10.2 Fraud Investigation, Payment Recovery, and Sanctions

Lead Agencies must have the necessary controls to identify fraud and other program violations to ensure program integrity. Program violations can include both intentional and unintentional client and/or provider violations, as defined by the Lead Agency. These violations and errors, identified through the error-rate review process and other review processes, may result in payment or nonpayment (administrative) errors and may or may not be the result of fraud, based on the Lead Agency definition. 10.2.1 Strategies used to identify and prevent program violations Check the activities the Lead Agency employs to ensure program integrity, and for each checked activity, identify what type of program violations the activity addresses, describe the activity and the results of these activities based on the most recent analysis. a. [ ] Share/match data from other programs (e.g., TANF program, Child and Adult Care Food Program, Food and Nutrition Service (FNS), Medicaid) or other databases (e.g., State Directory of New Hires, Social Security Administration, Public Assistance Reporting Information System (PARIS)). i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: b. [x] Run system reports that flag errors (include types). i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Provider Compliance Team evaluates providers flagged on a report from the DHHS Office of Internal Audit. The report measures ￿all absent￿ attendance entries in NC FAST for three months. Many providers are using incorrect attendance codes and not following the Child Care Provider Agreement with regard to absences. Referral evaluations most often result in uncovering providers billing for children that did not attend for an extended period. All discovered provider irregularities are corrected in NC FAST. Other issues found related to violations of the child care provider agreement are addressed with Non-Compliance actions. The Provider Compliance Unit followed up on 15 OIA referrals SFY 22-23 and 19 in SFY 23-24 thus far. In SFY 22-23, five Providers were found to have errors resulting in overpayments. These overpayments totaled $4866. Non-Compliance actions were taken on two providers. These two actions resulted in overpayments of $16,660. The activities of the Provider Compliance Unit resulted in a process of revisiting providers who have a Non-Compliance action. These providers will be revisited in 6 months to ensure the provider has maintained compliance after completing the corrective action plan. iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: c. [x] Review enrollment documents and attendance or billing records. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Provider Compliance team performs attendance evaluations on approximately 400 randomly selected providers each SFY. In addition, the Provider Compliance team receives referrals from the Local Purchasing Agencies; Regulatory Services through Intake and regulatory actions taken against providers; Office of the Internal Auditor; and internal referrals when providers are found out of compliance with SCCA program requirement in random evaluations. As a result of referral referrals, providers may have overpayments, Determinations of Non-Compliance, Termination of Eligibility, and/or sanctions. Result: In SFY 23-24, one provider was terminated from subsidy participation due violations of the Provider Agreement. More training in needed for providers to ensure they understand the Subsidized Child Care Provider Agreement. DCDEE has revamped and improved the Provider Portal. In this portal the provider has to check a checkbox for each item on the Provider Agreement prior to electronically signing the agreement. The result of the all Provider Compliance activities is to plan for comprehensive provider training on the Provider Agreement. DCDEE believes this will improve provider performance on adherence to the Provider Agreement. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Provider Compliance team performs attendance evaluations on approximately 400 randomly selected providers each SFY. In addition, the Provider Compliance team receives referrals from the Local Purchasing Agencies; Regulatory Services through Intake and regulatory actions taken against providers; Office of the Internal Auditor; and internal referrals when providers are found out of compliance with SCCA program requirement in random evaluations. As a result of referrals, providers may have overpayments, Determinations of Non-Compliance, and/or Termination of Eligibility. In SFY 22-23, nine evaluations were completed from Regulatory-issued Administrative Actions. In SFY 22-23, a total of 87 referrals were evaluated. This resulted in overpayments of $186,044. Of these 87 referrals, 32 resulted in Non- Compliance actions and 26 resulted in Determination of Errors. More training is needed for providers to ensure they understand the Subsidized Child Care Provider Agreement. DCDEE has developed a revamped Provider Portal. In this portal the provider has to check a checkbox for each item on the Provider Agreement prior to electronically signing the agreement. Additional training is also needed on the use of proper attendance codes and reporting requirements when children do not attend according to their plans of care. The result of the all Provider Compliance activities is to plan for comprehensive provider training on the Provider Agreement. DCDEE believes this will improve provider performance in accurate attendance entry. iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: d. [x] Conduct supervisory staff reviews or quality assurance reviews. i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Local Purchasing Agency staff are encouraged to perform second party reviews in their agencies. There are no report requirements for Local Purchasing Agencies to provide these reviews to DCDEE staff. The Program Compliance staff presented to the Counties on May 8, 2024 regarding the new monitoring processes and scheduling. This training was later recorded and placed on the DCDEE Moodle training platform. The Program Compliance Team also presented at the annual Social Services Institute. A part of the monitoring presentation is a second party review form and DCDEE staff encourage the counties to do second party reviews. DCDEE increased monitoring from triennial to biannually for SFYs 25 and 26. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Program Compliance Consultants evaluate eligibility decisions made by the Local Purchasing Agencies. The evaluation assesses Documents Review. This includes: Signed Application and Redetermination Form, Signed Voucher, Signed Rights and Responsibilities, and Timely Processing. Need for Care is evaluated for: verifications for the need for care in five categories. Income is evaluated for earned income, Self-Employment, unearned income, and system checks completed. Evidence is assessed for accurate entry of: Level of Care, accurate service for the child, need for care, payment by enrollment or attendance, and priority group placement. Results data include the following: SFY 22-23, average score 90.71% with 15 counties scoring equal to or greater than 95%. In SFY 22-23, overpayments totaled $50,547.00. For SFY 23-24, to date, the average score is 93.93% with 13 Local Purchasing Agencies scoring equal to or greater than 95%. DCDEE Program Compliance staff complete referrals to the Technical Assistance Unit for errors cited in the Error Rate Review. Some modifications were made the the items assessed on the monitoring checklist used by DCDEE staff to focus on eligibility items. e. [x] Audit provider records. i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Provider Compliance team performs attendance evaluations on approximately 400 randomly selected providers each SFY. In addition, the Provider Compliance team receives referrals from the Local Purchasing Agencies; Regulatory Services through Intake and regulatory actions taken against providers; Office of the Internal Auditor; and internal referrals when providers are found out of compliance with SCCA program requirement in random evaluations. As a result of referral referrals, providers may have overpayments, Determinations of Non-Compliance, and/or Termination of Eligibility. In SFY 22-23, nine evaluations were completed from Regulatory- issued Administrative Actions. In SFY 22-23, a total of 87 referrals were evaluated. This resulted in overpayments of $186,044. Of these 87 referrals, 32 resulted in Non-Compliance actions and 26 resulted in Determination of Errors. More training is needed for providers to ensure they understand the Subsidized Child Care Provider Agreement. DCDEE developed a revised and improved Provider Portal. In this portal the provider has to check a checkbox for each item on the Provider Agreement prior to electronically signing the agreement. Additional training is also needed on the use of proper attendance codes and reporting requirements when children do not attend according to their plans of care. Monitoring & Compliance Unit: The monitoring & compliance unit conducts annual CCDF contract monitoring and reviews a sampling of fiscal records, performance outputs, policies, board meeting minutes, subrecipient monitoring, independent audit results, and other contract specific activities. Sample sizes and monitoring focus is based on risk assessment scores and prior monitoring report concerns. Monitoring results are included in a monitoring report, reviewed by internal staff and the Division director prior to issuing to contractors. Any corrective action is reviewed and approved before monitoring is closed. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Program Compliance Consultants evaluate eligibility decisions made by the Local Purchasing Agencies. The evaluation assesses Documents Review. This includes: Signed Application and Redetermination Form, Signed Voucher, Signed Rights and Responsibilities, and Timely Processing. Need for Care is evaluated for: verifications for the need for care in five categories. Income is evaluated for earned income, Self-Employment, unearned income, and system checks completed. Evidence is assessed for accurate entry of: level of Care, accurate service for the child, need for care, payment by enrollment or attendance, and priority group placement. Results data include the following: SFY 22-23, average score 90.71% with 15 counties scoring equal to or greater than 95%. In SFY 22-23, overpayments totaled $50,547.00. For SFY 23-24, to date, the average score is 93.93% with 13 Local Purchasing Agencies scoring equal to or greater than 95%. DCDEE Program Compliance staff complete referrals to the Technical Assistance Unit for errors cited in the Error Rate Review. Referrals the the technical assistance unit are used to plan training activities for the counties. f. [x] Train staff on policy and/or audits. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Senior Subsidy Compliance Manager delivers a presentation to the Program Integrity Regional Meetings across the state. As a result of the program integrity presentations, at least 3 counties are pursuing more fraudulent activities by recipients. DCDEE identified the need for more training for counties related to monitoring providers for correct attendance reporting. Also, more information is needed in the Subsidized Child Care Assistance program manual related to how to implement the rules governing fraud, non-compliance, and sanctions. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Technical Assistance Unit within the Subsidy Services Section provides training on policy to staff members at LPAs who are administering the program. This is completed through face to face visits and remote meetings using Microsoft Teams and training does include information about unintentional program violations. LPAs can also contact the Section's Policy Unit using a dedicated email address to receive policy guidance and consultation when there is an unintentional program violation. The activities of the Technical Assistance Unit and the dedicated email for fraud inquiries resulted in DCDEE identifying the need for more training for counties related to monitoring providers for correct attendance reporting. Also, more information is needed in the Subsidized Child Care Assistance program manual related to how to implement the rules governing fraud, non-compliance, and sanctions. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Technical Assistance Unit within the Subsidy Services Section provides training on policy to staff members at LPAs who are administering the program. This is completed through face to face visits and remote meetings using Microsoft Teams and training does include information about agency errors. The results of monitoring completed by the Program Compliance Unit are shared with TA Consultants to use to craft individualized training and TA sessions with counties. The Technical Assistance Unit is making more on-site visits to counties. They are also doing more new worker trainings as high turnover in counties affects correct application of program policies. g. [ ] Other. Describe the activity(ies): i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: 10.2.2 Identification and recovery of misspent funds Lead Agencies must identify and recover misspent funds that are a result of fraud, and they have the option to recover any misspent funds that are a result of unintentional program violations or agency errors. a. Identify which agency is responsible for pursuing fraud and overpayments (e.g., State Office of the Inspector General, State Attorney): When Providers have overpayments due to fraud and no longer participate in the Subsidized Child Care Assistance Program, the Local Purchasing Agency has the responsibility to pursue providers with repayment agreements and court actions for default on those repayment agreements. Fraudulent misrepresentation is determined by the counties. b. Check and describe all activities, including the results of such activity, that the Lead Agency uses to investigate and recover improper payments due to fraud. Consider in your response potential fraud committed by providers, clients, staff, vendors, and contractors. Include in the description how each activity assists in the investigation and recovery of improper payment due to fraud or intentional program violations. Activities can include, but are not limited to, the following: i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: DCDEE requires repayment of amounts equal to and greater than $1. ii. [ ] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Providers may choose to repay overpayments by certified check or money order in installments. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: When providers have overpayments due to fraud, a deduction of 100% of the provider’s payments are withheld. If the total amount due is not deducted, the Local Purchasing Agency is responsible for entering into repayment agreements and pursuing court action as applicable. v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [ ] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: viii. [ ] Other. Describe the activities and the results of these activities: c. Does the Lead Agency investigate and recover improper payments due to unintentional program violations? [ ] No. [x] Yes. If yes, check and describe below any activities that the Lead Agency will use to investigate and recover improper payments due to unintentional program violations. Include in the description how each activity assists in the investigation and recovery of improper payments due to unintentional program violations. Include a description of the results of such activity. i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: DCDEE requires repayment of amounts equal to and greater than $1. ii. [x] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: The Provider Compliance Unit receives quarterly reports from the Office of the Internal Auditor. These reports contain a list of providers that have irregularities in their attendance billing and other attributes. A sample of providers from this list is evaluated by the Provider Compliance Consultants. Most often providers are found to be using incorrect attendance codes and overpayments result. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Local Purchasing Agencies have the responsibility to set up repayment plans with providers who cease to participate. This includes enforcement of the repayment agreement. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: All inadvertent errors are set up for deduction of future payments in amount not to exceed 20% on the provider’s monthly payment. Providers have the option to pay a higher percentage if they choose. v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [ ] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: viii. [ ] Other. Describe the activities and the results of these activities: d. Does the Lead Agency investigate and recover improper payments due to agency errors? [ ] No. [x] Yes. If yes, check and describe all activities that the Lead Agency will use to investigate and recover improper payments due to agency errors. Include in the description how each activity assists in the investigation and recovery of improper payments due to administrative errors. Include a description of the results of such activity. i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: DCDEE requires repayment of amounts equal to and greater than $1. ii. [ ] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: iii. [ ] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: iv. [ ] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ]Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [ ] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: viii. [x] Other. Describe the activities and the results of these activities: Program Compliance Consultants evaluate eligibility decisions made by the Local Purchasing Agencies. The evaluation assesses Documents Review. This includes: Signed Application and Redetermination Form, Signed Voucher, Signed Rights and Responsibilities, and Timely Processing. Need for Care is evaluated for: verifications for the need for care in five categories. Income is evaluated for earned income, Self-Employment, unearned income, and system checks completed. Evidence is assessed for accurate entry of: level of Care, accurate service for the child, need for care, payment by enrollment or attendance, and priority group placement. Results data include the following: SFY 22-23, average score 90.71% with 15 counties scoring equal to or greater than 95%. In SFY 22-23, overpayments totaled $50,547.00. For SFY 23-24, to date, the average score is 93.93% with 13 Local Purchasing Agencies scoring equal to or greater than 95%. DCDEE Program Compliance staff complete referrals to the Technical Assistance Unit for errors cited in the Error Rate Review. e. What type of sanction will the Lead Agency place on clients and providers to help reduce improper payments due to intentional program violations or fraud? Check and describe all that apply: i. [x] Disqualify the client. Describe this process, including a description of the appeal process for clients who are disqualified. Describe the activities and the results of these activities based on the most recent analysis: When a recipient or someone claiming to be a recipient does the following: (1) With intent to deceive, makes a false statement or representation regarding a material fact, omits or fails to disclose a material fact and as a result of the false statement or representation, omission, or submission of inaccurate records, obtains, attempts to obtain, or continues to receive a child care subsidy for himself or herself or for another person. Upon the first instance of fraudulent misrepresentation by a recipient, he or she must repay the amount of child care subsidy for which he or she was ineligible to receive, and the recipient shall be permanently ineligible to participate in the Subsidized Child Care Assistance Program. A recipient shall also be permanently ineligible to participate in the Subsidized Child Care Assistance Program if convicted of fraudulent misrepresentation pursuant to G.S. 110-107. When a court of competent jurisdiction finds a recipient or operator guilty of fraudulent misrepresentation pursuant to G.S. 110-107, the sanction imposed is not subject to appeal under this Rule. Appeals by recipients from services determinations pursuant to Section .1000 of this Chapter, changes in recipient fees pursuant to Section .1100 of this Chapter, terminations of payment pursuant to 10A NCAC 10 .1007, or a sanctions issued by the Local Purchasing Agency in accordance with 10A NCAC 10 .0308 shall be made in accordance with G.S. 108A- 79. References: chapter 10 rules.pdf (state.nc.us) ii. [x]Disqualify the provider. Describe this process, including a description of the appeal process for providers who are disqualified. Describe the activities and the results of these activities based on the most recent analysis: The Division shall impose sanctions for fraudulent misrepresentation when an operator/someone claiming to be an operator does the following: (1) With intent to deceive, makes a false statement or representation regarding a material fact, omits or fails to disclose a material fact, or submits inaccurate records; and as a result of the false statement or representation, omission, or submission of inaccurate records, obtains, attempts to obtain, or continues to receive a child care subsidy for himself or herself or for another person; or (2) Has an error rate in excess of 10 percent. ￿Error rate" shall mean the correct monthly payment divided by the monthly payment paid. The "correct monthly payment" shall mean the amount that should have been paid if the records submitted had not contained any errors. Upon the first instance of fraudulent misrepresentation by an operator, he or she must repay the amount of child care subsidy for which he or she was ineligible to receive, and the operator shall be permanently ineligible to participate in the Subsidized Child Care Assistance Program. An operator shall also be permanently ineligible to participate in the Subsidized Child Care Assistance Program if convicted of fraudulent misrepresentation pursuant to G.S. 110-107. When a court of competent jurisdiction finds a recipient or operator guilty of fraudulent misrepresentation pursuant to G.S. 110-107, the sanction imposed is not subject to appeal under this Rule. Procedures for an operator to appeal to the Local Purchasing Agency are as follows: (1) An operator wishing to contest an action shall contact the Local Purchasing Agency in writing to request an initial review. Requests shall be made within 30 calendar days after the date of the Local Purchasing Agency action. (2) The Local Purchasing Agency shall make a determination on the initial review within 10 business days of the request for an initial review. Within 30 calendar days of notice of the determination of the initial review by the Local Purchasing Agency, the operator may request a local appeal hearing by the Local Purchasing Agency. (3) The local appeal hearing shall be held within five business days of receipt of the request for a hearing. The Local Purchasing Agency shall grant a delay of up to 10 additional business days at the written request of the operator, but in no event shall the local appeal hearing be held more than 15 business days after the receipt of the request for a hearing. (4) The Local Purchasing Agency shall serve a written statement of decision within 10 business days following the local hearing. The decision shall include the facts and conclusions that support the determination by the Local Purchasing Agency. (5) The Local Purchasing Agency shall include with its written statement of decision instructions for appealing its decision in accordance with this Rule. (6) If the operator is not satisfied with the final decision of the Local Purchasing Agency, he or she may appeal to the State Subsidy Services Appeals Panel by filing a notice of appeal within 30 calendar days of receipt of the written statement of decision in accordance with this Rule. The following persons may appeal a decision of a Local Purchasing Agency or the Division to the Panel within 15 calendar days after having exhausted the appeals process at the appropriate Local Purchasing Agency or within 15 calendar days after the Division takes action as described in Subparagraphs (2) and (3) of this Paragraph: (1) an operator to whom a Local Purchasing Agency has issued a sanction pursuant to 10A NCAC 10 .0308; (2) an operator whom a Local Purchasing Agency or the Division has failed to approve for participation in or has terminated participation from the Subsidized Child Care Assistance Program pursuant to Section .0600 of this Chapter; or (3) an operator contesting the determination of an overpayment pursuant to 10A NCAC 10 .0309. (b) Upon notification of an appeal filed pursuant to this Section, the Local Purchasing Agency shall, within five business days of the date of notification, forward the appeal record to the Division Director or Subsidy Appeals Coordinator, with a copy to the appellant, consisting of the following: (1) a copy of its final decision; (2) the signed agreement between the Local Purchasing Agency and the operator, where applicable; and (3) all supplementary documentation considered during the local appeals process. (c) The Panel shall complete its review and notify the appealing party and the Local Purchasing Agency of its decision in writing within 30 business days of the Panel's receipt of the appeal record as follows: (1) the decision shall include the facts and conclusions that support the determination by the Panel; or (2) the decision may be delayed up to an additional 15 business days if the Panel lacks sufficient information to render a decision at the initial administrative review. The Panel may request additional information from the Local Purchasing Agency or the operator. (d) The appealing party may appeal the administrative review decision by filing a petition for a contested case hearing pursuant to G.S. 150B-23 and in accordance with G.S. 110-94. Appeals from the Panel shall be filed within 30 calendar days of notice of the Panel's decision, in accordance with G.S. 150B-23(f). (e) The administrative review decision may direct a Local Purchasing Agency to take an action or reverse an action based upon its review of the record as set forth in Paragraph (b) of this Rule. (f) An operator may appeal a final determination pursuant to 10A NCAC 10 .0308(k) by filing a petition for a contested case hearing pursuant to G.S. 150B-23 and in accordance with G.S. 110- 94. References: chapter 10 rules.pdf (state.nc.us) iii. [ ] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: iv. [ ] Other. Describe the activities and the results of these activities based on the most recent analysis: Appendix 1: Lead Agency Implementation Plan The Appendix will be available for Lead Agencies to use in CARS after the Plan approval letter is issued. For each non-compliance, Lead Agencies must describe the following: • Action Steps: List the action steps needed to correct the finding (e.g., update policy manual, legislative approval, IT system changes, etc.). For each action step list the: o Responsible Entity: Indicate the entity (e.g., agency, team, etc.) responsible for completing the action step. o Expected Completion Date: List the expected completion date for the action step. • Overall Target Date for Compliance: List date Lead Agency anticipates completing implementation, achieving full compliance with all aspects of the findings. (Note: Compliance will not be determined until the FFY 2025-2027 CCDF Plan is amended and approved). Appendix 1: Form [Plan question with non-compliance and associated provision will pre-populate based on preliminary notice of non-compliance] A. Action Steps for Implementation B. Responsible Entity(ies) C. Expected Completion Date Step 1: Step 2 (as necessary): [Additional steps added as necessary] Overall Target Date for Compliance: