caseworker according to policy. Caseworker will receive the DHB Admin Letter No. 13-23 “Child Support Cooperation and Applying for Other Monetary Benefits Post Eligibility Benefits During the Continuous Coverage Unwinding (CCU) handouts for review. 12/13/2024 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 190

View Audit 341498

Finding 522245 (2024-002)

Significant Deficiency 2024

Nash County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-002 Name of contact person: Corrective Action: Proposed completion date: Section III - Federal Award Findings and Questioned Costs For the Year Ended June 30, 2024 Corrective Action Plan 01/10/2025 and...

Finding 2024-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2024-002 Name of contact person: Corrective Action: Proposed completion date: Section III - Federal Award Findings and Questioned Costs For the Year Ended June 30, 2024 Corrective Action Plan 01/10/2025 and 01/24/2025 Angel Carpenter –Family and Children's Medicaid Supervisor; Goldie Davis - Adult Medicaid Supervisor Medicaid caseworkers will receive additional and/or refresher training to include but not limited to running online data (OVS) when required, reviewing case determinations to ensure correct income and household size are being counted for each household member actively receiving on case(s), and accuracy of data entered onto dashboard. Second Party reviews will continue to be conducted to monitor continued progress and to ensure policies and procedures are correctly followed by caseworkers. Documentation templates have also been created and put into place to assist in ensuring cases are thoroughly documented. Case errors will be included on the Agenda for upcoming Staff Meetings and discussion will include review of accuracy/double checking determination decisions to ensure they are correct prior to authorizing or releasing determinations from hold on cases in NC FAST and ensuring correct income and household compositions are correct on determinations prior to authorizing or releasing cases from hold on cases in NC FAST and ensuring correct income and household compositions are correct on determinations prior to authorizing or releasing cases from hold. Training scheduled by 01/10/2025 for “Income & Deduction Wizard and by 01/24/2025 for “Mastering Medicaid Policy”, “Recertification & NC Fast 20020 (July 2023) “ and “ Recertification & CCU Training. Target checks on correct income, household composition and completed documentation will be completed monthly. Section II - Financial Statement Findings Dec 31, 2024. Mary Hogan, Finance Director The County agrees with the finding and will appropriately budget and make budget anendments for all leases in the future per GASB 87. Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 189

View Audit 341498

Finding 522218 (2024-006)

Significant Deficiency 2024

Lee County

NC

Cash Management Eligibility Reporting

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: S...

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/09/2024 and 10/17/2024 Finding 2024-006 Untimely Review of SSI Terminations Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Section III - Federal Award Findings and Questioned Costs (continued) Training has been conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Untimely Review of SSI Terminations topic with staff specifically concerning the finding areas and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. 170

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Finding 522217 (2024-005)

Significant Deficiency 2024

Lee County

NC

Eligibility Reporting Significant Deficiency

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: S...

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/09/2024 and 10/17/2024 Finding 2024-006 Untimely Review of SSI Terminations Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Section III - Federal Award Findings and Questioned Costs (continued) Training has been conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Untimely Review of SSI Terminations topic with staff specifically concerning the finding areas and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. 170

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Finding 522216 (2024-004)

Significant Deficiency 2024

Lee County

NC

Eligibility Significant Deficiency

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: S...

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/09/2024 and 10/17/2024 Finding 2024-006 Untimely Review of SSI Terminations Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Section III - Federal Award Findings and Questioned Costs (continued) Training has been conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Untimely Review of SSI Terminations topic with staff specifically concerning the finding areas and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. 170

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Finding 522215 (2024-003)

Significant Deficiency 2024

Lee County

NC

Subrecipient Monitoring Eligibility Reporting

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 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Acti...

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 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/9/2024 6/30/2025 Section III - Federal Award Findings and Questioned Costs Training has been conducted on the Inaccurate Information Entry topic with staff specifically concerning the finding areas and ensuring all verified information is appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review verify that proper procedures are being followed with regard to these policies. Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings 6/30/2025 Candace Iceman, Finance Director Budget amendments will be prepared to properly account for lease and subscription principal payments and required reporting. In addition, the budget will be closely monitored going forward to ensure budget availability. Candace Iceman, Finance Director A full review of the existing lease and subscription agreements will be done to ensure accurate data is being tracked and terminations are being removed from all reporting schedules in a timely manner. Additionally, any existing agreements that have a change of terms will be terminated instead of modified to provide accurate and transparent information. Reviews of these documents will be conducted quarterly to make timely adjustments and corrections. 169

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