Corrective Action Plans

Finding 1227613 (2025-004)

Material Weakness 2025

TN

Eligibility HUD Housing Programs Significant Deficiency

Finding Reference: 2025-004 Description of Finding: The Authority was unable to provide documentation to show income had been verified during reexamination for 3 tenants out of a sample of 40 tenants. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Actio...

Finding Reference: 2025-004 Description of Finding: The Authority was unable to provide documentation to show income had been verified during reexamination for 3 tenants out of a sample of 40 tenants. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: Staff will attend annual file compliance training and upcoming rent calculation training to reinforce documentation requirements and ensure accurate income determinations going forward. We have also updated our file checklists, staff are reviewing all tenant files and we have an internal file review process, as noted in Finding 2025-002, to help ensure staff obtain and maintain all required third-party documentation for income reexaminations Name of Contact Person: Curtis Lokey, Director of Finance, 423-752-4893, clokey@chahousing.org

View Audit 409622

Finding 1227611 (2025-002)

Material Weakness 2025

Chattanooga Housing Authority

TN

Eligibility HUD Housing Programs Significant Deficiency

Finding Reference: 2025-002 Description of Finding: The Authority was unable to provide all documents required to be maintained to determine eligibility. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: We have updated our file checklists to bette...

Finding Reference: 2025-002 Description of Finding: The Authority was unable to provide all documents required to be maintained to determine eligibility. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: We have updated our file checklists to better ensure that staff collect all required supporting documentation needed to determine eligibility during each reexamination. Staff received training on the new checklist format in late 2025 and have begun using the updated checklists. We are also reviewing all participant files to verify they are complete and compliant. In addition, we have an internal file review process that includes quality control reviews of a percentage of files at each site to help ensure required documentation is present and program requirements are being met. Staff will also attend annual file compliance training to reinforce documentation requirements and support continued compliance going forward.

View Audit 409622

Finding 1227484 (2025-005)

Material Weakness 2025

Warren County, North Carolina

NC

Eligibility Material Weakness Equipment & Real Property Management

Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training st...

Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2026

View Audit 409520

Finding 1227482 (2025-004)

Material Weakness 2025

Art Academy of Cincinnati

OH

Student Financial Aid Eligibility Significant Deficiency

Condition: During testing of eligibility, 1 out of 40 students were not awarded their maximum subsidized loan amounts they should have been awarded. Views of Responsible Officials: AAC officials concur with the audit finding and acknowledge that one student did not receive the maximum subsidized loa...

Condition: During testing of eligibility, 1 out of 40 students were not awarded their maximum subsidized loan amounts they should have been awarded. Views of Responsible Officials: AAC officials concur with the audit finding and acknowledge that one student did not receive the maximum subsidized loan amount for which the student was eligible. The error resulted from an oversight during the financial aid packaging process and was not identified through the Academy's review procedures. Upon notification of the finding, the AAC reviewed the student's eligibility, recalculated the award, and initiated the appropriate corrective action to ensure the student received the correct subsidized loan amount, if still permissible under federal regulations. Management also reviewed its loan awarding procedures to identify opportunities to strengthen internal controls. Corrective Action Plan: To prevent similar occurrences, the AAC will implement an additional supervisory review of loan awards before disbursement, utilize system-generated eligibility reports to verify that students are awarded the maximum subsidized loan amount for which they qualify, and provide refresher training to financial aid staff on federal Direct Loan awarding requirements. Management believes these enhancements will improve the accuracy of loan packaging and reduce the likelihood of similar errors in future award years. Responsible Party: Executive Director of Administration and Finance Completion Date: The corrective action will be developed and implemented during the 2025-2026 fiscal year and will continue to be implemented in the 2026-2027 fiscal year.

View Audit 409518

Finding 1227481 (2025-003)

Material Weakness 2025

Art Academy of Cincinnati

OH

Student Financial Aid Subrecipient Monitoring Eligibility

Condition: During testing of Student Financial Assistance (SFA) eligibility and awarding, the Institution did not consistently apply federal requirements related to Cost of Attendance (COA), financial need determination, and award packaging. Specifically: • One student was awarded aid in excess of t...

Condition: During testing of Student Financial Assistance (SFA) eligibility and awarding, the Institution did not consistently apply federal requirements related to Cost of Attendance (COA), financial need determination, and award packaging. Specifically: • One student was awarded aid in excess of the federally allowable COA. • One student’s COA was overstated, which resulted in the student being potentially overawarded. • Six student’s were awarded the incorrect COA based on the grade level reported on the Institutional Student Information Record (ISIR). However, there is no code for year 4 on the ISIR, which resulted in the students receiving year 3 COA. • Two students received aid in excess of their calculated financial need, and the Institution did not maintain documentation supporting the adjustments or exceptions. • One student was enrolled at three quarter time during the fall semester and full time during the spring semester; however, the student received three quarter time Pell Grant disbursements for both semesters, resulting in an underpayment for the spring term and inaccurate Pell reporting. These errors demonstrate inconsistent application of federal awarding rules and insufficient review of eligibility and enrollment status changes. Views of Responsible Officials: AAC officials concur with the audit finding and acknowledge that the identified errors resulted from inconsistencies in the application of federal Student Financial Assistance awarding requirements and insufficient review of student eligibility, Cost of Attendance calculations, financial need determinations, and enrollment status changes. Management has reviewed each of the identified student files and is taking appropriate corrective action, including recalculating awards, making any required adjustments or corrections, and updating reporting where necessary. The AAC has also evaluated the circumstances surrounding the use of Cost of Attendance budgets, including the limitation of the Institutional Student Information Record (ISIR), which does not include a separate code for fourth-year undergraduate students. Procedures are being revised to ensure that staff apply the appropriate institutional Cost of Attendance budget regardless of the ISIR grade level code and that any manual adjustments are adequately documented. Corrective Action Plan: To strengthen internal controls, the AAC will implement enhanced review procedures for financial aid packaging, Cost of Attendance determinations, financial need calculations, enrollment status changes, and Pell Grant disbursements prior to disbursement. In addition, financial aid personnel will receive refresher training on federal awarding requirements, documentation standards, and exception processing. Management believes these corrective actions will improve compliance with federal regulations and reduce the likelihood of similar errors in future award years. Responsible Party: Executive Director of Administration and Finance Completion Date: The corrective action will be developed and implemented during the 2025-2026 fiscal year and will continue to be implemented in the 2026-2027 fiscal year.

View Audit 409518

Finding 1227454 (2025-002)

Material Weakness 2025

The Institute of World Politics

DC

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Identifying Number: 2025-002: Documentation of Internal Controls Over Compliance Finding: We noted that controls identified by management over all material compliance requirements lack sufficient documentation to conclude application of controls is in place. Corrective Actions Taken or Planned: Mana...

Identifying Number: 2025-002: Documentation of Internal Controls Over Compliance Finding: We noted that controls identified by management over all material compliance requirements lack sufficient documentation to conclude application of controls is in place. Corrective Actions Taken or Planned: Management agrees with the finding and has implemented, or is in the process of implementing, the following corrective actions: 1. Development of Written Policies and Procedures • The Institute will perform a comprehensive review of all applicable Student Financial Assistance compliance requirements and develop formal written policies and procedures documenting the processes and controls for each material compliance area. Procedures will include the individual responsible, required documentation, review requirements, and retention standards. 2. Documentation of Internal Controls • Management will establish standardized control documentation requirements for all compliance activities. Evidence of review and approval will be maintained through signatures, initials, electronic approvals, checklists, reconciliations, or other documented support sufficient to demonstrate that controls were performed and reviewed. 3. Compliance Monitoring Checklists • The Institute will implement compliance monitoring checklists covering all direct and material compliance requirements identified in the audit, including: o Cash Management o Reporting o Student Eligibility o Student Disbursements o Credit Balance Processing o NSLDS Reporting o Gramm-Leach-Bliley Act Information Security Requirements • The checklists will be completed and reviewed periodically to provide evidence of compliance and supervisory oversight. 4. Training and Cross-Training • Financial Aid and Administrative personnel will receive training on federal student aid compliance requirements, documentation expectations, and internal control responsibilities. Cross training will be performed to mitigate risks associated with employee turnover and ensure continuity of operations. 5. Management Review and Oversight • Management will implement periodic supervisory reviews of compliance activities and supporting documentation to verify controls operating as designed. Results of compliance monitoring activities and any identified deficiencies will be reported to senior administration, and corrective actions will be tracked to completion. 6. Annual Compliance Review • The Institute will conduct an annual review of Student Financial Assistance policies, procedures, and internal controls to ensure continued compliance with Department of Education regulations, Uniform Guidance requirements, and changes in federal program requirements. Identifying Number: 2025-002: Documentation of Internal Controls Over Compliance (Continued) Responsible Officials: • Executive Vice President – Ariane Sweeney • Director of Financial Aid – Dr Thelbert Snowden • Controller/Outsourced Accounting Partner – YPTC Associates Melissa McGuire & Samantha Glass • Compliance and Information Security Personnel, as applicable Anticipated completion date: The written policies and procedures, compliance monitoring tools, and documentation standards will be fully implemented by December 31, 2026. Ongoing monitoring, training, and annual reviews will continue thereafter.

View Audit 409492

Finding 1227379 (2025-004)

Material Weakness 2025

Community Action Partnership of Mercer County

PA

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility

Under the state of Pennsylvania, contractors doing home repairs in excess of $5000 a year must register with the state of Pennsylvania and receive their Home Improvement Contractor Certification. Applications are reviewed by the Attorney General’s Office , anyone who is debarred is not issued and HI...

Under the state of Pennsylvania, contractors doing home repairs in excess of $5000 a year must register with the state of Pennsylvania and receive their Home Improvement Contractor Certification. Applications are reviewed by the Attorney General’s Office , anyone who is debarred is not issued and HIC Certification. In addition, the Program Director has a list of debarred contractors that he reviews periodically to ensure that contractors are not on the list. The organization will take the auditors recommendation of copying the debarred alphabetical page indicating that the contractor is not on the debarred or suspended listing and placing it in the contractors file. Responsible Individual: Energy Director Zack Porrecca and Housing Director Vickie Bucker Estimated Completion Date: September 30, 2026

View Audit 409469

Finding 1227373 (2025-005)

Material Weakness 2025

SOLAR FAITHFUL

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.214

2025-005 – Lack of Documentation for SAM.gov Exclusion Checks Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Organization did not retain documentation to support that the exclusion checks...

2025-005 – Lack of Documentation for SAM.gov Exclusion Checks Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Organization did not retain documentation to support that the exclusion checks were performed for vendors. As a result, there is no evidence that the Organization verified whether these parties were suspended or debarred prior to entering covered transactions. Auditor Recommendation. We recommend that the Organization retain evidence that SAM.gov exclusion checks are being completed for vendors to document that vendors are not suspended or debarred prior to entering covered transactions. Corrective Action. The Organization will begin retaining documentation for its SAM.gov exclusion checks that it completes for vendors to verify whether these parties were suspended or debarred prior to entering covered transactions. Responsible Person. Rob Rafson, Executive Director Anticipated Completion Date: December 2026

View Audit 409461

Finding 1227347 (2025-013)

Material Weakness 2025

Wittenberg University

OH

Student Financial Aid Reporting Subrecipient Monitoring

Condition Summary: The institution's procedures and controls for determining and reporting withdrawal dates to NSLDS were not operating effectively to ensure that the actual effective date of withdrawal was reported accurately and that enrollment status changes were reported timely. Of the forty stu...

Condition Summary: The institution's procedures and controls for determining and reporting withdrawal dates to NSLDS were not operating effectively to ensure that the actual effective date of withdrawal was reported accurately and that enrollment status changes were reported timely. Of the forty student records tested for NSLDS withdrawal reporting, we identified the following: • One student where the effective date of withdrawal was reported as the end of the semester rather than the student's actual withdrawal date. • Six students where the effective date of withdrawal was reported as the date the student was notified rather than the actual effective withdrawal date. • One student where the student's withdrawal was not reported timely and was not included on the first enrollment roster following the withdrawal. Management Response / Corrective Action Plan: Management concurs with this finding. Turnover within the Financial Aid office resulted in a breakdown in the process for timely and accurate submission of reporting enrollment changes within NSLDS. Staff previously responsible for this function are no longer employed at the institution, and the engaged consulting firm has assumed interim responsibility for identifying enrollment status changes and completing NSLDS reporting within the required 60-day period. Responsible Party - Raymond Nault, Interim Director of Student Financial Services Title - Interim oversight: Engaged Consulting Firm Anticipated Completion Date - August 24, 2026 Note: Because the corrective actions described above were substantially implemented during and after the fiscal year 2025 audit period, management anticipates that this condition, or elements of it, may continue to be identified as a finding in the University's fiscal year 2025-2026 single audit. Full operating effectiveness of the revised controls will not be demonstrable until they have been in place for a complete testing cycle.

View Audit 409430

Finding 1227089 (2025-002)

Material Weakness 2025

Le Mars Community School District

IA

School Nutrition Programs Cash Management Eligibility

Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance: Meal Count Reporting and Reconciliation U.S Department of Agriculture Child Nutrition Cluster Passed through State of lowa Department of Education Federal Assistance Listing Number: 10.555, 10.559, 10.553 Feder...

Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance: Meal Count Reporting and Reconciliation U.S Department of Agriculture Child Nutrition Cluster Passed through State of lowa Department of Education Federal Assistance Listing Number: 10.555, 10.559, 10.553 Federal Award Year: 2025Criteria: Districts are required are required to submit accurate claims for reimbursement and maintain records supporting the number of meals claimed for reimbursement for the National School Lunch Program. Condition: During audit procedures over the School Nutrition Cluster, we identified multiple instances in the National School Lunch Program in which the number of claims submitted was incorrect. Cause: The District did not have an effective review and reconciliation control in place to compare meal-count support to the claim summary reports before reimbursement claims were submitted. In addition, meal-count and eligibility reports were not consistently generated and retained at the time the claims were prepared. As a result, subsequent changes in student eligibility status may have affected the reports available to support the meal counts claimed during the applicable reporting periods. Effect: Meal counts reported for reimbursement were not fully supported by contemporaneous records, resulting in noncompliance with reporting and recordkeeping requirements. Without an effective review and reconciliation control, errors in meal counts or claim summary reports may not be identified before reimbursement claims are submitted, increasing the risk that federal reimbursement claims could be inaccurate. Questioned Costs: Known questioned costs identified were below the reporting threshold and are not reported in this finding. Recommendation: We recommend that the District implement a documented monthly review and reconciliation process before reimbursement claims are submitted. The reconciliation should compare meal-count and eligibility support to the claim summary reports, identify and explain any differences, retain support for adjustments, and include evidence of review and approval by an individual independent of claim preparation. We also recommend that management generate and retain meal-count and eligibility report for each applicable reporting period at the time claims are prepared to ensure support reflects student eligibility status as of the applicable claim period. Management Response: Management acknowledges the finding and the District will generate and retain monthly meal-count and eligibility reports at the time reimbursement claims are prepared. The District will also implement a documented review and reconciliation process for National School Lunch Program reimbursement claims.

View Audit 409272

Finding 1226974 (2025-005)

Material Weakness 2025

Operation Hope of Fairfield, Inc.

CT

Questioned Costs Subrecipient Monitoring Eligibility

Management has updated the policies and procedures manual to address this finding. For each housing unit, we are using the Department of Housing and Urban Development (HUB) rent reasonableness form at lease signing. This form will be updated annually for each unit. We will also be following the HUD ...

Management has updated the policies and procedures manual to address this finding. For each housing unit, we are using the Department of Housing and Urban Development (HUB) rent reasonableness form at lease signing. This form will be updated annually for each unit. We will also be following the HUD fair market rent determinations.

View Audit 409146

Finding 1226485 (2025-001)

Material Weakness 2025

Beacon Health System, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. S...

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of the WIC applicant’s proof of eligibility. Therefore, the auditors were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Compliance with State of Indiana participant eligibility requirements is the responsibility of Rebecca Lies, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.

View Audit 409117

Finding 1226481 (2025-006)

Material Weakness 2025

Reach Community Development, Inc.

OR

Eligibility Questioned Costs HUD Housing Programs

REACH has policies in place to ensure recertifications and income verification are performed timely, tenant eligibility is correctly determined, and the tenant files are properly maintained. During the second quarter of 2026, REACH outsourced property management and compliance functions to a third-p...

REACH has policies in place to ensure recertifications and income verification are performed timely, tenant eligibility is correctly determined, and the tenant files are properly maintained. During the second quarter of 2026, REACH outsourced property management and compliance functions to a third-party management company to address the outstanding compliance issues.

View Audit 409109

Finding 1226480 (2025-001)

Material Weakness 2025

Reach Community Development, Inc.

OR

Eligibility Questioned Costs Significant Deficiency

REACH’s 2024 consolidated audit report was issued in mid-November 2025. REACH Compliance Management reviewed the Oregon Housing and Community Services (OHCS) Housing Trust Fund (HTF) program manual and did not find any specific requirements about certifications other than at move-in. REACH reached o...

REACH’s 2024 consolidated audit report was issued in mid-November 2025. REACH Compliance Management reviewed the Oregon Housing and Community Services (OHCS) Housing Trust Fund (HTF) program manual and did not find any specific requirements about certifications other than at move-in. REACH reached out to OHCS and did not receive any clarifications. REACH operated with the available guidance for HTF at the time. OHCS have since updated the HTF manual as of June 2026. REACH now have an updated HTF manual which outlines when full recertification with income verifications are required and will follow those rules going forward.

View Audit 409109

Finding 1226479 (2025-005)

Material Weakness 2025

Reach Community Development, Inc.

OR

Eligibility Questioned Costs HUD Housing Programs

Once REACH Asset Management Team was notified of this audit finding, our Asset Management team communicated this finding to Ad-West. They would set up a new process to ensure the reporting of HOME units, HOME unit types, and compliance would be met on all HOME units.

View Audit 409109

Finding 1226478 (2025-004)

Material Weakness 2025

Reach Community Development, Inc.

OR

Eligibility Questioned Costs HUD Housing Programs

Once REACH was notified about this audit finding, Property Management established a new review process to review the HOME units that would be re-classified the next time there is a vacant unit of the corresponding size/type. This is a “next available unit” rule. It will be addressed when the existin...

Once REACH was notified about this audit finding, Property Management established a new review process to review the HOME units that would be re-classified the next time there is a vacant unit of the corresponding size/type. This is a “next available unit” rule. It will be addressed when the existing resident moves out. Our third-party Property Management company will continue to monitor this finding.

View Audit 409109

Finding 1226477 (2025-003)

Material Weakness 2025

Reach Community Development, Inc.

OR

Eligibility Questioned Costs HUD Housing Programs

REACH’s 2024 consolidated audit report was issued in mid-November 2025. Once we were notified about this audit finding, Compliance Management conducted an in-depth review of this finding and determined that one extra 3-bedroom and one fewer 4-bedroom at Covington Commons were incorrectly set up in o...

REACH’s 2024 consolidated audit report was issued in mid-November 2025. Once we were notified about this audit finding, Compliance Management conducted an in-depth review of this finding and determined that one extra 3-bedroom and one fewer 4-bedroom at Covington Commons were incorrectly set up in our Yardi system. REACH have since corrected this issue in the Yardi system. REACH will continue to monitor vacant two-bedrooms at Cascadia Village as they become available. There are only two 2-bedrooms that are not designated as HOME. We noted that unit #72 was not set up properly in our Yardi system. REACH have corrected this issue in the system.

View Audit 409109

Finding 1226476 (2025-002)

Material Weakness 2025

Reach Community Development, Inc.

OR

Eligibility Questioned Costs HUD Housing Programs

REACH’s 2024 consolidated audit report was issued in mid-November 2025. REACH has policies and procedures in place to monitor compliance of recertifications, and correct income verification procedures are performed timely. Once we were notified of this finding, Compliance Management Compliance team ...

REACH’s 2024 consolidated audit report was issued in mid-November 2025. REACH has policies and procedures in place to monitor compliance of recertifications, and correct income verification procedures are performed timely. Once we were notified of this finding, Compliance Management Compliance team conducted a full review of all HOME regulatory agreements in the portfolio, including County, City and Commerce HOME funding. Compliance Management also created a spreadsheet to track which units are due for the appropriate HOME recertification.

View Audit 409109

Finding 1226338 (2025-002)

Material Weakness 2025

Retired Steelworkers Housing and Health Development Corporation

FL

HUD Housing Programs Reporting Eligibility

FINDING No. 2025-002: Section 236 Interest Reduction Payments, ALN 14.103 Recommendation: Management should implement procedures to ensure the Project verifies tenant eligibility through the EIV system. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV repo...

FINDING No. 2025-002: Section 236 Interest Reduction Payments, ALN 14.103 Recommendation: Management should implement procedures to ensure the Project verifies tenant eligibility through the EIV system. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance. If the audit Oversight Agency has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO

View Audit 408975

Finding 1226207 (2025-004)

Material Weakness 2025

Baden Street Settlement of Rochester, Inc.

NY

Eligibility Cash Management § 200.512

Views of Responsible Officials and Planned Corrective Actions: Current staff and new staff will be trained on the importance of keeping accurate records. A checklist will be developed for quarterly internal audits to cross-verify names between applications and attendance records, plus other applicab...

Views of Responsible Officials and Planned Corrective Actions: Current staff and new staff will be trained on the importance of keeping accurate records. A checklist will be developed for quarterly internal audits to cross-verify names between applications and attendance records, plus other applicable records. If discrepancies are identified in the internal audits, they will be corrected promptly.

View Audit 408854

Finding 1226195 (2025-002)

Material Weakness 2025

Opening Doors, Inc.

CA

Questioned Costs Subrecipient Monitoring Eligibility

Auditor's Recommendation: Strengthen controls over eligibility determinations by requiring Program Managers to document and retain evidence of review and approval of all intake forms/applications before services are provided. Management should also implement periodic monitoring procedures to ensure ...

Auditor's Recommendation: Strengthen controls over eligibility determinations by requiring Program Managers to document and retain evidence of review and approval of all intake forms/applications before services are provided. Management should also implement periodic monitoring procedures to ensure review approvals are consistently documented and maintained for audit purposes. Management Response: ODI is diligent in understanding and implementing the steps necessary to review and collect the required documentation to determine client eligibility for programs. Due to the large number of clients serviced and the volume of documents collected and reviewed, many of the programs track eligibility via proprietary on line portals provided by the funders to capture and document the steps performed to determine eligibility. These portals automatically determine whether a client is eligible based on the information provided. The Program Managers see the client eligibility on the portal when they assign caseworkers to the clients, but there is no formal Program Manager signature provided or captured in the portal. Corrective Action: • Regarding the specific program 90ZQ(l}011-01-0 Support for Trauma-Affected Refugees (STAR} referenced in this finding, client eligibility is determined by requirements established by the Office of Refugee Resettlement (ORR} that apply to other programs administered by ODI. To address the auditor's recommendation regarding this program, ODI will set up a procedure to review and retain documentation for clients entering the STAR program or who were referred from other ORR programs showing they are eligible to receive the STAR services. •Regarding the specific program ALSP23-0001 Afghan Legal Services Project (ALSP}, ODI has serviced, and is still servicing, approximately 500 clients. Although ODI asserts that it has and retains the documentation to demonstrate client eligibility for this program, to address the auditor's recommendation, ODI will set up a procedure to track and document that the program manager will approve. Responsible Personnel: Mao Vang, Health & SOT Program Director; Alyssa Eckels, ILS Program Director Implementation Date: Immediate implementation

View Audit 408833

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 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 1226049 (2025-010)

Material Weakness 2025

State of California

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.214 § 200.303

Suspension and Debarment California Department of Public Health The California Department of Public Health (CDPH) agrees with this finding. CDPH has implemented interim procedures to verify vendor suspension and debarment status prior to the execution of federally funded procurements, including agre...

Suspension and Debarment California Department of Public Health The California Department of Public Health (CDPH) agrees with this finding. CDPH has implemented interim procedures to verify vendor suspension and debarment status prior to the execution of federally funded procurements, including agreements funded through emergency programs. CDPH is in the process of finalizing department-wide procedures and updating procurement checklists to ensure compliance with federal requirements. Until the formal procedures are published, staff will continue applying the interim procedures to ensure all required verifications are completed and appropriately documented in procurement files. Estimated Implementation Date: July 2026 Contact: - Louise Karsten, Emergency Funding Coordination Branch Manager, Center for Preparedness and Response

View Audit 408731

Corrective Action Plans

Filters