Corrective Action Plans

Finding 524346 (2024-003)

Significant Deficiency 2024

MN

Subrecipient Monitoring Cash Management Reporting

Finding 2024-003 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District has already begun evaluating current procedures for accurately monitoring, recording, and re...

Finding 2024-003 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District has already begun evaluating current procedures for accurately monitoring, recording, and reporting the number and type of meals served. 3. Official Responsible Mr. Greg Johnson, Superintendent, is the official responsible for ensuring corrective action. 4. Planned Completion Date The planned completion date is June 30, 2025. 5. Plan to Monitor Completion The Board of Directors will be monitoring this Corrective Action Plan.

View Audit 343576

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 524338 (2024-002)

Significant Deficiency 2024

Culberson County-Allamoore Independent School District

TX

Reporting § 200.512

Recommendation: We recommend the District review policies and procedures to ensure all submissions as required by 2 U.S. Code of Federal Regulations (CFR) 200.512 are submitted timely. Action Taken: District management will review their grant management policies and procedures to ensure that they...

Recommendation: We recommend the District review policies and procedures to ensure all submissions as required by 2 U.S. Code of Federal Regulations (CFR) 200.512 are submitted timely. Action Taken: District management will review their grant management policies and procedures to ensure that they are in compliance with all reporting requirements. Anticipated Completion Date: Throughout Fiscal Year Ending August 31, 2025

View Audit 343557

Finding 524336 (2024-001)

None 2024

South Cook County Intermediate Service Center #4

IL

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

CONDITION: The South Cook Intermediate Service Center #4 had inadequate controls over grant compliance to ensure all grant reports during the fiscal year were timely reported and grant requirements were met. During testing of the South Cook Intermediate Service Center #4’s compliance with the grant...

CONDITION: The South Cook Intermediate Service Center #4 had inadequate controls over grant compliance to ensure all grant reports during the fiscal year were timely reported and grant requirements were met. During testing of the South Cook Intermediate Service Center #4’s compliance with the grant requirements, we noted the following: For Public Safety Partnership and Community Policing Grants - • One of 2 (50%) quarterly federal financial reports were submitted 36 days late. • One of 1 (100%) semi-annual performance report was submitted 47 days late. For McKinney-Vento Education for Homeless Children and Youth - • Four of 4 (100%) quarterly expenditure reports and the Grant Accountability and Transparency Act (GATA) reports were submitted but the South Cook Intermediate Service Center #4 was unable to provide proof of submission; therefore, we were unable to determine if the required reports were submitted timely or at all. • South Cook Intermediate Service Center #4 did not formally establish a Community Advisory Group. PLAN: Management will develop more formal and comprehensive grant monitoring procedures that will include a checklist for all the necessary reporting and compliance requirements. Specifically for the Mc-Kinney Vento grant, formal documentation for the established Community Advisory Group will be obtained in consultation with the grantor. ANTICIPATED DATE OF COMPLETION: June 30, 2025 CONTACT PERSON: Dr. Anthony Marinello, Executive Director

View Audit 343535

Finding 524330 (2024-001)

Material Weakness 2024

Town of Brunswick Maine

ME

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. ...

Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. Moving forward, any employee who has time split between multiple grants or Federal and non-Federal activities will be expected to complete a personnel activity report. This report will record actual time spent working on eligible activities for each fund. If the employee has a regular schedule, the employee’s schedule will suffice as their personnel activity report, as long as it follows the guidelines. The personnel activity reports will be requested each month during the reimbursement request process and will be signed by the employee and their supervisor.

View Audit 343523 Questioned Costs: $1

Finding 524327 (2024-004)

None 2024

Town of Brunswick Maine

ME

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Management Response/Corrective Action Plan: We have had a lot of turnover in the business office with a new finance director, payroll coordinator, and finance accounts coordinator (bookkeeper). Since being notified of the issue, we have put procedures in place to ensure issues related to MainePERS ...

Management Response/Corrective Action Plan: We have had a lot of turnover in the business office with a new finance director, payroll coordinator, and finance accounts coordinator (bookkeeper). Since being notified of the issue, we have put procedures in place to ensure issues related to MainePERS contributions do not occur and/or are resolved in a timely manner. As employees are hired, or change funding accounts, the payroll coordinator now has procedures in place to check the appropriate deductions for each account. We also are up to date with MainePERS reconciliation, which includes reviewing contributions for federally funded employees. If an error occurs, the process will cause us to review the issue and reconcile the accounts as necessary.

View Audit 343523 Questioned Costs: $1

Finding 524324 (2024-003)

Significant Deficiency 2024

Town of Brunswick Maine

ME

Procurement, Suspension & Debarment

Management Response/Corrective Action Plan: Once notified of this requirement, the School District put procedures in place to comply with 2 CFR part 180. If federal funds are to be used to contract with a party that is expected to equal or exceed $25,000, the finance department will check SAM.gov e...

Management Response/Corrective Action Plan: Once notified of this requirement, the School District put procedures in place to comply with 2 CFR part 180. If federal funds are to be used to contract with a party that is expected to equal or exceed $25,000, the finance department will check SAM.gov exclusions to ensure the contractor is not suspended or debarred. Administration who may enter into a contract with a party using federal funds will be given a memo describing the need to notify the finance department before entering into a contract.

View Audit 343523

Finding 524321 (2024-002)

Significant Deficiency 2024

Town of Brunswick Maine

ME

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. ...

Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. Moving forward, any employee who has time split between multiple grants or Federal and non-Federal activities will be expected to complete a personnel activity report. This report will record actual time spent working on eligible activities for each fund. If the employee has a regular schedule, the employee’s schedule will suffice as their personnel activity report, as long as it follows the guidelines. The personnel activity reports will be requested each month during the reimbursement request process and will be signed by the employee and their supervisor.

View Audit 343523 Questioned Costs: $1

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 524318 (2024-009)

Significant Deficiency 2024

Northampton County

NC

Eligibility

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 524316 (2024-001)

Significant Deficiency 2024

Iona College

NY

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

FINDING 2024-001 Name of Responsible Individual: Daniel Arndt, Registrar Corrective Action: Management acknowledges the finding regarding the inaccurate reporting of student data elements under the Program-Level record on the NSLDS website. To address this issue, the University has implemented a cor...

FINDING 2024-001 Name of Responsible Individual: Daniel Arndt, Registrar Corrective Action: Management acknowledges the finding regarding the inaccurate reporting of student data elements under the Program-Level record on the NSLDS website. To address this issue, the University has implemented a corrective action plan that includes updating our reporting frequency and enhancing our data review processes: Updated Reporting Frequency: As of January 2025, the University now includes the non-compulsory terms, summer 1 and winter sessions, in its reporting. Previous institutional practice did not include reporting program level data for these terms given that said terms do not involve federal financial aid. This change ensures that all Program-Level data, regardless of federal financial aid involvement, is accurately reported. Secondary Check Process: Each month, the Compliance Officer will review a sample of 100 students from NSLDS to verify significant data elements, including program enrollment effective dates. After the initial review, the Compliance Officer will summarize the findings and share them with the Associate Registrar and Registrar for a secondary review. Any necessary edits will be made, followed by a review of an additional 25 students to ensure accuracy. We believe these corrective action steps are critical to ensuring accurate reporting and preventing this issue in the future. Anticipated Completion Date: January 31, 2025

View Audit 343512

Finding 524287 (2024-002)

Significant Deficiency 2024

Close Up Foundation

VA

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.329

Views of Responsible Officials: Historically, the Foundation has submitted all required documents per the grant agreement. GrantSolutions is a newer platform by which all documents must be uploaded. When the final financial reports were submitted, the grant was closed without the performance report ...

Views of Responsible Officials: Historically, the Foundation has submitted all required documents per the grant agreement. GrantSolutions is a newer platform by which all documents must be uploaded. When the final financial reports were submitted, the grant was closed without the performance report and the grant was removed from the dashboard. The performance report was prepared by the deadline, but the grant manager was not aware of the alternative dropdown to upload the file. Moving forward, everyone who has access to GrantSolutions, both in Finance and Development, must acquaint themselves with the site and crosscheck that the required documents are uploaded timely, especially prior to a grant closing.

View Audit 343499

Finding 524286 (2024-001)

None 2024

Bcfs Health and Human Services

TX

Reporting

Views from Responsible Officials and Corrective Action Plan Audit Finding Reference Number: 2024-001 Finding: Non-compliance with timely submission of required performance reports. Responsible Person(s): Rosa Baez, Acting President Views from Responsible Officials: A change in management led to a de...

Views from Responsible Officials and Corrective Action Plan Audit Finding Reference Number: 2024-001 Finding: Non-compliance with timely submission of required performance reports. Responsible Person(s): Rosa Baez, Acting President Views from Responsible Officials: A change in management led to a delay in transferring reporting deadlines to the successor team, resulting in a late performance report submission. Corrective Action Plan: Management has created a compliance planner tracker that lists all reporting deadlines. This tracker will automatically send notifications seven days before each deadline to ensure timely submissions. Anticipated Completion Date: February 15th, 2025

View Audit 343489

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

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