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. [ ] 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. [ ] 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: 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: At least quarterly, Lead Agency staff compare child care provider daily attendance sign-in/out documentation with Electronic Attendance Verifications (EAV) reported by the provider using the Lead Agency’s web-based provider portal to identify errors, intentional and unintentional, or potential fraud. The Lead Agency’s provider portal is also capable of identifying anomalies in reported EAVs. Lead Agency program and Fiscal Services staff review EAV documentation submitted by child care providers contracting to participate in the Child Care Payment Assistance/Certificate Program each billing cycle consistent with Lead Agency Policy 11.35 Child Care Certificate Reimbursement. Review of EAV documentation may include indications of excessive absences, inconsistencies in enrollment status, lack of variation in attendance, and other indicators. If documentation is questionable, Lead Agency program staff coordinate with Fiscal Services to review and provide guidance before payment approval. Procedures are in place to automate enrollment terminations upon 20 days of absences upon a 48-hour notification/response to the participating family. The eligibility remains open for the family through the full 12-month period to allow for re-enrollment if needed. The Lead Agency also refers complaints to the Office of Inspector General, Division of Audit Services for follow up. During the period of July 1, 2023, through June 30, 2024, Division of Audit Services followed up on more than 20 referrals of child care providers. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Lead Agency staff compare child care provider daily attendance sign-in/out documentation with Electronic Attendance Verifications (EAV) reported by the provider using the Lead Agency’s web-based provider portal to identify errors, intentional and unintentional, or potential fraud. The Lead Agency’s provider portal is also capable of identifying anomalies in reported EAVs. Lead Agency program and fiscal staff perform review EAV documentation submitted by child care providers contracting to participate in the Child Care Payment Assistance/Certificate Program each billing cycle consistent with Lead Agency Policy 11.35 Child Care Certificate Reimbursement. Review of EAV documentation may include indications of excessive absences, inconsistencies in enrollment status, lack of variation in attendance, and other indicators. If documentation is questionable, Lead Agency fiscal staff coordinate with program staff to review and provide guidance before payment approval. A child care provider may be referred to or identified by the Lead Agency’s Office of Inspector General, Division of Audit Services for review based on risk assessments, complaints, and/or Lead Agency recommendations. Audit reviews of provider records are conducted based upon random sampling or in response to specific complaints consistent with Lead Agency Policy 11.31 Child Care Certificate Program Questioned and Disallowed Cost Process. When an audit review is complete, Audit Services will provide an audit review report to Lead Agency Child Care Program Reliability and Compliance staff and the child care provider who must complete a Corrective Action Plan (CAP) based on any findings, observations, and identified questions costs. The Lead Agency will issue management decisions relating to costs determined to be disallowed. During the period of July 01, 2023, through June 30, 2024, Lead Agency program staff received 25 audit reviews of child care providers that contract with the Lead Agency to participate in the Child Care Payment Assistance/Certificate Program from the Office of Inspector General, Division of Audit Services. Lead Agency program staff received and monitored 24 CAPs and issued 17 management decision letters identifying any disallowed costs. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Lead Agency licensing staff review child provider records, including daily attendance sign-in/out documentation, during monitoring visits and refer anomalies to Child Care Program Reliability and Compliance and/or Audit Services. Examples of anomalies may include a child consistently reported as absent throughout but not 20 consecutive days, listed as full-time, but sign-in/out documentation indicates par-time. Lead Agency program management also provide payment guidelines to its Fiscal Services that uses EAVs to base payments. Adjustments may be made to payments based on these attendance logs. When questions arise, Fiscal Services consults Lead Agency program management for guidance prior to payment. During the period of July 01, 2023, through June 30, 2024, Lead Agency program staff identified 10 child care providers that contract to participate in the Child Care Payment Assistance/Certificate Program that received overpayments. Lead Agency program staff issued overpayment notifications identifying any recoverable costs. 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. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Case reading reviews are conducted monthly by Lead Agency Child Care Payment Assistance/Certificate Program supervisors to monitoring for accuracy when determining eligibility using a structured case reading tool and random sample of cases provided by Lead Agency management. Case reading review scores that do not meet the Lead Agency’s standard are discussed as opportunities for improvement with individual staff and monitoring during staff monthly conference reviews. Additional corrective action may be taken if overall improvement is not demonstrated. Case reading reviews are integrated with Lead Agency performance management and included in the individual performance plan for each Child Care Payment Assistance/Certificate program supervisor assigned child care specialists who determine eligibility. e. [x] Audit provider records. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: A child care provider may be referred to or identified by the Lead Agency’s Office of Inspector General, Division of Audit Services for review based on risk assessments, complaints, and/or Lead Agency recommendations. Child care providers that contract with the Lead Agency to participate in the Child Care Payment Assistance/Certificate Program are also randomly sampled for review by Audit Services to monitor for compliance. When an audit review is complete, Audit Services will provide an audit review report to Lead Agency Child Care Program Reliability and Compliance staff and the child care provider who must complete a Corrective Action Plan (CAP) based on any findings, observations, and identified questions costs. The Lead Agency will issue management decisions relating to costs determined to be disallowed. Audit Services also interviews appropriate staff to evaluate internal controls and the risk of fraud, waste, or abuse. The Lead Agency also refers complaints to the Office of Inspector General, Division of Audit Services for follow up. During the period of July 1, 2023, through June 30, 2024, Division of Audit Services followed up on more than 20 referrals of child care providers. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: A child care provider may be referred to or identified by the Lead Agency’s Office of Inspector General, Division of Audit Services for review based on risk assessments, complaints, and/or Lead Agency recommendations. Child care providers that contract with the Lead Agency to participate in the Child Care Payment Assistance/Certificate Program are also randomly sampled for review by Audit Services to monitor for compliance. When an audit review is complete, Audit Services will provide an audit review report to Lead Agency Child Care Program Reliability and Compliance staff and the child care provider who must complete a Corrective Action Plan (CAP) based on any findings, observations, and identified questions costs. The Lead Agency will issue management decisions relating to costs determined to be disallowed. During the period of July 01, 2023, through June 30, 2024, Lead Agency program staff received 25 audit reviews of child care providers that contract with the Lead Agency to participate in the Child Care Payment Assistance/Certificate Program from the Office of Inspector General, Division of Audit Services. Lead Agency program staff received and monitored 24 CAPs and issued 17 management decision letters identifying any disallowed costs. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: A child care provider may be referred to or identified by the Lead Agency’s Office of Inspector General, Division of Audit Services for review based on risk assessments, complaints, and/or Lead Agency recommendations. Child care providers that contract with the Lead Agency to participate in the Child Care Payment Assistance/Certificate Program are also randomly sampled for review by Audit Services to monitor for compliance. When an audit review is complete, Audit Services will provide an audit review report to Lead Agency Child Care Program Reliability and Compliance staff and the child care provider who must complete a Corrective Action Plan (CAP) based on any findings, observations, and identified questions costs. The Lead Agency will issue management decisions relating to costs determined to be disallowed. Audit Services also facilitates the Lead Agency’s annual risk assessment review process. f. [x] Train staff on policy and/or audits. 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. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Lead Agency staff are provided training and/or guidance on changes to policies and procedures and in response to audit findings. g. [x] Other. Describe the activity(ies): Please see detailed activities at 10.2.1.g.i-iii. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency's Office of Inspector General investigates allegations of fraud and intentional program violations. Recovery of funds associated with fraud or intentional program violations is a joint effort between the Lead Agency’s CCDF program, Fiscal Services, and Office of General Counsel in coordination with the State of Tennessee Attorney General's Office. During the period of July 01, 2023, through June 30, 2024, the Lead Agency referred two (2) child care providers that contracted to participate in the Child Care Payment Assistance/Certificate Program to the Tennessee Department of Human Services Office of General Counsel for collections. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency's Office of Inspector General, Division of Audit Services receives complaint referrals from multiple sources and may conduct audit reviews of child care providers following a complaint. During the period of July 01, 2023, through June 30, 2024, the Lead Agency referred two (2) child care providers that contracted to participate in the Child Care Payment Assistance/Certificate Program to the Tennessee Department of Human Services Office of General Counsel for collections. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency’s Quality Improvement and Strategic Solutions (QISS) Division conducts a modified review based on the ACF-403 criteria (used in the cohort 2 review) annually to monitor the error rate during years between the formal ACF-404 submissions. Results of error rate reviews are disseminated to Lead Agency management and Child Care Payment Assistance/Certificate Program management to evaluate and strengthen internal controls, including potential enhancements of information systems, training, and revisions to the terms and conditions of the Lead Agency’s Child Care Payment Assistance/Certificate Program contract to support requirements. 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): The Tennessee Attorney General’s Office is the state’s debt collector which attempts collections only after a referral is made by the Lead Agency’s Office of General Counsel and only after Lead Agency staff have made repeated unsuccessful attempts to collect. Only one case has resulted been determined as fraud by a court law, which established orders for restitution and amounts collected are remitted to the Lead Agency’s Fiscal Services. 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. [ ] 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: 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 Tennessee Attorney General’s Office is the state’s debt collector which attempts collections only after a referral is made by the Lead Agency’s Office of General Counsel and only after Lead Agency staff have made repeated unsuccessful attempts to collect. Only one case has resulted been determined as fraud by a court law, which established orders for restitution and amounts collected are remitted to the Lead Agency’s Fiscal Services. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Recovery of child care overpayments and establishment of repayment plans for providers and parents are conducted by the Lead Agency based on policies and procedures to send management decision letters, billing notices, negotiate repayment plans and, when necessary, pursue collection efforts if the prior actions are unsuccessful in cases determined not to be fraudulent. The Lead Agency may establish an installment plan repayment agreement with the contracting child care provider allows to repay funds over a defined time period consistent with the Child Care Payment Assistance/Certificate Program contract terms and conditions. Lead Agency Fiscal Services offsets future payment amounts on the basis of the installment plan repayment agreement. Lead Agency program and fiscal staff monitor the status of repayment plans and implements remedies for non- compliance should an installment plan repayment agreement be violated iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Recovery of child care overpayments and establishment of repayment plans for providers and parents are conducted by the Lead Agency based on policies and procedures to send management decision letters, billing notices, negotiate repayment plans and, when necessary, pursue collection efforts if the prior actions are unsuccessful in cases determined not to be fraudulent. The Lead Agency may establish an installment plan repayment agreement with the contracting child care provider allows to repay funds over a defined time period consistent with the Child Care Payment Assistance/Certificate Program contract terms and conditions. Lead Agency Fiscal Services offsets future payment amounts on the basis of the installment plan repayment agreement. Lead Agency program and fiscal staff monitor the status of repayment plans and implements remedies for non- compliance should an installment plan repayment agreement be violated. 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: The Lead Agency and its Office of Inspector General and Office of General Counsel determine consult to determine when engagement of U.S. Health and Human Services Administration of Children and Families Office of Inspector General and/or the Tennessee Comptroller of the Treasury in instances of potential waste, fraud, or abuse. These activities maximize the available options for recovering improper payment due to fraud and may serve as a deterrent to help prevent future fraud. These strategies have resulted in the recovery of identified improper payments, whether due to fraud or other circumstances. 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. [ ] 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: 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 Tennessee Attorney General’s Office is the state’s debt collector which attempts collections only after a referral is made by the Lead Agency’s Office of General Counsel and only after Lead Agency staff have made repeated unsuccessful attempts to collect. Only one case has resulted been determined as fraud by a court law, which established orders for restitution and amounts collected are remitted to the Lead Agency’s Fiscal Services. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Recovery of child care overpayments and establishment of repayment plans for providers and parents are conducted by the Lead Agency based on policies and procedures to send management decision letters, billing notices, negotiate repayment plans and, when necessary, pursue collection efforts if the prior actions are unsuccessful in cases determined not to be fraudulent. The Lead Agency may establish an installment plan repayment agreement with the contracting child care provider allows to repay funds over a defined time period consistent with the Child Care Payment Assistance/Certificate Program contract terms and conditions. Lead Agency Fiscal Services offsets future payment amounts on the basis of the installment plan repayment agreement. Lead Agency program and fiscal staff monitor the status of repayment plans and implements remedies for non- compliance should an installment plan repayment agreement be violated. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Recovery of child care overpayments and establishment of repayment plans for providers and parents are conducted by the Lead Agency based on policies and procedures to send management decision letters, billing notices, negotiate repayment plans and, when necessary, pursue collection efforts if the prior actions are unsuccessful in cases determined not to be fraudulent. The Lead Agency may establish an installment plan repayment agreement with the contracting child care provider allows to repay funds over a defined time period consistent with the Child Care Payment Assistance/Certificate Program contract terms and conditions. Lead Agency Fiscal Services offsets future payment amounts on the basis of the installment plan repayment agreement. Lead Agency program and fiscal staff monitor the status of repayment plans and implements remedies for non- compliance should an installment plan repayment agreement be violated. 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: The Lead Agency and its Office of Inspector General and Office of General Counsel determine consult to determine when engagement of U.S. Health and Human Services Administration of Children and Families Office of Inspector General and/or the Tennessee Comptroller of the Treasury in instances of potential waste, fraud, or abuse. These activities maximize the available options for recovering improper payment due to fraud and may serve as a deterrent to help prevent future fraud. These strategies have resulted in the recovery of identified improper payments, whether due to fraud or other circumstances. 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. [ ] 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: 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 Tennessee Attorney General’s Office is the state’s debt collector which attempts collections only after a referral is made by the Lead Agency’s Office of General Counsel and only after Lead Agency staff have made repeated unsuccessful attempts to collect. Only one case has resulted been determined as fraud by a court law, which established orders for restitution and amounts collected are remitted to the Lead Agency’s Fiscal Services. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Recovery of child care overpayments and establishment of repayment plans for providers and parents are conducted by the Lead Agency based on policies and procedures to send management decision letters, billing notices, negotiate repayment plans and, when necessary, pursue collection efforts if the prior actions are unsuccessful in cases determined not to be fraudulent. The Lead Agency may establish an installment plan repayment agreement with the contracting child care provider allows to repay funds over a defined time period consistent with the Child Care Payment Assistance/Certificate Program contract terms and conditions. Lead Agency Fiscal Services offsets future payment amounts on the basis of the installment plan repayment agreement. Lead Agency program and fiscal staff monitor the status of repayment plans and implements remedies for non- compliance should an installment plan repayment agreement be violated. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Recovery of child care overpayments and establishment of repayment plans for providers and parents are conducted by the Lead Agency based on policies and procedures to send management decision letters, billing notices, negotiate repayment plans and, when necessary, pursue collection efforts if the prior actions are unsuccessful in cases determined not to be fraudulent. The Lead Agency may establish an installment plan repayment agreement with the contracting child care provider allows to repay funds over a defined time period consistent with the Child Care Payment Assistance/Certificate Program contract terms and conditions. Lead Agency Fiscal Services offsets future payment amounts on the basis of the installment plan repayment agreement. Lead Agency program and fiscal staff monitor the status of repayment plans and implements remedies for non- compliance should an installment plan repayment agreement be violated. 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: The Lead Agency and its Office of Inspector General and Office of General Counsel determine consult to determine when engagement of U.S. Health and Human Services Administration of Children and Families Office of Inspector General and/or he Tennessee Comptroller of the Treasury in instances of potential waste, fraud, or abuse. These activities maximize the available options for recovering improper payment due to fraud and may serve as a deterrent to help prevent future fraud. These strategies have resulted in the recovery of identified improper payments, whether due to fraud or other circumstances. 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: In instances where parents may no longer be eligible to participate in the Child Care Payment Assistance/Certificate Program, a client may appeal through the administrative hearing process with the Lead Agency's Division of Appeals and Hearings as defined at Lead Agency Policy 7.05 Smart Steps Child Care Payment Assistance Appeal Process and Policy 7.06 Child Care Payment Assistance Appeal Process. 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 Lead Agency is the final decisionmaker of any payment disputes and can deny payments as defined in among the terms and conditions of the Lead Agency contract to participate in the Child Care Payment Assistance/Certificate Program. The Lead Agency offers a payment dispute resolution process allowing contacting child care providers to request an administrative review related to adverse administrative actions, i.e., disallowed costs, refused payments, or payment reductions, as defined in at Policy 11.36 Provider Requested Child Care Certificate Program Administrative Review. Requests for administrative review must be received in writing by the Lead Agency’s Division of Appeals and Hearings no later than 15 calendar days after a date management decision notification is issued. The Division of Appeals and Hearings will acknowledge receipt of the request within five (5) business days. A child care provider has 20 calendar days to provide all supporting written documentation. In instances where a provider may no longer be eligible to participate in the Child Care Payment Assistance/Certificate Program, e.g., if the circumstances associated with a case are egregious, the Lead Agency may terminate the provider’s contract. iii. [x] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency is the final decisionmaker of any payment disputes and can deny payments as defined in among the terms and conditions of the Lead Agency contract to participate in the Child Care Payment Assistance/Certificate Program. The Lead Agency offers a payment dispute resolution process allowing contacting child care providers to request an administrative review related to adverse administrative actions, i.e., disallowed costs, refused payments, or payment reductions, as defined in at Policy 11.36 Provider Requested Child Care Certificate Program Administrative Review. Requests for administrative review must be received in writing by the Lead Agency’s Division of Appeals and Hearings no later than 15 calendar days after a date management decision notification is issued. The Division of Appeals and Hearings will acknowledge receipt of the request within five (5) business days. A child care provider has 20 calendar days to provide all supporting written documentation. In instances where a provider may no longer be eligible to participate in the Child Care Payment Assistance/Certificate Program, e.g., if the circumstances associated with a case are egregious, the Lead Agency may terminate the provider’s contract. 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: