Corrective Action Plans

Finding 1226928 (2025-011)

Material Weakness 2025

VA

Allowable Costs / Cost Principles § 200.302 § 200.430

We agree with the auditor's comments. Prior to transferring financial responsibilities back to Essex County Public Schools Administration effective July 1, 2026, a process was put into place for all staff to have current and fully executed contracts stating their pay rate, FLSA status, expected leng...

We agree with the auditor's comments. Prior to transferring financial responsibilities back to Essex County Public Schools Administration effective July 1, 2026, a process was put into place for all staff to have current and fully executed contracts stating their pay rate, FLSA status, expected length of contract (with number of workdays), and associated benefits. A process was also established to utilize an automated or manual timekeeping report to reflect all hours worked and approved by the supervisor prior to submission for payment. All records should be matched and retained to support payroll payments.

View Audit 409120

Finding 1226451 (2025-003)

Material Weakness 2025

Catherine McAuley Center, Inc.

IA

Allowable Costs / Cost Principles

The accounting system will also be used to track expenditures by grant. Grant agreements will also be saved in a central location for simple access.

View Audit 409086

Finding 1226447 (2025-005)

Material Weakness 2025

Phoenix Indian Center

AZ

Allowable Costs / Cost Principles Reporting § 200.403 § 200.502 § 200.510

A designated Finance staff member with knowledge of the Uniform Guidance requirements will be responsible for overseeing SEFA preparation for each fiscal year-end. A grant-by-grant SEFA reconciliation will be completed prior to yearend close, with particular attention to period-end cutoff. The SEFA ...

A designated Finance staff member with knowledge of the Uniform Guidance requirements will be responsible for overseeing SEFA preparation for each fiscal year-end. A grant-by-grant SEFA reconciliation will be completed prior to yearend close, with particular attention to period-end cutoff. The SEFA will be independently reviewed by the Finance Director and compared to grant expenditure reports before the audit commences. Management will engage its external accountants earlier in the year-end close process.

View Audit 409082

Finding 1226423 (2025-005)

Material Weakness 2025

City of North Miami Beach

FL

Reporting Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.512

SD 2025-005 REPORTING - DATA COLLECTION FORM (REPEAT FINDING PREVIOUSLY REPORTED AS - SD2024-005) Current Year Corrective Actio1t Response: Management concurs with the findings . Management will implement policie s and procedures as per the auditor' s recommendation.

View Audit 409026

Finding 1226400 (2025-006)

Material Weakness 2025

Council Bluffs Community School District

IA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs

Finding Summary – During the audit, it was determined that an employee used a District purchasing card to make unauthorized personal purchases that were subsequently charged to the Twenty-First Century Community Learning Centers federal program. Existing monitoring and approval procedures did not id...

Finding Summary – During the audit, it was determined that an employee used a District purchasing card to make unauthorized personal purchases that were subsequently charged to the Twenty-First Century Community Learning Centers federal program. Existing monitoring and approval procedures did not identify the improper expenditures. As a result, approximately $7,000 of unallowable costs were charged to the federal award, resulting in a significant deficiency in internal control over compliance related to allowable costs and cost principles. Contact Person Responsible for Corrective Action – Dr. Chace Ramey, Superintendent Corrective Actions Planned – The District has implemented additional review and monitoring procedures over purchasing card transactions and federal program expenditures. Supporting documentation is reviewed to ensure expenditures are allowable, properly approved, and directly related to program purposes. District administration will continue to monitor compliance with federal requirements to reduce the risk of unallowable costs being charged to federal awards. Anticipated Completion Date of Corrective Action Plan – June 30, 2026.

View Audit 408984

Finding 1226336 (2025-001)

Material Weakness 2025

Cass County Electric Cooperative

ND

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2025-001 Department of Homeland Security and Emergency Management Federal Financial Assistance Listing 97.036 Disaster Grant Public Assistance Allowable Costs/Activities Allowed or Unallowed Material Weakness in Internal Control over Compliance Finding Summary: In the testing of allowable co...

Finding 2025-001 Department of Homeland Security and Emergency Management Federal Financial Assistance Listing 97.036 Disaster Grant Public Assistance Allowable Costs/Activities Allowed or Unallowed Material Weakness in Internal Control over Compliance Finding Summary: In the testing of allowable costs and activities, there were instances where material inventory expenses were submitted for federal reimbursement at a cost per unit that did not agree to the replacement cost. Responsible Individuals: Troy Knutson, Andy Weiss, and Ann Watson Corrective Action Plan: The Cooperative will perform a thorough review and reconciliation of supporting documentation for expenditures, including material transactions, before amounts are claimed for reimbursement. Anticipated Completion Date: December 31, 2026

View Audit 408974

Finding 1226288 (2025-001)

Material Weakness 2025

City of Greensburg

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

FINDING 2025-001 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Amy Borns Contact Phone Number and Email Address: 812-663-8582 ext 1 & aborns@greensburg.in.gov Views of Responsible Officials: We concur with th...

FINDING 2025-001 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Amy Borns Contact Phone Number and Email Address: 812-663-8582 ext 1 & aborns@greensburg.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When the SLFRF Compliance report is completed by the Clerk-Treasurer, either the Accounts Payable/Receivable Specialist or the Personnel Administrator will double check it and sign off (or send an email) concurring with the report. Anticipated Completion Date: This will be completed no later than April 30, 2027.

View Audit 408956

Finding 1226273 (2025-005)

Material Weakness 2025

Kipp Delta, Inc. D/b/a Kipp Delta Public Schools

AR

Allowable Costs / Cost Principles § 200.430

The School has now made personnel and policy changes, and established procedures regarding time certifications that provide assurance that charges are accurate, allowable, and properly allocated.

View Audit 408950

Finding 1226272 (2025-003)

Material Weakness 2025

Kipp Delta, Inc. D/b/a Kipp Delta Public Schools

AR

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs

The School has made personnel and policy changes and has put in place a purchase order process of approval that documents expenditures in compliance with audit regulations. The School has also made coding corrections and implemented proper controls over program expenditures.

View Audit 408950

Finding 1226268 (2025-001)

Material Weakness 2025

Kipp Delta, Inc. D/b/a Kipp Delta Public Schools

AR

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties

The School has contacted DESE for guidance regarding this matter and has implemented proper controls over Title One program expenditures.

View Audit 408950

Finding 1226267 (2025-004)

Material Weakness 2025

Kipp Delta, Inc. D/b/a Kipp Delta Public Schools

AR

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties

The School has made personnel and policy changes and has also been in contact with DESE for guidance. The School has since made coding corrections and implemented proper controls over program expenditures.

View Audit 408950

Finding 1226261 (2025-002)

Material Weakness 2025

HIGH WEST ENERGY, INC.

WY

Allowable Costs / Cost Principles § 200.303

Views of Responsible Officials and Planned Corrective Actions: (Prepared by Cooperative Management) 2025 -002 – Significant Deficiency in Internal Controls When the Cooperative completed the Essential Elements of Information (EEI) Worksheet, they excluded amounts billed to the Cooperative for mutual...

Views of Responsible Officials and Planned Corrective Actions: (Prepared by Cooperative Management) 2025 -002 – Significant Deficiency in Internal Controls When the Cooperative completed the Essential Elements of Information (EEI) Worksheet, they excluded amounts billed to the Cooperative for mutual aid help that was performed in an area that was not included in the declared area on the same invoice as work performed in the declared area. On September 25, 2024, the Cooperative sent an email to the FEMA representative with a reconciliation worksheet attached to the email showing the difference between the amounts listed on the mutual aid invoices and the amount reported by the Cooperative on the EEI Worksheet for mutual aid because the FEMA representative could not tie the invoice amounts to the amount reported on the EEI Worksheet. Notation of the amount to be excluded, $11,746, and why it should be excluded was documented on the reconciliation worksheet that was attached to the email. It was the FEMA representative that ultimately included an amount in the final submission that the Cooperative did not include in the EEI Worksheet and clearly communicated should not be included. In the future the Cooperative will verify all final numbers that the FEMA representative intends to report to the CRC. In December 2025, when the Cooperative was reviewing a work order for damage that happened in Colorado during the same storm that was the declared event, it was discovered that $2,294 in retirement costs performed by a contractor was accidentally included in the FEMA claim. In May 2024 when the contractor invoice was received and paid, it was accidentally coded as 100% Nebraska when 3.5% of the invoice should have been coded as Colorado retirement. In the future the Cooperative will have a better review process to catch any accidental coding errors. The Cooperative acknowledges that a total of $14,040 in costs were included when they should not have been.

View Audit 408922

Finding 1226260 (2025-001)

Material Weakness 2025

HIGH WEST ENERGY, INC.

WY

Allowable Costs / Cost Principles § 200.303

Views of Responsible Officials and Planned Corrective Actions: (Prepared by Cooperative Management) 2025 -001 – Significant Deficiency in Internal Controls The electronic timesheet system used by the Cooperative, which is also used to track vehicle and equipment used by an employee only allows track...

Views of Responsible Officials and Planned Corrective Actions: (Prepared by Cooperative Management) 2025 -001 – Significant Deficiency in Internal Controls The electronic timesheet system used by the Cooperative, which is also used to track vehicle and equipment used by an employee only allows tracking of vehicle/equipment by mileage and/or hour usage, since the trailers owned by the Cooperative do not have a meter to track either mileage and/or hour usage it is not normal business practice to track the trailer usage on the timesheets. There is a comment section on the timesheet where the information can be entered to bypass the system requirement of entering mileage and/or hour usage, in future storm situations, trailer usage will be entered into the comment section of the timesheet. As for the ATV’s and loader/skid steer equipment it is not normal practice to enter those on the timesheet even though they have a meter to track miles and/or hours. In future storm situations, usage for such equipment will be tracked on the timesheet. The basis for including the trailers in question even though they were not tracked on timesheets was that the trailers were used to haul material (poles) that were checked out of inventory. The Cooperative had to change out over 500 poles, the poles had to be hauled at least 45 miles from the Cooperative inventory yard to the job site, the trailers are pulled by specific trucks which the usage of the trucks was documented on timesheets. The trailers were loaded with the poles in the morning, pulled to job site, a pole unloaded at each pole location, returned in the evening when the shift of the employee driving the truck that pulled the trailer was over. Between inventory records and timesheets documenting the trucks pulling the trailers, the Cooperative was able to determine when the trailers were used. The operations manager made note every day of the ATV’s and loader/skid steers that were used and by which employee. That equipment had to be hauled to the job sites which were at least 45 miles away from the office where they are normally kept. The equipment was pulled to the job sites with the assigned trailer (dump trailers) for that equipment in the morning and returned in evening when the employees shift was over. The FEMA representative the Cooperative worked with wanted the force equipment usage in excel format, the directive given to the Cooperative by the FEMA representative was to add the trailers, ATV’s, loader/skid steers to the excel spreadsheet based upon the documentation that was kept by the operations manager, the inventory records and timesheets. The FEMA representative gave the advice that the handwritten documents did not need to be kept once it was added to the excel spreadsheet since that was the document submitted to the FEMA representative, not the timesheets. In future storm situations all handwritten documents will be scanned as a pdf document and electronically kept.

View Audit 408922

Finding 1226249 (2025-001)

Material Weakness 2025

American Physical Society

MD

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.303 § 200.403

Finding Number: 2025-001 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Action Plan In March 2026, following the recognition of the issue, APS immediately conducted a comprehensive review of all payroll related charges, and promptly corrected t...

Finding Number: 2025-001 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Action Plan In March 2026, following the recognition of the issue, APS immediately conducted a comprehensive review of all payroll related charges, and promptly corrected the accounting records and updated the SEFA to remove all duplicated costs. In response to this finding, APS implemented additional policies, procedures, and controls to strengthen oversight of payroll processing and grant expenditure reporting. Specifically, APS established a documented review process to identify and investigate duplicate payroll postings prior to and following the upload of payroll data to the general ledger and grant accounting records. In addition, APS enhanced its system change management procedures to ensure that future modifications or upgrades to payroll and grants management systems include validation testing of key controls before implementation. APS will continue to review payroll charges and grant expenditures regularly and maintain documentation of all review and reconciliation activities to ensure costs charged to federal awards are accurate, allowable, properly supported, and recorded only once. APS implemented the corrective action plan on April 30, 2026. Management's contact responsible for the implementation of the Corrective Action Plan: Name: Jane Hopkins Gould Position: Chief Financial & Operating Officer Telephone number: 301-209-3276

View Audit 408898

Finding 1226186 (2025-002)

Material Weakness 2025

Low Rent Housing Agency of Burlington

IA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs

To properly ensure internal controls, all segregation of duties will be documented beyond what is currently being done. For additional oversight of monthly reconciliation, it will be documented that this has had a secondary review. Additionally, a board member or another individual will review month...

To properly ensure internal controls, all segregation of duties will be documented beyond what is currently being done. For additional oversight of monthly reconciliation, it will be documented that this has had a secondary review. Additionally, a board member or another individual will review monthly bank statements, invoices, and related documentation. The board will review policy and focus on stricter internal controls to prevent any form of fraud.

View Audit 408828

Finding 1226110 (2025-002)

Material Weakness 2025

Center for Mental Health

MT

Allowable Costs / Cost Principles § 200.426

This error resulted from staff turnover and transition of the draw process to new accounting personnel. We will review the allocation of allowable costs and strengthen controls to ensure accurate cost accounting for future submissions. The error will be corrected in the August 2026 draw submission. ...

This error resulted from staff turnover and transition of the draw process to new accounting personnel. We will review the allocation of allowable costs and strengthen controls to ensure accurate cost accounting for future submissions. The error will be corrected in the August 2026 draw submission. The Controller and CFO are responsible for implementing and monitoring these corrective actions.

View Audit 408781

Finding 1226108 (2025-001)

Material Weakness 2025

Advisewell, Inc. Formerly Known As Eqhealth Qio, Inc.

LA

Allowable Costs / Cost Principles § 200.403 § 200.405 § 200.414

Corrective Action Plan: Management is in the process of working with HHS to renew the Provisional Rate agreements. The anticipation is that the agreement will be completed by the end of 2026. Anticipated Completion Date: December 31, 2026

View Audit 408759

Finding 1226098 (2025-002)

Material Weakness 2025

The Boulevard of Chicago, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles

Management will review all contracts to ensure the appropriate indirect costs rates are being used in calculations. A review process is in place in which a staff or grant accountant will prepare the indirect cost calculation, and the Accounting Manager or Director will review and approve. The accoun...

Management will review all contracts to ensure the appropriate indirect costs rates are being used in calculations. A review process is in place in which a staff or grant accountant will prepare the indirect cost calculation, and the Accounting Manager or Director will review and approve. The accounting team will also use formula driven excel calculations to try and avoid any manual input errors.

View Audit 408754

Finding 1226085 (2025-026)

Material Weakness 2025

State of California

CA

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

Special Tests and Provisions California Governor’s Office of Emergency Services On December 10, 2025, Cal OES implemented communication protocol improvements by reemphasizing correct threshold applicability prior to payment during team meetings. In addition, by August 31, 2026, Cal OES will revise i...

Special Tests and Provisions California Governor’s Office of Emergency Services On December 10, 2025, Cal OES implemented communication protocol improvements by reemphasizing correct threshold applicability prior to payment during team meetings. In addition, by August 31, 2026, Cal OES will revise its Project Threshold standard operating procedure to include a review control that verifies the applicability of project thresholds, specifically the Large Project threshold, based on the appropriate timing criteria. Cal OES will also provide training to all grants processing and support staff on the revised procedure, including how to correctly identify and enter Large Project Thresholds, verify disaster data against approved sources, and apply the appropriate thresholds for specific declaration dates. Refresher training will be provided as needed thereafter. Furthermore, guidance on Large Project Thresholds will be incorporated into the onboarding process for all new staff. Estimated Implementation Date: August 2026 Contact: - Heidi Palchik, Chief, Recovery Financial Administration Branch, lnteragency Recovery Coordination Section

View Audit 408731

Finding 1226083 (2025-024)

Material Weakness 2025

State of California

CA

Allowable Costs / Cost Principles Period of Performance Subrecipient Monitoring § 200.303 § 200.77

Period of Performance California Governor’s Office of Emergency Services In July of 2024, Cal OES implemented EMPOWER, a new electronic time reporting system. EMPOWER captures employees' daily time worked, and activities identified with service locations (funding code) by cost category. The establis...

Period of Performance California Governor’s Office of Emergency Services In July of 2024, Cal OES implemented EMPOWER, a new electronic time reporting system. EMPOWER captures employees' daily time worked, and activities identified with service locations (funding code) by cost category. The established EMPOWER Standard Operating Procedure instructs Cal OES Administrative Services staff on how to set the service location incident period start date, which creates system controls to not allow any activities to be entered prior to the start date. To address the transaction identified by CLA and prevent recurrence, Cal OES is troubleshooting and testing potential solutions to develop a systematic fix in EMPOWER. In addition, Cal OES will provide refresher training for all first-line managers to improve their oversight of funding codes and cost categories and ensure their staff submit time entries accordingly. Cal OES Administrative Services will also integrate a resource checklist into its monthly pre-labor review and posting process to add an extra layer of transaction oversight. Currently, Cal OES Administrative Services reviews and reconciles all cost category claims and supporting documentation before submitting to FEMA for obligation. This continuous review ensures Cal OES flags and corrects ineligible or out-of-period transactions before requesting reimbursement. Furthermore, Cal OES will review and correct the identified transaction. Estimated Implementation Date: October 2026 Contact: - Mary Rucker, Assistant Director Administrative Services, Finance & Logistics Administration

View Audit 408731

Finding 1226082 (2025-023)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Eligibility California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS wo...

Eligibility California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS would leverage data to monitor application processing times. The data will be used to select counties for focused reviews targeting application processing times and procedures to ensure counties are performing eligibility determinations timely and accurately. DHCS has implemented multiple monitoring activities to address the recommendation and strengthen oversight of county processing of Medi-Cal applications. In May 2024, DHCS issued Medi-Cal Eligibility Division Letter (MEDIL) 24-12, ending the temporary hold harmless provisions and resumed standard county performance accountability. Subsequently, DHCS issued ACWDL 24-17, which established the Department's transition to using system-generated eligibility data, rather than county self-certification, to monitor application timeliness. Under this approach, DHCS evaluates county performance using statewide eligibility data, publishes application timeliness performance through statewide dashboards, and uses the data to identify counties for focused reviews. Focused reviews evaluate both the timeliness and accuracy of county eligibility determinations. Counties that do not meet established performance expectations are subject to corrective actions consistent with the Welfare and Institutions Code (WIC) section 14154 performance monitoring framework, including the application of statutory performance corrective action plans (CAPS), and financial penalties where applicable. Collectively, these actions establish an ongoing oversight process that enables DHCS to monitor county compliance with Medi-Cal application timeliness requirements, identify performance issues, require counties to implement corrective actions to address any deficiencies identified through focused reviews, and promote continued improvement in the timely and accurate processing of Medi-Cal applications. In 2025, DHCS issued MEDIL I 25-19, Reinstatement of the Aid Code Clean-Up Effort, which reinstated the Department's statewide process for identifying beneficiaries assigned to obsolete pre-Affordable Care Act (ACA) aid codes, transitional aid codes, or other records that may require reevaluation of eligibility. As part of this effort, DHCS provides counties with standardized reports on a bi-monthly basis to assist in identifying records that require review and action. Counties are required to review records, and either transition beneficiaries to the appropriate Medi-Cal aid code or discontinue eligibility, as applicable. Through the reinstated Aid Code Clean-Up process, DHCS performs ongoing statewide monitoring of aid code usage, identifies obsolete or inappropriate aid codes, and requires counties to take the appropriate action to ensure these beneficiaries are enrolled under the correct Medi-Cal aid category. Estimated Implementation Date: Fully Implemented Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226080 (2025-022)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Questioned Costs Allowable Costs / Cost Principles § 200.303

Activities Allowed and Unallowed California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL noti...

Activities Allowed and Unallowed California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS would leverage data to monitor application processing times. The data will be used to select counties for focused reviews targeting application processing times and procedures to ensure counties are performing eligibility determinations timely and accurately. DHCS has implemented multiple monitoring activities to address the recommendation and strengthen oversight of county processing of Medi-Cal applications. In May 2024, DHCS issued Medi-Cal Eligibility Division Letter (MEDIL) 24-12, ending the temporary hold harmless provisions and resumed standard county performance accountability. Subsequently, DHCS issued ACWDL 24-17, which established the Department's transition to using system-generated eligibility data, rather than county self-certification, to monitor application timeliness. Under this approach, DHCS evaluates county performance using statewide eligibility data, publishes application timeliness performance through statewide dashboards, and uses the data to identify counties for focused reviews. Focused reviews evaluate both the timeliness and accuracy of county eligibility determinations. Counties that do not meet established performance expectations are subject to corrective actions consistent with the Welfare and Institutions Code (WIC) section 14154 performance monitoring framework, including the application of statutory performance corrective action plans (CAPS), and financial penalties where applicable. Collectively, these actions establish an ongoing oversight process that enables DHCS to monitor county compliance with Medi-Cal application timeliness requirements, identify performance issues, require counties to implement corrective actions to address any deficiencies identified through focused reviews, and promote continued improvement in the timely and accurate processing of Medi-Cal applications. In 2025, DHCS issued MEDIL I 25-19, Reinstatement of the Aid Code Clean-Up Effort, which reinstated the Department's statewide process for identifying beneficiaries assigned to obsolete pre-Affordable Care Act (ACA) aid codes, transitional aid codes, or other records that may require reevaluation of eligibility. As part of this effort, DHCS provides counties with standardized reports on a bi-monthly basis to assist in identifying records that require review and action. Counties are required to review records, and either transition beneficiaries to the appropriate Medi-Cal aid code or discontinue eligibility, as applicable. Through the reinstated Aid Code Clean-Up process, DHCS performs ongoing statewide monitoring of aid code usage, identifies obsolete or inappropriate aid codes, and requires counties to take the appropriate action to ensure these beneficiaries are enrolled under the correct Medi-Cal aid category. Estimated Implementation Date: Fully Implemented Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226078 (2025-021)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Special Tests and Provisions California Department of Public Health Public Health concurs with the finding that a portion of the federally-required Skilled Nursing Facility (SNF) and Intermediate Care Facility (ICF) recertification surveys were not completed within the 15.9-month requirement. Public...

Special Tests and Provisions California Department of Public Health Public Health concurs with the finding that a portion of the federally-required Skilled Nursing Facility (SNF) and Intermediate Care Facility (ICF) recertification surveys were not completed within the 15.9-month requirement. Public Health’s ability to meet survey workload was hindered by the nearly three-month federal shutdown, reduced staffing capacity due to budget constraints, and competing high-priority workloads. Surveys that were overdue in FFY 2024-25 have been prioritized in FFY 2025-26, focusing first on facilities presenting the highest risk and those with the longest intervals since their last survey. Public Health will continue prioritizing the highest-risk federal workload within the limits of available staffing and budget. The federal contract allotment has remained stagnant despite increased expectations, and reductions in state funding during SFY 2024-25 and continuing through SFY 2025-26 limit Public Health’s ability to backfill gaps with state resources. As a result, Public Health will focus surveyor efforts on Immediate Jeopardy (IJ) investigations, quality-of-care issues, access-to-careconcer, and Tier 1 workload (including SNFs and ICFs). This approach aligns with CMS’s shift toward prioritizing IJ and high-risk intakes over lower-tier recertification surveys. Public Health remains committed to completing all federal workload assignments and will strive to meet Mission and Priorities Document (MPD) and State Performance Standards Systems (SPSS) requirements to the fullest extent possible given current staffing and budget limitations. Estimated Implementation Date June 2027 Contact - Andy Barbusca, State Surveyors Branch Chief, Center for Health Care Quality, California Department of Public Health

View Audit 408731

Finding 1226073 (2025-020)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Eligibility California Department of Health Care Services DHCS is currently in the process of reevaluating its Medi-Cal Eligibility Data System (MEDS) monitoring process by taking the following steps: Research and Data Collection - DHCS will initiate the revised MEDS alert hierarchy process by condu...

Eligibility California Department of Health Care Services DHCS is currently in the process of reevaluating its Medi-Cal Eligibility Data System (MEDS) monitoring process by taking the following steps: Research and Data Collection - DHCS will initiate the revised MEDS alert hierarchy process by conducting targeted research. This effort will include obtaining the total number of records associated with each MEDS Alert, encompassing the entire universe of MEDS alerts. - As part of this research, DHCS will review the highest volume alerts and identify the root causes. County Staff Workgroup: DHCS will form a workgroup with County Staff to collaborate on refining the MEDS Alerts process. The objectives of this workgroup are to: - Determine whether certain alerts can be streamlined to improve efficiency. - Assess if additional functionality can be added to CalSAWS to address issues that lead to high volume alerts. - Develop strategies to ensure counties have sufficient support to resolve MEDS alerts both accurately and timely. Hierarchy Revision and Implementation - DHCS will use the findings from the research phase and the input provided by the workgroup to revise the MEDS Alerts Hierarchy and ACWDL. - The Program Review Branch will update the BI tool to incorporate all MEDS alerts that affect eligibility, and pertinent high-volume alerts. - We are considering amendments to WIC section 14154.5 to reflect any changes in calculating performance standards for MEDS alerts. - DHCS will postpone posting MEDS Alerts performance data to the public facing dashboard until the end of this process. DHCS does not resolve MEDS Alerts. The purpose of the above process is to reduce the number of MEDS alerts created because of caseworker action by providing additional guidance to counties and potentially adding functionality to CalSAWS that would reduce the number of alerts created due to system discrepancies. This is anticipated to reduce the number of MEDS alerts, which would ease the county staff workload and allow counties to better manage the MEDS alerts workload. Focused reviews will continue to assist the department in identifying counties that do not act upon newly reported information that negatively impacts eligibility. DHCS will require counties to submit a corrective action plan and emphasize implementing ongoing trainings to mitigate inappropriate continuation of benefits. DHCS will continue to monitor progress until the identified issues no longer persist. Estimated Implementation Date: June 2027 Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226068 (2025-019)

Material Weakness 2025

State of California

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.328 § 200.329

Reporting California Department of Social Services CDSS will implement improved procedures and consider if a grant management solution would be feasible and necessary. CDSS has already begun establishing a process that determines and documents whether funding actions are reportable subrecipients or ...

Reporting California Department of Social Services CDSS will implement improved procedures and consider if a grant management solution would be feasible and necessary. CDSS has already begun establishing a process that determines and documents whether funding actions are reportable subrecipients or contractors. CDSS has also begun establishing a field within the CDSS accounting system that identifies subrecipients at the contract level so this data is automatically included when extracted for FFATA reporting, which will ensure reports are submitted accurately and timely. CDSS is also developing a Federal Reporting Dashboard to track all grants with FFATA reporting requirements, including due dates and completion status. Additionally, CDSS will designate a primary point and a backup person within the Federal Reporting Section to monitor all FFATA reporting deadlines. This designated staff member will issue 45 days advance notifications to the grant owner and reviewing manager, set calendar reminders for grant owners, and provide regular status updates to Accounting Management. To strengthen timely compliance, these reminders will also instruct grant owners to complete the FFATA submission 10 days before the federal deadline, ensuring sufficient time to resolve any errors that may occur during the upload process. Estimated Implementation Date: November 2026 Contact: - Rosali Bautista, Chief, Accounting and Reporting Bureau, Accounting and Fiscal Systems Branch, Finance and Accounting Division

View Audit 408731

Corrective Action Plans

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