Finding 515744 (2024-001)

Significant Deficiency Repeat Finding
Requirement
E
Questioned Costs
-
Year
2024
Accepted
2024-12-18
Audit: 333590
Organization: Forsyth County, North Carolina (NC)

AI Summary

  • Core Issue: The County failed to consistently follow up on eligibility reviews and did not perform required Register of Deeds checks during recertification.
  • Impacted Requirements: Internal controls over Federal awards were not effectively maintained, violating Section 200.303 of the Uniform Guidance.
  • Recommended Follow-Up: Assign individuals to ensure timely reviews and follow-ups, and ensure all eligibility checks are completed as per policy.

Finding Text

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal Assistance Listing Number: 93.778 Significant Deficiency and Non-Material Noncompliance – Eligibility Finding 2024-001 Criteria: In accordance with Section 200.303 of the Uniform Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The non-federal entity is also required to confirm that the Register of Deeds was checked for aged, blind, or disabled cases or MQB programs to determine if the individual owns property and is documented in the case file and agrees to information in the NC FAST system. Condition: The County did not follow up with individuals after reviews were completed and issues were noted in the review in accordance with its policies on a consistent basis. The County did not perform a Register of Deeds check during the recertification period. Context: There were 11 instances out of 60 reviews tested in which the County did not remediate the errors identified timely. There was 1 instance out of 60 eligibility samples tested that did not have a Register of Deeds check performed during the recertification period. Questioned Costs: No questioned costs reported. Effect: The caseworkers that had errors identified in their eligibility determinations were not notified timely of the issues which could result in potential future issues. The required procedures and verification checks were not fully followed during the period of recertification. Cause: The County has a policy in place but does not have a way to ensure the policy is being enforced. The County missed the step to run the Register of Deeds check at the time of recertification. Recommendation: We recommend the County assign individuals to ensure all reviews are taking place timely in accordance with its policy including timely follow up with case workers once the review is complete. We also recommend all required steps are performed during eligibility check and the recertification period. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan. Corrective Action Plan: See Corrective Action Plan prepared by the County.

Corrective Action Plan

Finding 2024-001, Significant Deficiency and Non-Material Non-Compliance - Eligibility: During the Medicaid control testing, eleven cases were identified that required subsequent corrections in NCFAST; however, these corrections were not completed within the 20-day requirement following the case worker’s audit, as mandated by DHHS policy. Corrective Action Plan: Case Corrections Goal: To ensure Medicaid error findings identified by internal and external audits are timely and accurately corrected for compliance, oversight will be provided by Medicaid Leadership and applicable staff. Plan: The county’s Medicaid Audit Submission tool has been revised to include a case correction due date for eligibility, procedural, and internal control findings. The revision ensures compliance with timely and accurate case corrections. Case corrections must be initiated within five business days of the case audit date. When policy allows, case corrections should be completed within 20 days of the case audit. Performance Improvement Strategies: 1. Program managers, supervisors, applicable lead staff, and trainers, will be provided access and training on the audit tool to monitor the compliance of timely and accurate case corrections. 2. Audit reports will be stored on the county’s OneDrive in the Medicaid Division folder. 3. Supervisors will begin to follow up no later than the 6th business day from the date of audit to ensure case corrections have been completed or initiated, at minimum, by the eligibility specialist. Supervisors will follow up throughout the case correction process to ensure corrections are complete and accurate. 4. Each month, for the prior month, each program manager will select a total of ten audit findings from the Medicaid Audit Finding spreadsheet to ensure their assigned supervisors are compliant with the case correction procedure. These compliance reviews will be conducted and saved to the Medicaid Division folder by the last day of the month. Program managers will take further corrective measures if noncompliance is discovered, by first reporting the continued deficiencies to the Medicaid Division Director. Responsible Parties: Medicaid Program Mangers, Jennifer Hurdle and Alison Westbrook Timeframes: A Medicaid Division meeting will be held no later than November 30, 2024, with all program managers, supervisors, lead staff, and trainers to discuss roles and responsibilities, receive the required training, and the state’s requirement of compliance with monthly audits, case corrections, and corrective actions to mitigate risks from recurring. Agenda and sign-in sheet are required and due to D. Hill no later than December 5, 2024. Finding 2024-001, Significant Deficiency and Non-Material Non-Compliance - Eligibility: During the eligibility compliance testing, it was identified that a Register of Deeds (ROD) check had not been performed at the time of recertification for one case. Although this was an oversight, it did not impact the eligibility determination for the case. The ROD results were subsequently reviewed during the audit process, confirming that the beneficiary was appropriately eligible to receive benefits. This error was classified as a procedural and documentation issue related to the completion of the ROD check. Corrective Action Plan: Register of Deeds Goal: To ensure Register of Deeds (ROD) is inquired and the results are uploaded to the County’s document imaging system when policy requires. Plan: Medicaid programs that have a resource limit require inquiries to be made to the local ROD in the applicant's county of residence to assist with identifying countable and non-countable assets such as real property when determining Medicaid eligibility at application and redetermination. Performance Improvement Strategies: 1. Adult Medicaid - program manager, supervisors, applicable lead staff, and trainers, will develop a required documentation template for all Adult Medicaid staff to use when completing applications and recertifications. The template will be used for all programs under the Adult Medicaid umbrella without exception. The template will include a subsection for resources, highlighting the date ROD checks were conducted and uploaded into NC FAST, if applicable. ROD verification of real property and verification of no real property should be uploaded to the attachments folder within the administrative tab on the Income Support Case. 2. The documentation template will be included in the note section on the beneficiary’s person page or the head of household’s (HOH) person page, if the applicant is not the HOH. 3. The required template will be added to the audit tool to ensurecompliance. 4. Supervisors are required to provide compliance when conducting monthly second party reviews by ensuring the required template, documentation, and uploaded ROD verification is present and correct. 5. Supervisors will take further corrective measures if noncompliance is discovered by first reporting the continued deficiencies to the Medicaid Division Director and Adult Medicaid Program Manager. Responsible Parties: Adult Medicaid Program Manager, Supervisors, Lead Staff, and Trainers Timeframes: A Medicaid Division meeting will be held no later than November 30, 2024, with the Adult Medicaid program managers, supervisors, lead staff, trainers, and other applicable staff to introduce and provide training on the mandatory template. The template will be effective December 1, 2024, with supervisor compliance beginning January 1, 2025, for dates of applications beginning December 1, 2024, and redeterminations initiated beginning December 1, 2024. Agenda and sign-in sheet are required and due to D. Hill no later than December 5, 2024.

Categories

Subrecipient Monitoring Eligibility Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1092186 2024-001
    Significant Deficiency Repeat

Programs in Audit

ALN Program Name Expenditures
93.778 Medical Assistance Program $7.93M
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $4.19M
93.563 Child Support Services $2.97M
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $1.96M
93.658 Foster Care Title IV-E $1.11M
93.044 Special Programs for the Aging, Title Iii, Part B, Grants for Supportive Services and Senior Centers $900,283
93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund $835,764
93.045 Special Programs for the Aging, Title Iii, Part C, Nutrition Services $747,517
93.767 Children's Health Insurance Program $613,502
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $503,935
93.994 Maternal and Child Health Services Block Grant to the States $443,878
66.001 Air Pollution Control Program Support $328,908
93.667 Social Services Block Grant $251,962
93.217 Family Planning Services $248,118
93.268 Immunization Cooperative Agreements $244,682
93.659 Adoption Assistance $236,807
93.052 National Family Caregiver Support, Title Iii, Part E $213,118
93.568 Low-Income Home Energy Assistance $201,516
93.923 Disadvantaged Health Professions Faculty Loan Repayment Program (flrp) $186,914
16.922 Equitable Sharing Program $181,245
93.940 Hiv Prevention Activities Health Department Based $180,179
93.053 Nutrition Services Incentive Program $138,336
21.023 Emergency Rental Assistance Program $119,109
93.645 Stephanie Tubbs Jones Child Welfare Services Program $86,596
93.556 Marylee Allen Promoting Safe and Stable Families Program $74,304
16.738 Edward Byrne Memorial Justice Assistance Grant Program $73,319
93.917 Hiv Care Formula Grants $56,449
66.034 Surveys, Studies, Research, Investigations, Demonstrations, and Special Purpose Activities Relating to the Clean Air Act $51,604
93.069 Public Health Emergency Preparedness $48,978
11.307 Economic Adjustment Assistance $45,500
14.239 Home Investment Partnerships Program $41,095
93.558 Temporary Assistance for Needy Families $40,347
93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response $40,330
21.027 Coronavirus State and Local Fiscal Recovery Funds $35,193
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $32,550
93.991 Preventive Health and Health Services Block Grant $32,028
93.116 Project Grants and Cooperative Agreements for Tuberculosis Control Programs $24,877
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $11,720
93.136 Injury Prevention and Control Research and State and Community Based Programs $7,509
93.674 John H. Chafee Foster Care Program for Successful Transition to Adulthood $3,410