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. [x] 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. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: CDD staff can access the database used by ESD to verify information provided by the client applying for CCFAP, along with querying other databases including Ancestry, Parcel Viewer and CLEAR to verify information provided to other programs such as household composition, address, and income. This helps to verify that applications submitted are complete and accurate. An eligibility specialist will complete a Program Integrity Inquiry form and submit it to the Program Integrity Unit to query the data from other programs under the State prevue. If a discrepancy is noted, the Program Integrity Unit will start the investigation process and if fraud is found, the provider or client is removed from subsidy and if necessary, recoupment of funds is initiated. Historically, CCFAP has not differentiated between intentional or unintentional program violations. After reviewing data, for better informed practice, intentional program violations will have less time to pay back the improper payment verses unintentional program violations. Payment plans for unintentional violations are to be paid back in 5 years, or longer in exceptional circumstances. Intentional violations are set up on a 3-year payment plan. From October 2021 to present, three (3) clients have been found to have program violations. One (1) subsidy client has been removed from CCFAP. Total dollar amount of program violations is $110,493.43. Of the total violations amount, one (1) is considered Federal Restitution. To date, we have recouped $48,665.30. One client paid in full with a check. The other three (3) clients are making payments. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: CDD staff can access the database used by ESD to verify information provided by the client applying for CCFAP, along with querying other databases including Ancestry, Parcel Viewer and CLEAR to verify information provided to other programs such as household composition, address, and income. This helps to verify that applications submitted are complete and accurate. An eligibility specialist will complete a Program Integrity Inquiry form and submit it to the Program Integrity Unit to query the data from other programs under the State prevue. If a discrepancy is noted, the Program Integrity Unit will start the investigation process and if fraud is found, the provider or client is removed from subsidy and if necessary, recoupment of funds is initiated. Historically, CCFAP has not differentiated between intentional or unintentional program violations. After reviewing data, for better informed practice, intentional program violations will have less time to pay back the improper payment verses unintentional program violations. Payment plans for unintentional violations are to be paid back in 5 years, or longer in exceptional circumstances. Intentional violations are set up on a 3-year payment plan. From October 2021 to present, three (3) clients have been found to have program violations. One (1) subsidy client has been removed from CCFAP. Total dollar amount of program violations is $110,493.43. Of the total violations amount, one (1) is considered Federal Restitution. To date, we have recouped $48,665.30. One client paid in full with a check. The other three (3) clients are making payments. 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. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: CDDIS generates regular reports to detect multiple and double payments of subsidized children, children with multiple providers along with providers with consistently high subsidy reimbursements. These system reports help identify improper payment program violations and inform policy updates when policy may clarify common issues. If issues are found, the appropriate CDD unit is notified, and corrective action is taken. These actions may include payment sanctions, change in payment certificates, or additional training for staff or child care providers. Since the inception of CDDIS, the total sum of recoupments is 398,851.11 with a sum of 381,500.61 paid to date. All detected issues are dealt with immediately through a payment adjustment, referral to licensing or a change in eligibility. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: CDDIS generates regular reports to detect multiple and double payments of subsidized children, children with multiple providers along with providers with consistently high subsidy reimbursements. These system reports help identify improper payment program violations and inform policy updates when policy may clarify common issues. If issues are found, the appropriate CDD unit is notified, and corrective action is taken. These actions may include payment sanctions, change in payment certificates, or additional training for staff or child care providers. Since the inception of CDDIS, the total sum of recoupments is 398,851.11 with a sum of 381,500.61 paid to date. All detected issues are dealt with immediately through a payment adjustment, referral to licensing or a change in eligibility. 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 CCFAP Program and Licensing Unit routinely collaborate around child care providers and any discrepancies with billing, attendance and enrollment records along with any other concerns that could impact provider participation in the CCFAP program. The program integrity unit for the CCFAP program performs unannounced site visits when referrals are made or after spot checking attendance and identifying problematic records. Each provider payment goes through a two-step approval process. During this process 10-15% of the total number of invoices submitted receive a secondary screening of authorized child care hours versus attendance hours submitted. This results in approximately 100 claims being reviewed per month. Providers are contacted if the hours, coded days, or payment amount does not look accurate or if the provider submitted for the incorrect service period. If fraud is suspected attendance records are requested/picked up from the child care provider and compared with CDDIS billing records. Between January and June 2024, the regular review of claims and program integrity inquiries resulted in technical assistance being provided to 22 providers either in person, via email, or over the telephone. Common errors in claim submission, such as improper usage of attendance codes and requirements for accurate billing, have been incorporated into the CCFAP Program Integrity training for providers. Ongoing, the data from risk assessments will be used to identify updates in the training material and technical assistance needs. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The CCFAP Program and Licensing Unit routinely collaborate around child care providers and any discrepancies with billing, attendance and enrollment records along with any other concerns that could impact provider participation in the CCFAP program. The program integrity unit for the CCFAP program performs unannounced site visits when referrals are made or after spot checking attendance and identifying problematic records. Each provider payment goes through a two-step approval process. During this process 10-15% of the total number of invoices submitted receive a secondary screening of authorized child care hours versus attendance hours submitted. This results in approximately 100 claims being reviewed per month. Providers are contacted if the hours, coded days, or payment amount does not look accurate or if the provider submitted for the incorrect service period. If fraud is suspected attendance records are requested/picked up from the child care provider and compared with CDDIS billing records. Between January and June 2024, the regular review of claims and program integrity inquiries resulted in technical assistance being provided to 22 providers either in person, via email, or over the telephone. Common errors in claim submission, such as improper usage of attendance codes and requirements for accurate billing, have been incorporated into the CCFAP Program Integrity training for providers. Ongoing, the data from risk assessments will be used to identify updates in the training material and technical assistance needs. 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. [ ] 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: CCCSA processes are monitored through the following processes: Performance based agreements specifying the quality and accuracy of eligibility determination activities required by the CDD. Data is pulled from case reviews and CDDIS to determine if performance measures are met. The CCCSA must submit a plan of correction for any performance measure not met. Regular on-site monitoring to ensure compliance with regulations and quality assurance including individual case reviews by CCFAP Grant Monitors. Errors found are corrected and additional training provided if necessary. Regular on-site technical assistance from CCFAP Grant Monitors is provided to prevent case eligibility issues from developing. From 7/1/21-12/31/21, all contracted CCCSA agencies with the exception of one met the required performance measures which is to stay at or below an 8% error rate. Winston Prouty 3.2%, Umbrella 6.5%, St Albans 3.2%, Springfield 3.4%, Rutland 1.6%. Norwich 1.6%, Newport 1.6%, Montpelier 0%. Middlebury 6.6%, Lamoille 6.1%, Bennington 0% and CCR 9.1%. These performance measures were waived between 1/1/22-9/30/23 due to the launch of the new information system, CDDIS. Between January and June 2024, 243 case file assessments were completed statewide. These case file assessments identified 15 applications with eligibility determination errors. Ongoing, 2-3 case file assessments are completed per month for each of the 12 Community Child Care Support Agency locations. The current target is one case assessment per eligibility specialist per month, however, there is flexibility to focus case assessments on new staff or as a tool for eligibility specialists who need additional support with eligibility determination. The Quality Control Unit will review data from the case assessments to inform needed training topics and policy updates. e. [x] Audit provider records. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Each provider payment goes through a two-step approval process. During this process 10-15% of the total number of invoices submitted (or approximately 100 invoices per month) receive a secondary screening of authorized child care hours versus attendance hours submitted. Providers are contacted if the hours, coded days, or payment amount does not look accurate or if the provider submitted for the incorrect service period. If a program violation is suspected attendance records are requested/picked up from the child care provider and compared with CDDIS billing records. If the program violation is substantiated, the Integrity Unit will either recoup the improper payment through future claims for existing providers, set up a payment plan for expired providers or move for a tax intercept. In addition, clients and the general public may submit potential payment/fraud issues through the CDD complaint portal. Since the inception of CDDIS, $381,500.61 has been adjusted or recouped for both intentional and unintentional program violations along with 31 early invoicing letters were sent to providers. The total sum of recoupments and adjustments is $398,851.11 with a sum balance of $17350.50. Claims that were submitted prior to the end of the service period were rejected and followed up with an early invoicing letter. Providers that submitted early had to wait until the end of the service period to resubmit the rejected claim. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Each provider payment goes through a two-step approval process. During this process 10-15% of the total number of invoices submitted (or approximately 100 invoices per month) receive a secondary screening of authorized child care hours versus attendance hours submitted. Providers are contacted if the hours, coded days, or payment amount does not look accurate or if the provider submitted for the incorrect service period. If a program violation is suspected attendance records are requested/picked up from the child care provider and compared with CDDIS billing records. If the program violation is substantiated, the Integrity Unit will either recoup the improper payment through future claims for existing providers, set up a payment plan for expired providers or move for a tax intercept. In addition, clients and the general public may submit potential payment/fraud issues through the CDD complaint portal. Since the inception of CDDIS, $381,500.61 has been adjusted or recouped for both intentional and unintentional program violations along with 31 early invoicing letters were sent to providers. The total sum of recoupments and adjustments is $398,851.11 with a sum balance of $17350.50. Claims that were submitted prior to the end of the service period were rejected and followed up with an early invoicing letter. Providers that submitted early had to wait until the end of the service period to resubmit the rejected claim. iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: 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: All CDD CCFAP staff are trained on eligibility policies and procedures. During this training, Identification of fraud and potential program violations is reviewed. In addition, CCFAP staff members are actively involved with the state and federal audit process and are cross trained in all aspects of CCFAP. This ensures that staff are able to detect and prevent fraud throughout the eligibility and payment process. CCCSA eligibility specialists are also trained on policy related to identifying client/provider eligibility issues and improper payments. Regional and Statewide trainings are provided each fiscal year. Eligibility Specialists are required to complete a case file checklist form for every application submitted. This form ensures that all required documentation is in the file and the information is accurate. Overall, staff are well trained in policy. The most recent Error Rate Review for eligibility determined between October 1, 2021 and September 30, 2022 resulted in a .72% error rate. Additionally, 243 case file assessments completed between January and June 2024 identified only 15 applications with eligibility determination errors. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: All CDD CCFAP staff are trained on eligibility policies and procedures. During this training, Identification of fraud and potential program violations is reviewed. In addition, CCFAP staff members are actively involved with the state and federal audit process and are cross trained in all aspects of CCFAP. This ensures that staff are able to detect and prevent fraud throughout the eligibility and payment process. CCCSA eligibility specialist are also trained on policy related to identifying client/provider eligibility issues and improper payments. They are required to complete a case file checklist form for every application submitted. This form ensures that all required documentation is in the file and the information is accurate. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: All new Eligibility Specialists are trained on policies. Policies are frequently reviewed with Eligibility Specialists to ensure understanding and consistency. Grant Monitors visit each CCCSA agency to review case files and complete case assessments. If errors are found, technical assistance is provided as it relates to policy and procedure comprehension. 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): Department for Children and Families, Child Development Division 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: The state of Vermont has not defined a minimum dollar amount of an improper payment to be recovered. If the improper payment is confirmed and the billing window is still open, an adjustment is done to the original invoice and the entire improper payment amount is recovered. If the billing window is closed, a repayment plan is set up with the provider. In cases of program violation by a client, the Eligibility Specialist and Grant Monitor meets with the parent to verify the eligibility information. If an improper payment occurred, a repayment plan is established with the client to recover the overpayment. Since July 2022, $381,500.61 has been either adjusted or recouped for both intentional and unintentional program violations. 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: Misspent funds can be collected through a negative voucher with the State of Vermont. This negative voucher allows the state to collect any money that would have been paid to the provider from another state agency. Since June 2023, two negative vouchers from other state agencies went towards recovering improper CCFAP payments for a total of $1,200 recovered. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: In cases of program violation by a child care provider, the case is referred to the Integrity Unit for the CCFAP. If the improper payment is confirmed and the billing window is still open, an adjustment is done to the original invoice. If the billing window is closed, a repayment plan is set up with the provider. In cases of program violation by a client, if an improper payment occurred, a repayment plan is established with the client to recover the overpayment. Since July 2022, a total of $398,851.11 has been identified as overpayments due to intentional and unintentional program violations from providers. A balance of $17350.50 is being paid through repayment plans from providers. Since January 2024, two families were found to have intentionally violated program rules and had repayments for overpayments of $14,456 arranged. iv. [ ] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: v. [x] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: Tax intercepts will be utilized when a client refuses to set up a payment plan with CDD. If a child care provider is no longer in operation and repayment has stopped, a tax intercept will be initiated. Tax intercept letters are sent to clients and former providers prior to their names being submitted to the Tax Department. This often results in an increase in money being returned on a voluntary basis. No tax intercepts were set up for SFY23 and SFY24. vi. [ ] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [x] 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: The CCFAP has an integrity unit which consists of two quality control specialists, assigned specifically educated to CCFAP improper payments. The Integrity unit receives referrals from Eligibility Specialists, licensing, other state programs and community members about possible improper payments. The Child Care Benefits Administrator works closely with them on ensuing investigation and repayment plan. This position has access to state databases and has built connections with town departments allowing for statewide verification of information. Between January and June 2024, 52 program integrity inquiries were received and investigated. Of these 52 inquiries, 46 were regarding family applications and 6 were regarding provider claims. As a result of these inquiries, 2 families were found to have intentionally violated program rules and had repayments for overpayments of $14,456 arranged. Between January and June 2024, the regular review of claims and program integrity inquiries resulted in technical assistance being provided to 22 providers either in person, via email, or over the telephone. 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: The state of Vermont has not defined a minimum dollar amount of an improper payment to be recovered. If the improper payment is confirmed and the billing window is still open, an adjustment is done to the original invoice and the entire improper payment amount is recovered. If the billing window is closed, a repayment plan is set up with the provider. In cases of program violation by a client, the Eligibility Specialist and Grant Monitor meets with the parent to verify the eligibility information. If an improper payment occurred, a repayment plan is established with the client to recover the overpayment. Since July 2022, $381,500.61 has been either adjusted or recouped for both intentional and unintentional program violations. 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: Misspent funds can be collected through a negative voucher with the State of Vermont. This negative voucher allows the state to collect any money that would have been paid to the provider from another state agency. Since June 2023, two negative vouchers from other state agencies went towards recovering improper CCFAP payments for a total of $1,200 recovered. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: In cases of program violation by a child care provider, the case is referred to the Integrity Unit for the CCFAP. If the improper payment is confirmed and the billing window is still open, an adjustment is done to the original invoice. If the billing window is closed, a repayment plan is set up with the provider. In cases of program violation by a client, if an improper payment occurred, a repayment plan is established with the client to recover the overpayment. Since July 2022, a total of $398,851.11 has been identified as overpayments due to intentional and unintentional program violations from providers. A balance of $17350.50 is being paid through repayment plans from providers. No improper payments for families have had payment plans arranged. iv. [ ] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: v. [x] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: Tax intercepts will be utilized when a client refuses to set up a payment plan with CDD. If a child care provider is no longer in operation and repayment has stopped, a tax intercept will be initiated. Tax intercept letters are sent to clients and former providers prior to their names being submitted to the Tax Department. This often results in an increase in money being returned on a voluntary basis. No tax intercepts were set up for SFY23 and SFY24. vi. [ ] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [x] 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: The CCFAP has an integrity unit which consists of two quality control specialists, assigned specifically educated to CCFAP improper payments. The Integrity unit receives referrals from Eligibility Specialists, licensing, other state programs and community members about possible improper payments. The Child Care Benefits Administrator works closely with them on ensuing investigation and repayment plan. This position has access to state databases and has built connections with town departments allowing for statewide verification of information. Between January and June 2024, 52 program integrity inquiries were received and investigated. Of these 52 inquiries, 46 were regarding family applications and 6 were regarding provider claims. As a result of these inquiries, 2 families were found to have intentionally violated program rules and had repayments for overpayments of $14,456 arranged. Between January and June 2024, the regular review of claims and program integrity inquiries resulted in technical assistance being provided to 22 providers either in person, via email, or over the telephone. 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? [x] No. [ ] 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. [ ] 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. [ ] Other. Describe the activities and the results of these activities: 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 cases of suspected program violations, the case is referred to the Quality Control Specialists in the CCFAP Unit. If fraud is substantiated, the Child Care Financial Assistance client is excluded from further participation in the CCFAP, and a payment plan is established to recover overpayments. This may include tax or other income intercepts. CCFAP clients may appeal to the CCFAP Program Administrator and/or the Vermont Human Services Board if they feel they have been unfairly excluded from participation in the CCFAP. This process includes a review and decision by the CCFAP Program Administrator in which the client has an opportunity to present their perspective on the grounds for exclusion. If the client is not satisfied with the appeal decision, they can request a Fair Hearing with an impartial Human Services Board. From October of 2021 to present, one (1) client has been disqualified from CCFAP. 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: In cases of suspected program violations, the case is referred to the Quality Control Specialists in the CCFAP Unit. If fraud is substantiated, the CCFAP provider may be excluded from further participation in CCFAP. Providers may appeal to the CCFAP Program Administrator and/or the Vermont Human Services Board if they feel they have been unfairly excluded from participation. Overpaid funds are recouped with the option for a repayment plan to recover improperly paid funds. Repayment may include tax or other income intercepts. To date, no child care providers have been disqualified from CCFAP. iii. [x] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: The Vermont Attorney General's office makes decisions on whether to accept these cases for prosecution. To date the Attorney General's Office has not prosecuted any clients or child care providers for committing fraud. 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: