Corrective Action Plans

Finding 406040 (2021-003)

Significant Deficiency 2021

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial sta...

Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial statements and single audit, for the Hospital to file its reporting package within it´s due date, as required by the CFR. Also, Mr. Julio Colón, Chief Financial Officer, will be the designated officer in charge of supervising and monitoring compliance with timely submittance each year. Name (s) of the Contact Person (s) Responsible for Corrective Action Mr. Julio Colón, Chief Financial Officer Anticipated Completion Date December 2024

View Audit 311582

Finding 406039 (2021-002)

Significant Deficiency 2021

Hospital Damas INC

PR

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief ...

Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be de designated officer in charge of supervising and monitoring compliance with timely submittance each month. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on July 29, 2022

View Audit 311582

Finding 404941 (2021-008)

None 2021

Clark County Fiscal Court

KY

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

County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.

View Audit 311338

Finding 404940 (2021-007)

Material Weakness 2021

Clark County Fiscal Court

KY

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure that expenses for Federal Reimbursement are eligible for reimbursement.

View Audit 311338 Questioned Costs: $1

Finding 404908 (2021-004)

Significant Deficiency 2021

Iroquois Memorial Hospital

IL

Allowable Costs / Cost Principles Cash Management Reporting

The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under th...

The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under the program. One of the updates included utilization of additional lost revenue to cover nonallowable expenses under the first phases of reporting for Provider Relief Funds due to elimination of some expenses and reduction for Medicare cost reimbursement against expenses. Management developed a more detailed expense log and review those against current terms and conditions prior to any future portal submissions and took into account the use of additional lost revenue. The worksheets were mocked up internally as if these were submitted in the portal in Phase I reporting so that in the future for the next phases of reporting, these lost revenues are not utilized toward future Provider Relief Funding. One additional control being added for this reporting is that the CEO and CFO will be also completing a detailed review of the spreadsheets for entry into the portal and comparing this to the Compliance Supplement which governs the use of the Provider Relief Funds as to allowable costs as well as the Frequently Asked Questions (FAQs) available on HRSAs website. This may impact future reports, so management will ensure to take these updates into account on any future provider relief funds are they are released or future grant receipts if the Organization receives new grants in the future.

View Audit 311307

Finding 404821 (2021-007)

Material Weakness 2021

Shattuck Hospital Authority D/b/a Newman Memorial Hospital, Inc.

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federa...

Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal, states, regulations and conditions of the federal award. Corrective Action Plan: We will modify internal control policies to ensure there is an understanding of reporting requirements to ensure that reports are accurate and amounts are not inadvertently claimed that are considered unallowable. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: June 2024

View Audit 311207

Finding 403372 (2021-006)

Material Weakness 2021

First Choice Community Healthcare, Inc.

NM

Allowable Costs / Cost Principles Equipment & Real Property Management Questioned Costs

2021-006—Allowable Costs Corrective Action: FCCH Management shall conduct training of human resource and accounting personnel to ensure they understand the requirement for allowable costs under 2 CFR Part 225 and shall follow the principles in 2 CFR Part 200, Subpart E. Current policies and procedu...

2021-006—Allowable Costs Corrective Action: FCCH Management shall conduct training of human resource and accounting personnel to ensure they understand the requirement for allowable costs under 2 CFR Part 225 and shall follow the principles in 2 CFR Part 200, Subpart E. Current policies and procedures shall be reviewed to ensure adequacy of measures to ensure compliance. FCCH leadership shall also be trained in the elements of allowable cost principles. Person Responsible: Shawna Gonzales, Chief Financial Officer and Abigail Jackson, Human Resources Director Completion Date: December 31, 2024

View Audit 310507 Questioned Costs: $1

Finding 402820 (2021-001)

Significant Deficiency 2021

Brownfield Regional Medical Center

NM

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.403 § 200.430

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. ...

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. Action Taken: 1. Policy Revision and Development: o Develop or revise existing policies to clearly define the processes for documenting and retaining expenditure information related to federal awards. These policies should explicitly follow the requirements over 2 CFR Section 200.430(g)(i), ensuring that all expenditures are properly documented and justified as per federal award conditions. Specifically, approval of differential rates will be added to those policies. o Ensure that the policy includes guidelines for regularly reviewing employee pay rates against approved rates for compliance with federal award conditions. 2. Training and Awareness Programs: o Implement comprehensive training programs for all staff involved in charging costs to federal awards. This training should cover the importance of compliance with federal regulations, specifically focusing on the documentation and retention of expenditure information and adherence to approved pay rates. o Schedule regular refresher training sessions to ensure ongoing compliance and awareness. 3. Enhanced Monitoring and Audit Trails: o Introduce monitoring mechanisms to regularly review expenditures charged to federal awards for compliance with documented policies and federal requirements. o Develop an audit trail system that allows for the easy retrieval of documentation supporting expenditures and payroll compliance. This system should enable auditors to trace the documentation back to the federal award and the approved budget items. 4. Internal Control Improvements: o Review and strengthen internal controls related to the processing of expenditures and payroll to ensure that all transactions are authorized, recorded accurately, and in compliance with federal award requirements. o Implement segregation of duties where possible, to reduce the risk of errors or fraud in the charging of costs to federal awards. 5. Regular Compliance Reviews and Updates: o Conduct periodic internal reviews to assess compliance with federal award requirements and the effectiveness of the implemented corrective actions. o Ensure that any changes in federal regulations or award-specific requirements are promptly incorporated into the hospital's policies and training programs. 6. Documentation and Communication: o Maintain comprehensive records of all actions taken to address the audit findings, including policy revisions, training sessions, and internal review outcomes. Specifically, records for those these expenditures will remain onsite and not sent to long-term storage if the employee or vendor no longer has a relationship with the facilities. o Communicate regularly with federal awarding agencies to update them on the corrective actions taken and to seek guidance on compliance matters as needed. Implementation Timeline and Responsibility Assignment: • Management positions including the CEO, CFO and CNO for the 2021 fiscal year are no longer employed by Terry Memorial Hospital District. Administration employed in 2023 acknowledges these deficiencies and accepts responsibility for developing, applying and maintaining this corrective action plan going forward. • Assign specific responsibilities to designated staff members or departments for each component of the corrective action plan. • Set clear deadlines for the completion of each action item, with an initial goal to address all significant deficiencies within one to three months from the date of the audit report. Monitoring and Reporting: • Establish a mechanism for ongoing monitoring of the effectiveness of the corrective action plan, with periodic reports to senior management and the board of directors. Feedback Loop: • Create a feedback loop with employees and management to continuously improve internal controls and compliance processes based on practical experiences and challenges encountered during implementation. Responsible Person: Whitney Wilson, CFO

View Audit 310010 Questioned Costs: $1

Finding 402384 (2021-016)

Material Weakness 2021

State of California

CA

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference...

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference Number 2021-003. The other three claimants were receiving regular Unemployment Insurance (UI) benefits (one claimant) and Pandemic Emergency Unemployment Compensation (PEUC) benefits (two claimants). Those three claimants were paid pending the adjudication of potential eligibility issues, which were later found to be disqualifying. EDD has corrected both issues that resulted in the LWA payments being made to ineligible claimants. Regarding the issue of PUA claimants paid prior to the discovery of the potential identity issues, as outlined in the response to the finding for Reference Number 2021-003, during the years 2020 and 2021, the EDD implemented multiple new fraud prevention measures. Regarding the issue of the regular UI and PEUC claimants being paid prior to the adjudication of the potential eligibility issues, the EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete the remaining retroactive workload by April 30, 2023. Estimated Implementation Date: September 2020 (Fraud Enhancements) and January 2021 (Resumption of Adjudications) Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402380 (2021-015)

Significant Deficiency 2021

State of California

CA

Reporting Questioned Costs Special Tests & Provisions § 200.303

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assista...

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assistance Program vs. Children’s Health Insurance Program) for each overpayment account receivable set up after the effective date. The FFP rate and Budget Program information for each overpayment is provided on the Action Notices to the FI. The SDN also made updates to the California Omnibus Budget Reconciliation Act of 1985 (COBRA) system to enable the system to receive the FFP rate and Budget Program information for each overpayment set up by the FI and updated COBRA reports, thereby allowing Health Care Services to report the correct FFP rate for overpayments on the CMS-64 and CMS-21. Estimated Implementation Date: September 30, 2021 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913 Questioned Costs: $1

Finding 402371 (2021-011)

Material Weakness 2021

State of California

CA

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guideli...

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. During this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 309913

Finding 402369 (2021-010)

Material Weakness 2021

State of California

CA

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Reference No. 2021-010: Health Care Services agrees with the finding. The U.S. Centers for Medicare and Medicaid Services (CMS) has confirmed the continuous enrollment requirement is now delinked from the Public Health Emergency (PHE) in the Consolidation Appropriations Act of 2023, (enacted Decemb...

Reference No. 2021-010: Health Care Services agrees with the finding. The U.S. Centers for Medicare and Medicaid Services (CMS) has confirmed the continuous enrollment requirement is now delinked from the Public Health Emergency (PHE) in the Consolidation Appropriations Act of 2023, (enacted December 29, 2022), which ends on March 31, 2023. Health Care Services will begin the continuous coverage requirement unwinding activities, including the resumption of renewals, on April 1, 2023. Per the current county oversight timeline established within the California Advancing and Innovating Medi-Cal (CalAIM) implementation timeline, the resumption of oversight and monitoring activities shall begin 14 months after the onset of continuous coverage requirement unwinding activities; therefore, the new implementation date to initiate these activities is May 1, 2024. Estimated Implementation Date: May 1, 2024 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913 Questioned Costs: $1

Finding 402368 (2021-009)

Significant Deficiency 2021

State of California

CA

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.305

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

View Audit 309913

Finding 402364 (2021-008)

Material Weakness 2021

State of California

CA

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

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

View Audit 309913

Finding 402361 (2021-006)

Material Weakness 2021

State of California

CA

Eligibility Questioned Costs Allowable Costs / Cost Principles § 200.303

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

Finding 402359 (2021-005)

Material Weakness 2021

State of California

CA

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

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

Finding 402357 (2021-004)

Material Weakness 2021

State of California

CA

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

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

Finding 402355 (2021-003)

Material Weakness 2021

State of California

CA

Eligibility Questioned Costs Allowable Costs / Cost Principles § 200.303

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

View Audit 309913

Finding 402354 (2021-002)

Material Weakness 2021

State of California

CA

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.502 § 200.510

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.

View Audit 309913

Finding 401852 (2021-003)

Material Weakness 2021

McIntosh County

OK

Allowable Costs / Cost Principles

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.

View Audit 309759

Finding 401706 (2021-005)

Significant Deficiency 2021

Northwest Indian College

WA

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

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

View Audit 309644

Finding 401311 (2021-002)

Material Weakness 2021

Chicago Recovery Alliance

IL

Allowable Costs / Cost Principles § 200.430

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.

View Audit 309372

Finding 401298 (2021-002)

Significant Deficiency 2021

The Center in Hollywood

CA

Allowable Costs / Cost Principles HUD Housing Programs

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.

View Audit 309351

Finding 400778 (2021-005)

Significant Deficiency 2021

City of Hollister

CA

Allowable Costs / Cost Principles Reporting

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.

View Audit 308797

Finding 400511 (2021-004)

Significant Deficiency 2021

Recreation & Park Commission for Parish of East Baton Rouge

LA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.318

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

View Audit 308504

Corrective Action Plans

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