Corrective Action Plans

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Finding 402368 (2021-009)
Significant Deficiency 2021
Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. T...
Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. The Care Branch has also put an increased emphasis on tracking and reviewing invoices for payment to prevent similar delays. Subsequently, the Ryan White Grant closeouts had all invoices processed and paid prior to the Federal Financial Report closeout deadlines to ensure that drawn cash for invoices was not held for extended timeframes. Estimated Implementation Date: July 1, 2021 Contact: Joseph Gonzales, Branch Chief Office of AIDS Support Branch California Department of Public Health
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law D...
Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law DHCS must enforce compliance with the terms of the DHCS’ contracts with Mental Health Plans and Drug Medi-Cal Organized Delivery System counties, as well as ensure compliance with applicable state and federal laws and regulations, in accordance with its authority and obligations under state and federal requirements.” Lastly, under the section titled ‘Exhibit A - Attachment 3’ of the County Mental Health Plan Contract counties are required to submit cost reports timely which would allow Health Care Services to impose sanctions on counties who do not submit cost reports in a timely manner. This BHIN resolves the finding. Additionally, Health Care Services will not be collecting cost reports for dates of service after State Fiscal Year 2022-23. Under the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and pursuant to Welfare and Institutions Code, Section 14184.403(b), Health Care Services will replace the current Certified Public Expenditures (CPE) reimbursement methodology with an intergovernmental transfer (IGT) reimbursement methodology. The IGT reimbursement methodology will make a single and final payment for services provided to the county, which includes the non-federal portion of the claims. This change will eliminate the requirement for the county submission of cost reports. Estimated Implementation Date: October 31, 2022 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
The EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete any remaining retroactive workload by April 30, 2023. Estimated Implementation Date: January 2021 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California ...
The EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete any remaining retroactive workload by April 30, 2023. Estimated Implementation Date: January 2021 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 309913 Questioned Costs: $1
Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condit...
Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board (FTB) records in November 2020 to assist in verifying the income of PUA claimants. Claimants who could not be automatically verified through the FTB wage record match were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California weekly benefit amount (WBA) of $167, in June 2022, the EDD submitted a blanket waiver application to the U.S. Department of Labor (DOL), pursuant to the DOL Unemployment Insurance Program Letter 20-21, Change 1. EDD’s application is pending the DOL’s determination. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, failed to provide proof of income substantiation to support the increase or whose WBA will be decreased because the proof they provided was insufficient. Regarding the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), this verification process is being implemented in two phases. Phase 1 of the SEES effort was implemented on November 10, 2021, and involved notifying claimants registered in California’s UI Online (UIO) system by email and text of their requirement to provide SEES documentation. Phase 2 will involve notifying claimants who did not respond to the UIO request for SEES documentation, and those who are not registered in UIO, via a paper notice mailed through the United States Postal Service (USPS). EDD submitted a blanket overpayment waiver application in June 2022 to DOL regarding this issue. EDD will assess further implementation based on the DOL’s decision. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, provided insufficient documentation or did not provide any documentation. Estimated Implementation Date: To be determined once the DOL provides a decision on the waiver application. Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 309913 Questioned Costs: $1
Since fiscal year 2020-21, EDD has implemented dozens of strict anti-fraud measures to continue to evaluate and enhance its fraud detection. These measures, described in last year’s response to finding Reference Number 2020-005, included, but were not limited to, cross matching claimant information ...
Since fiscal year 2020-21, EDD has implemented dozens of strict anti-fraud measures to continue to evaluate and enhance its fraud detection. These measures, described in last year’s response to finding Reference Number 2020-005, included, but were not limited to, cross matching claimant information against law enforcement and government databases and implementing rigorous new identity verification procedures. As a result, EDD caught and stopped multiple fraud attempts starting in September 2020. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating Pandemic Unemployment Assistance (PUA) claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. The EDD will continue to evaluate and enhance the fraud detection/prevention tools that have been put in place. Estimated Implementation Date: September 2020 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 309913 Questioned Costs: $1
The Women, Infants, and Children Division (WIC) of the California Department of Public Health (Public Health) agrees that the WIC WISE system does not currently store eligibility history that should be included in the “Cert History Report.” Currently, the initial eligibility data is overwritten when...
The Women, Infants, and Children Division (WIC) of the California Department of Public Health (Public Health) agrees that the WIC WISE system does not currently store eligibility history that should be included in the “Cert History Report.” Currently, the initial eligibility data is overwritten when subsequent eligibility information is keyed into WIC WISE. WIC WISE does include preventative internal stops or check points that do not allow ineligible individuals to be certified and issued benefits (e.g., over income, not a CA resident, no nutrition risk factor, etc.). User acceptance testing vetted these items prior to system implementation. The certification history condition will be remediated via a system Defect Correction to WIC WISE. WIC has entered Defect Correction #6972 in Team Foundation Services (TFS), the tracking system used to capture system changes and defects. This correction is included in a release that is currently being tested and is targeted for release into production by May 2023. The defect supports a system change to ensure initial eligibility information is retained when subsequent eligibility information is entered into WIC WISE. Estimated Implementation Date: May 2023 Contact: William Welch, Assistant Division Chief, Operations Women, Infants, and Children Division California Department of Public Health
Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will up...
Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will update the procedures to document the SEFA reporting for the ELC program.
The BOCC will work with all departments receiving grant funds to ensure compliance with federal grant requirements and adequate documentation of grant expenditures will be maintained.
The BOCC will work with all departments receiving grant funds to ensure compliance with federal grant requirements and adequate documentation of grant expenditures will be maintained.
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the cha...
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the challenge of hiring a Payroll Specialist. In September 2022, the College outsourced “Payroll” to Paycom. We continue to develop and communicate the unique needs of our College Payroll structure and Federal and private funding sources with Paycom and the College Human Resources to ensure that employees are paid properly. As such, the Business Office is undergoing a restructure and we have identified an internal candidate to take the lead on Payroll. Name of the contact person responsible for corrective action: Raquel Vigil, Chief Financial Officer, Clarissa Salhus, Finance Manager, Reatha Tom, Accounts Payable Specialist, Michelle Ferron-Guppy, Director – Human Resources, and Zoy Zamudio-Lane, Human Resources Generalist Planned completion date for corrective action plan: September 30, 2024
Personnel files were not maintained while CRA was without a Director and human resources professional for 2020 and 2021. We have since hired a Human Resources Director, Beth Anne Falco, who is in the process of bringing all employee files current. As part of the updated files, CRA intends to issue n...
Personnel files were not maintained while CRA was without a Director and human resources professional for 2020 and 2021. We have since hired a Human Resources Director, Beth Anne Falco, who is in the process of bringing all employee files current. As part of the updated files, CRA intends to issue new employee forms in the beginning of FY25, which will include updated job descriptions, salary information, payroll, and benefits.
The Center’s payroll practices were found to not be in compliance with federal funding in two areas. a. The Center’s time tracking software does not have the capacity to track employees’ time by funding stream b. The Center has not been auditing and signing off on bi-weekly payroll. This is an addit...
The Center’s payroll practices were found to not be in compliance with federal funding in two areas. a. The Center’s time tracking software does not have the capacity to track employees’ time by funding stream b. The Center has not been auditing and signing off on bi-weekly payroll. This is an additional required step on-top of supervisors reviewing and approving timesheets. The Center has migrated to a new Payroll Processing System, Gusto, as of 5/15/24 and will be fully migrated by the start of the 24-25 FY. Gusto will enable all employees who are billed to multiple funding streams tie their work activities to the appropriate funding streams. The Center is also continuing to develop its Operations Department. Chase Weaver has completed additional audit and compliance trainings and has been promoted to the role of Compliance Manager. His new scope includes the addition of payroll audits among additional internal agency compliance checks.
Finding 400778 (2021-005)
Significant Deficiency 2021
The City will analyze the agency’s existing procedures associated with the preparation of the annual Schedule of Expenditures of Federal Awards (SEFA), make any necessary modifications, and ensure these procedures are both adequate and consistently followed.
The City will analyze the agency’s existing procedures associated with the preparation of the annual Schedule of Expenditures of Federal Awards (SEFA), make any necessary modifications, and ensure these procedures are both adequate and consistently followed.
While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP will be developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility for fe...
While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP will be developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility for federally eligible expenditures. o Anticipated Completion Date: July 31, 2024 o Responsable Contact Person: Rhonda Williams
Condition Management provided excel workbooks of costs they determined allowable under the PRF program. Although the workbook totals for some cost reporting categories did match the PRF reporting form, there were several categories that did not. Other reporting errors were also noted on the PRF po...
Condition Management provided excel workbooks of costs they determined allowable under the PRF program. Although the workbook totals for some cost reporting categories did match the PRF reporting form, there were several categories that did not. Other reporting errors were also noted on the PRF portal reporting document. Views of responsible officials and planned corrective actions We will review our current reporting processes and internal controls over PRF reporting to ensure all future reporting requirements are met. Anticipated completion date Ongoing
Condition Supporting expense workbooks provided by management did not agree with certain amounts reported in the PRF portal reporting form. Additionally, certain expenses reported were related to direct patient care costs and management was unable to provide sufficient supporting documentation the ...
Condition Supporting expense workbooks provided by management did not agree with certain amounts reported in the PRF portal reporting form. Additionally, certain expenses reported were related to direct patient care costs and management was unable to provide sufficient supporting documentation the amounts were related to providing care to COVID-19 patients. This resulted in the auditors reporting total questioned costs of $911,136. Views of responsible officials and planned corrective actions Management does not agree with the noted finding. The Health Center feels as though costs incurred did qualify under the provision of being prepared and treating COVID positive, and suspected COVID patients. The Health Center does have amounts that could have been reported as lost revenues that would cover some of the questioned costs. The Health Center was unable to include the lost revenue amounts in the original submission because the website did not allow submission of lost revenues if enough costs were reported to cover the PRF funds received. Anticipated completion date Ongoing
View Audit 308322 Questioned Costs: $1
We will create and follow policies and procedures to adhere to the grant requirments. This was the first time we had this kind of federal grant program fund and now we know and understand the requirements and reporting better.
We will create and follow policies and procedures to adhere to the grant requirments. This was the first time we had this kind of federal grant program fund and now we know and understand the requirements and reporting better.
View Audit 307918 Questioned Costs: $1
Finding 399399 (2021-009)
Material Weakness 2021
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
View Audit 307906 Questioned Costs: $1
Finding 399398 (2021-008)
Material Weakness 2021
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
Finding 399397 (2021-007)
Material Weakness 2021
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
The criteria for use of the Provider Relief Funds (PRF) changed subsequent to the receipt and expenditure by the Hospital. The Hospital utilized the best information available at the time, during the early days of the public health emergency, in its use of the funds. The Hospital consistently revi...
The criteria for use of the Provider Relief Funds (PRF) changed subsequent to the receipt and expenditure by the Hospital. The Hospital utilized the best information available at the time, during the early days of the public health emergency, in its use of the funds. The Hospital consistently reviews the frequently asked questions for PRF maintained by the Health Resources & Services Administration (HRSA) for guidance on changes and clarification to the rules surrounding the program. In October 2021 — long after most critical access hospitals (CAHs), including Selling, had expended their initial PRF distributions - HRSA added an FAQ addressing cost-based reimbursement, specifically, "How does cost-based reimbursement relate to my Provider Relief Fund payment?" HRSA subsequently has made minor modifications to the language of this FAQ — most recently on October 27, 2022 — but the substantive guidance has remained the same. Unlike E.H.R. capital equipment, where specific cost report guidance was provided, no such guidance was provided for assets purchased to prevent, prepare for, and respond to COVID-19. Neither Prospective Payment System (PPS) nor CAH facilities were required to offset the full amount of funds received because they were considered grants, consistent with the treatment of PRF. We disagree with the audit findings and believe that no corrective action is required.
View Audit 307896 Questioned Costs: $1
Finding 2021-001: Condition and Context: The Hospital included expenses in its filing that did not meet criteria of allowable expenses as defined by the U.S. Department of Health and Human Services guidance. The filing included various expenses associated with the facility that were not specificall...
Finding 2021-001: Condition and Context: The Hospital included expenses in its filing that did not meet criteria of allowable expenses as defined by the U.S. Department of Health and Human Services guidance. The filing included various expenses associated with the facility that were not specifically used to prevent, prepare for, and respond to the coronavirus. During our testing we noted exceptions on 7 of 40 samples. Upon further analysis of the entire population, we noted that the Hospital reported expenses associated with the facility that were not specifically used to prevent, prepare for, and respond to the coronavirus totaling $1,359,809. The Hospital received distributions totaling $3,736,717 and reported total expenses of $1,950,653. Our sample was not a statistically valid sample. Corrective Action Plan: Subsequent to the filing of the Period 1 report, the Hospital instituted new policies and procedures surrounding the use, tracking and reporting on federal funds, including the Provider Relief Fund and American Rescue Plan Act (ARP) Rural Distribution. Under the new policies and procedures, the usage of all funds is accumulated and reviewed on a periodic basis, and interpretive of most updated, published guidance, and all reporting is subjected to reviews by Kevin Gessler prior to reporting. Name of Contact Person Responsible for Corrective Action: Kevin Gessler, Chief Financial Officer Anticipated Completion Date: As guidance fluctuated, even through 2022, framework for updated procedures was instituted for subsequent submissions for increased accuracy. Updated policies and procedures, prospectively, have been updated by May 2023.
View Audit 306879 Questioned Costs: $1
Finding 2021-005 Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: A walkthrough of fourteen individuals was performed to agree personnel files a...
Finding 2021-005 Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 U.S. Department of Human Services Condition: A walkthrough of fourteen individuals was performed to agree personnel files and to payroll. Of the fourteen files reviewed, seven had no approved current pay rate documented, and the salary or hourly rate paid was not the rate contained in the file. Action Planned in Response to the Finding: Effective immediately, the human resources team will begin using of a checklist within each file as an additional procedure to ensure that each file contains all necessary documents and that the file has been updated for current rates of pay. Official Responsible for Ensuring the CAP: Becky Howard Planned Completion Date: June 30th, 2024
View Audit 306434 Questioned Costs: $1
Finding Number: 2021-001 Condition: The Organization's controls in place for reporting submission did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: The Organization accepts the finding and has implemented additional layers of review r...
Finding Number: 2021-001 Condition: The Organization's controls in place for reporting submission did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: The Organization accepts the finding and has implemented additional layers of review regarding expense submission to ensure the reports are submitted within the established guidelines. The submission was prepared by prior management that is no longer at the organization during a period of transition from the acquisition by Beacon. Subsequent reporting was performed for TRH by Beacon management after this initial submission and subsequent audits were performed with all findings resolved. As stated above, the Organization had sufficient additional expenditures and lost revenue from the COVID-19 pandemic and there are no resulting PRF recognition issues. Contact person responsible for corrective action: Harley McCoige, Controller Anticipated Completion Date: N/A - Completed
View Audit 306248 Questioned Costs: $1
The Organization will designate a knowledgeable person separate from the preparer of the reports to review all expenditures that go into the reports prior to submission.
The Organization will designate a knowledgeable person separate from the preparer of the reports to review all expenditures that go into the reports prior to submission.
Finding 2021-005 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Contact Person: Joel Rusco, Chief F...
Finding 2021-005 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Contact Person: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Program Director Corrective Action Plan: • CFSC has reviewed the payroll procedures and has retained Clark Nuber to implement an additional review of grant-related charges as well as the procedure to ensure charges are accurately recorded. • Clark Nuber has done a review of the current time and effort policy and procedures and proposed updates and revisions. Clark Nuber’s recommendations will be reviewed and approved cy CFSC management and thereafter implemented by CFSC staff. • Any changes to timecards or reporting allocations for payroll be substantiated by supporting documentation. Journal entry and cost transfer policies and procedures will be enhanced to require sufficient documentation, attestations, and approvals before the charges are recorded or reported to funders. • A full review of costing policies and procedures, IDC rate calculations, and cost allocation plan is anticipated to begin mid-2024. Anticipated Completion Date: The Payroll and Time and Effort policies and procedures review is to be completed by the end of Quarter 2 of FY 2024.
View Audit 305892 Questioned Costs: $1
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