GUILFORD COUNTYLocal Government

Finding 2024-001 U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services Maternal & Child Health Services Assistance Listing # 93.994 Nonmaterial Noncompliance – Eligibility Criteria: To be eligible for maternal and child health ambulatory services provided by MCH program funds, clients must meet the eligibility criteria established by the local provider. Financial eligibility requirements may not be more restrictive than the official poverty line issued annually by the United States Department of Health and Human Services (10A NCAC 43B.0105). Appropriate fees should be collected from each participant upon each visit to the clinic which are based on the determination of eligibility classification. Condition: Out of 40 case files tested, one case was noted where the fee was properly assessed at 60%, however, was not charged correctly when the participant visited the clinic. Questioned Costs: $60. Context: The participant should have been billed for 60%, or $60, for clinic services. Effect: By not charging the proper fee based on eligibility criteria, the County may be reimbursed for unallowed amounts and may have to return these funds. Cause: A staff member in Central Billing believed the teen clinic was free of charge. Recommendation: We recommend the County ensure caseworkers are receiving necessary training to ensure they are aware of compliance requirements. Management’s Response: Management agrees with the finding and has already provided training to staff that teen clinic services are billable based on income and eligibility requirements.

U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services Medical Assistance Programs Assistance Listing # 93.778 Finding 2023-001 Nonmaterial Noncompliance – Eligibility Criteria: The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NC FAST, and to ensure all required physical documentation is located in the file to properly document eligibility with program requirements. The County should ensure all countable resources are computed accurately and all income information is entered into NCFAST correctly. Condition: There were 5 out of 60 participants tested with various filing errors noted below. Due to theCOVID-19 Public Health Emergency, there were waivers in place during the fiscal year in which prevented the termination of benefits. In all instances, participants were found to be eligible for benefits. Questioned costs: None. Context: There was one instance where the approval notice was not in case file but case was properly approved; one instance where OVS was generated but not documented on the Evidence dashboard; one instance where DMA-5097 was not in the case file; one instance where income was calculated incorrectly; and one instance where checking account amount was not included in resources. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk that the County could not immediately substantiate the eligibility determination. Cause: The increased workload caused by the global pandemic, coupled with Federal and State directives to not reduce or terminate benefits leading to human errors regarding clerical and data entry activities. Recommendation: Although this issue will occur from time to time considering the volume of case files that the County processes and maintains, we recommend procedures be reinforced by means of training to ensure all proper documentation is kept and maintained. Management’s Response: Management agrees with the finding but wishes to stress that Federal directives mandated eligibility for all applicants. Although eligibility was not affected, DSS mid-management will continue to close any continuous quality improvement process issues as well as work to improve trainings / supervision to reduce these technical errors. The results of the Single Audit will be focus areas for monthly refreshers and future trainings.

U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services Medical Assistance Programs Assistance Listing # 93.778 Finding 2022-001 Nonmaterial Noncompliance - Eligibility Criteria: The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NC FAST, and to ensure all required physical documentation is located in the file to properly document eligibility with program requirements. The County should ensure all countable resources are computed accurately and all income information is entered into NCFAST correctly. Condition: There were 10 out of 60 participants tested with various filing errors noted below. Due to the COVID-19 Public Health Emergency, there were waivers in place during the fiscal year. In all instances, participants were found to be eligible for benefits. Questioned costs: None Context: There was one instance where the countable resources was not computed accurately in NCFAST. There were three instances where income was not entered into NCFAST correctly. There was one instance where the DMA-5097 was not on file. There were two instances where the income from the tax return was not counted correctly. There was one instance where the OVS was not run on a client. There were two instances where the OLV was not documented in the system. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk that the County could not immediately substantiate the eligibility determination. Cause: The increased workload caused by the global pandemic, coupled with Federal and State directives to not reduce or terminate benefits. Recommendation: Although this issue will occur from time to time considering the volume of case files that the County processes and maintains, we recommend procedures be reinforced in order to ensure all proper documentation is kept and maintained. Management?s Response: Management agrees with the finding but wishes to stress that Federal directives mandated eligibility for all applicants. Management also wishes to note that due to the pandemic they were unable to fully staff and properly train workers who were found and hired.

U.S. Department of Treasury Emergency Rental Assistance Program Assistance Listing # 21.023 Finding 2022-002 Nonmaterial Noncompliance ? Reporting Criteria: Monthly and quarterly reports are due to the Department of Treasury within 15 days of month-end. The County should ensure all necessary reports are submitted timely. Condition: There was 1 out of 8 reports submitted late as noted below. Questioned costs: None Context: There was one instance where a report was submitted 13 days later than the required deadline. Effect: Expenditures may not be reviewed and approved by the grantor Agency in a timely manner. Cause: Staff turnover at the Director level. Also, increased workload caused by the global pandemic, coupled with staffing shortages during the year. Recommendation: We recommend the County implement a process to track and meet required reporting deadlines going forward. Management?s Response: The delay in reporting was due to turnover in the Finance Director position in mid-June 2022 and a subsequent misunderstanding of the due date. The newly appointed interim Finance Director believed the report to be due by July 31, 2022. We agree with the recommendation.

U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services Maternal and Child Health Services Block Grant to the States (Federal and State Awards) Assistance Listing # 93.994 Finding 2021-001 Significant Deficiency ? Eligibility Criteria: The County should have adequate monitoring controls to ensure that quality reviews and appropriate documentation is maintained in accordance with County/Federal/State guidance. Condition: There were three months during the year in which no Maternity reviews were completed and eight months in which no Family Planning reviews were completed. Questioned costs: None Context: * There were three months where no quality reviews of Maternity cases were performed. * There were eight months where no quality reviews of Family Planning cases were performed. Effect: By not having the reviews completed on a regular basis or the issues found in the reviews not being discussed or addressed, there is a risk that the required documentation is not obtained or maintained in the files. Cause: The ongoing COVID-19 pandemic and general staffing issues seen across departments has put a strain on the resources. As a result, the reviews were either not performed or timely discussion and/or corrections were not completed. Recommendation: We recommend procedures be reinforced in order to ensure reviews are made and training and caseworker follow-up is performed. Views of responsible officials: During the Covid-19 pandemic, the County deployed limited resources where they could best service the citizens of the County. We performed an appropriate number of reviews given our resources. We will update our review schedule to better reflect the review standards going forward.

U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services Medical Assistance Programs Assistance Listing # 93.778 Finding 2021-002 Nonmaterial Noncompliance ? Eligibility Criteria: The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NC FAST, and to ensure that all required physical documentation is located in the file to properly document eligibility with program requirements. Condition: There was 1 out of 60 participants tested with the filing error noted below. Questioned costs: $7.76 Context: There was one instance where supporting documentation of the Online Verification System/Online Verification (?OVS/OLV?) was not adequately included in the case file. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk that the County could not immediately substantiate the eligibility decision. Cause: The increased workload caused by the global pandemic, coupled with the State?s directive to not reduce or terminate benefits. Recommendation: Although this issue will occur from time to time considering the volume of case files that the County processes and maintains, we recommend procedures be reinforced in order to ensure that all proper documentation is kept and maintained. Views of responsible officials: The OLV was reviewed prior to granting eligibility; however, the OLV was not attached as required. The County will continue to stress the importance of attaching documentation in future training sessions. The County re-substantiated that the recipient was eligible to receive Medicaid benefits.

U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services Medical Assistance CFDA # 93.778 Finding 2020-001 Nonmaterial Noncompliance ? Eligibility Criteria: The County should have adequate monitoring controls to ensure that all information is updated appropriately in recipient?s files and in the NC FAST system, and to ensure that all required physical documentation is located in the file to properly document eligibility with program requirements. Condition: There were 12 out of 60 participants tested with errors noted below. All were determined to have properly been eligible. Questioned costs: None. Costs are under the amount to be reported. Context: The following are the results of non-material, non-compliance noted for each criteria listed above out of the 60 program participants selected for testing: * There were four instances where the OVS/OLV were not completed during the period tested. * There were four instances where income determination was incorrectly calculating client?s income, which affected the client?s program classification. * There were four instances where income determination (earned or unearned income) was incorrectly calculating the client?s income, but was still in the proper Medicaid class. * There was one instance where the household count did not include a member of the household that should have been counted and the category class was incorrect. Client should have received MIC-1 and not MAF-C. * There were one instance in which the SSN was not verified * There was one instance in which the DSS-5097 was never sent by the County and the IV-D referral should have been completed. * There was two instances where the DMV in OVS/OLV did not agree to the information entered into NC FAST. * There was one instance where the AVS search in OVS/OLV did not agree to the information entered into NC FAST. Upon reexamination of each of the files listed above, the County was able to substantiate that all of the recipients were eligible to receive Medicaid benefits. This was accomplished by such means as re-computation of the budget by retrieving the online verification form (OLV) which matched the Medicaid Coverage period to ensure all appropriate income sources were included in the computation. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk that the County could provide funding to individuals who are not eligible. Cause: Workers attention to detail and insuring that all OVS/OLV/AVS results are run and that staff are aware and able to troubleshoot the results that are inconclusive. Workers attention to certification period based on type of Medicaid being approved. County oversight when performing reviews over applications. Recommendation: Although these issues will occur from time to time considering that Guilford County processes and maintains more than 54,000 recertifications each year, we recommend that procedures be reinforced in order to ensure that all proper documentation is kept and maintained in the case file. Views of responsible officials: Guilford County agrees with the above finding.

U.S. Department of Health and Human Services Passed through N.C. Department of Health and Human Services, Division of Child Development Program Name: Subsidized Child Care Cluster CFDA#: 93.575 and 93.596 Finding: 2019-001 Nonmaterial Noncompliance ? Allowable Costs/Activities, Eligibility, and Special Tests and Provisions (Federal) Criteria or Specific Requirement: As noted in the Subsidized Child Care Service Manual, Chapter 4, the DCD-0456, Application for Child Care Services, must be signed by the parent, responsible adult, or designated staff person (if the child is in county custody or services are needed to support Child Protective Services) at the time of initial determination of eligibility. As noted in the Subsidized Child Care Service Manual, Chapter 9, DCD-0446, Child Care Vouchers are to be printed for parental signature. Condition: We noted one instance out of 40 cases tested in which the case file was missing the required signatures on the DCD-0456. Known questioned costs: None noted. Context: We noted one instance in which a case file include the DCD-0456 but the form was not signed by the applicant or caseworker. Effect: The County was not in compliance with the Subsidized Child Care Service Manual. Cause: The County?s review control was not operating effectively. Recommendation: We recommend the County implement a process to ensure all forms are adequately signed. Views of responsible officials: Management agrees with the finding.

U.S. Department of Health and Human Services Passed-through the N.C. Dept. of Health and Human Services, Division of Social Services Program Name: Temporary Assistance for Needy Families CFDA # 93.558 Finding: 2019-002 Significant Deficiency ? Nonmaterial Noncompliance ? Eligibility (Federal) Criteria: County should adhere to all determinations and redeterminations in accordance with program eligibility requirements. Condition: During our testing of eligibility, we noted seven instances where there was noncompliance with the Temporary Assistance for Needy Families program requirements. Context: A sample of 40 case files was tested. Of the 40 files sampled, we noted the following: - Three instances in which payment was incorrectly calculated. - Three instances where the OLV had not been run for the period tested. - One instance where resources or countable assets were not verified. Known Questioned Costs: For one case the caseworker did not run online verification form (?OLV?) which would have shown a social security payment in July. The questioned costs for this case is $715 as the benefit payment should have been adjusted. For one case the caseworker did not run OLV which would have shown child support being received. The reduction in benefits for this case would have be $86 per month for a total of three months or $258. For one case the caseworker did not included child support in the calculation of countable assets. The reduction in benefits for this case would have been $27 for one month. Effect: The County may provide benefits to individuals that are not eligible for the program. By not maintaining supporting documentation of the OLV in the file, there is the risk that countable income could have been calculated incorrectly. If countable income is incorrectly counted, recipients could receive incorrect benefit payments. Cause: Caseworker oversight. Recommendation: Although these issues will occur from time to time considering the volume of case files that the County processes and maintains, it is recommended that procedures are enforced to verify all required eligibility information is obtained, recorded, and updated appropriately. Views of Responsible Officials: Management agrees with the finding.

U.S. Department of Health and Human Services Passed through N.C. Department of Health and Human Services, Division of Social Services Program Name: Temporary Assistance for Needy Families CFDA#: 93.558 Finding: 2019-003 Significant Deficiency ? Nonmaterial Noncompliance ? Eligibility (Federal) Criteria or Specific Requirement: In accordance with Section 200.303 of the Uniform Grant Guidance, each non-federal entry must establish and maintain effective internal controls over the federal award that provides assurance that the non-federal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: We noted one instance in which corrective action on an eligibility case selected by the County?s Quality Assurance Department was not remediated during the fiscal year, resulting in an ineligible case. Context: Out of 40 cases tested for eligibility, one case did not meet the County?s documentation and process standards. Corrections to this case were not made until 3 months after the date of recertification. Case was deemed ineligible once the review occurred as the participant was in non-cooperation status with Child Support at the time of application. Known Questioned Costs: Total questioned costs of $703 based on payments made during the period of ineligibility. Effect: Case file was incomplete or did not adhere to the County?s policies or procedures. Cause: The County?s policy to quality review remediation is to only correct cases if the individual?s eligibility status could change (due to the case load of current workers). Other quality control case findings are considered during training exercises. The case noted was not corrected due to caseworker oversight. Recommendation: We recommend the County implement procedures to ensure cases selected for quality review that could result in an individual being ineligible to be remediated in a timely manner. Best practices in this regard are within 30 days. Views of Responsible Officials: Management agrees with the finding.

U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services Program Name: Medical Assistance CFDA # 93.778 Finding 2019-004 Nonmaterial Noncompliance ? Eligibility (Federal and State) Criteria: The County should have adequate monitoring controls to ensure that all information is updated appropriately in recipient?s files and in the NCFAST system, and to ensure all required physical documentation is located in the file to properly document eligibility with program requirements. Condition: One instance in which documentation was missing or incorrectly documented in the case file. Two instances of incorrect eligibility determination were noted. Questioned Costs: None. Costs are under the amount to be reported. Context: We examined 93 case files. Of the 93 files sampled, we noted 3 of the files had missing or incorrect documentation as follows: - One case where the OVS/OLV were not completed. Wages were being incorrectly calculated, but did not affect Medicaid classification. - One case where MPW recertification was not conducted timely, forcing the month tested to a lesser benefit of MAF-C. Employment income was not being counted for one of the two listed jobs. Income determination was incorrectly calculating client?s income. - One case where the household detail was incorrect and the category class was incorrect. Client should have received MIC-N and not MIC-1. Upon reexamination of each of the files listed above, the County was able to substantiate all of the recipients were eligible to receive Medicaid benefits and no additional payments were made during the period. This was accomplished by such means as re-computation of the budget by retrieving the OLV which matched the Medicaid coverage period to ensure all appropriate income sources were included in the computation. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk the County could provide funding to individuals who are not eligible. Cause: Caseworker oversight. Identification of a Repeat Finding: This is a repeat finding from the Agreed-Upon Procedures performed over Medicaid for the fiscal year 2018. Recommendation: Although these issues will occur from time to time considering the volume of case files that the County processes and maintains, we recommend procedures be reinforced in order to ensure all proper documentation is kept and maintained in the case file in an attempt to prevent loose filings resulting in missing documentation. Views of Responsible Officials: Management agrees with the finding.

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