Corrective Action Plans

Finding 1167654 (2024-101)

Material Weakness 2024

Booker T. Washington Child Development Center, Inc.

AZ

Reporting Significant Deficiency Internal Control / Segregation of Duties

Person Responsible: Josie Ayon Estimated Completion Date: 3/31/2026 Planned Corrective Action: The organization converted from the Cash Basis of Accounting to the Accrual Basis of Accounting (GAAP) in fiscal year 2023. Additionally, the organization converted to a new accounting system and hired out...

Person Responsible: Josie Ayon Estimated Completion Date: 3/31/2026 Planned Corrective Action: The organization converted from the Cash Basis of Accounting to the Accrual Basis of Accounting (GAAP) in fiscal year 2023. Additionally, the organization converted to a new accounting system and hired outside consultants to assist with data entry and financial reporting. The audit for June 30, 2025 is planned to start in December 2025, which will provide adequate time to comply with this requirement.

View Audit 378906

Finding 1167595 (2024-001)

Material Weakness 2024

City of North Chicago

IL

Significant Deficiency Internal Control / Segregation of Duties

Finding 2024 – 001: Audit Journal Entries Condition: During audit fieldwork, our testing resulted in significant audit adjustments in order to present materially accurate financial statements. Corrective Action Plan: The Comptroller, along with staff, will review year-end adjustments as part of the ...

Finding 2024 – 001: Audit Journal Entries Condition: During audit fieldwork, our testing resulted in significant audit adjustments in order to present materially accurate financial statements. Corrective Action Plan: The Comptroller, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork. Anticipated Date of Completion: Fiscal Year 2025 Name of Contact Person: Tawanda Joyner, Comptroller Management Response: The Comptroller, with staff, will review year-end adjustments as part of audit preparation, aiming to reduce auditor-proposed entries and to deliver an adjusted trial balance before fieldwork. City was short staffed however, currently have a full staff to be able to complete journal entries. Our actions to correct include an internal review of year-end adjustments to identify causes and implement fixes, along with the use of pre-audit checklists and earlyanalytics to minimize auditor entries. Our team will finalize adjustments well ahead of fieldwork.At the start of the audit, the fully adjusted financial statements will be submitted and inquiries addressed. Our target is a 70% reduction in auditor-proposed entries and for adjustments resolved pre-fieldwork. The plan also calls for documenting any delays with the team responding to auditor inquiries within 24 hours and for misclassifications to be reviewed by two staff members to ensure accuracy.

View Audit 378791

Finding 1167498 (2024-004)

Material Weakness 2024

City of Jersey City

NJ

Equipment & Real Property Management Internal Control / Segregation of Duties

Planned Action: To address the internal control weakness and noncompliance with federal program requirements, the City will implement the following corrective measures: 1. Centralized Document Management: o Create a centralized digital and physical repository to maintain all documentation related to...

Planned Action: To address the internal control weakness and noncompliance with federal program requirements, the City will implement the following corrective measures: 1. Centralized Document Management: o Create a centralized digital and physical repository to maintain all documentation related to the Equitable Sharing Program, including: ▪ The Equitable Sharing Agreement and Certification (ESAC) ▪ Records of tangible and real property acquired ▪ Inventory logs of items purchased with program funds o Ensure access is controlled but available to authorized personnel for audit and compliance purposes. 2. Assignment of Compliance Oversight: o Designate a Fiscal Officer or Grants Administrator responsible for overseeing and maintaining compliance with the Federal Equitable Sharing Program. o Responsibilities will include submission of required certifications, tracking property acquired, maintaining inventory records, and responding to audit or federal requests. 3. Periodic Compliance Reviews: o Establish a schedule (i.e. monthly) for internal reviews of documentation to ensure ongoing compliance with: ▪ The Guide to Equitable Sharing for State, Local, and Tribal Law Enforcement Agencies ▪ The 2024 Compliance Supplement ▪ 2 CFR Part 200 Uniform Guidance o Review procedures to verify that ESACs are submitted on time and that all purchases and inventory are accurately tracked and recorded. 4. Training and Internal Controls: o Provide annual training to relevant departments on compliance requirements for federal grant programs, particularly those involving equipment and real property management. o Update internal grant management policies to reflect the specific requirements of the Equitable Sharing Program. Anticipated Completion Date: Immediate action has been requested. Contact Person Responsible for Corrective Action: Director of Public Safety or the assigned Program Manager in the Department of Public Safety Compliance Oversight & Advisement: Silendra Baijnauth, Director of Management & Budget to monitor expenditures. La Vivanan Webb, Director of Grant Administration & Compliance to provide access to the AmpliFund platform which is a tool for other City offices to use to manage their grant compliance and reporting. Additional Note: In light of the audit finding, the Department of Finance has restricted the Department of Public Safety from making any additional encumbrances against this account until the audit finding is addressed and reporting requirements are met.

View Audit 378547

Finding 1167491 (2024-004)

Material Weakness 2024

Southern Maryland Tri-County Community Action Committee, Inc.

MD

Reporting Internal Control / Segregation of Duties Material Weakness § 200.501

Finding Reference: 2024-004 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. In some contexts, the Agency experienced significant turnover in the Finance department during the third quarter, and a new Finance Director ...

Finding Reference: 2024-004 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. In some contexts, the Agency experienced significant turnover in the Finance department during the third quarter, and a new Finance Director was hired during the fourth quarter of fiscal year 2024. The turnover in fiscal staff hindered the accounting processes and oversight that included journal entry review and postings and account reconciliations promptly. As a corrective measure to ensure adhering to a closing schedule and maintaining timely account reconciliations, the Agency reevaluated the fiscal department’s needs and hired new staff, including a finance director, accounts payable, part-time fiscal support specialist, and contracted with a CPA to assist with the following scope of work:  Review all trial fund balance processes.  Prepare a closing schedule that includes reporting and data processing deadlines.  Reconcile all balance sheet accounts in the general ledger chart of accounts.  Timely prepare and file all financial reports required by each award.  Work with the independent auditor to implement an interim audit fieldwork schedule to reduce required work subsequent to fiscal year-end. Name of the contact person responsible for corrective action: Michael Young, President, (301) 274-4474. Planned completion date for corrective action plan: December 31, 2025

View Audit 378541

Finding 1167426 (2024-001)

Material Weakness 2024

MUNICIPALITY OF PARKSTON

SD

Reporting Internal Control / Segregation of Duties

Implement an internal reporting calendar for all SLFRF reporting deadlines, including automated reminders for preparers and approvers. Establish a formal internal control process for P&E Report preparation. Train all relevant staff on SLFRF reporting guidance. Correct prior inaccurate filings by sub...

Implement an internal reporting calendar for all SLFRF reporting deadlines, including automated reminders for preparers and approvers. Establish a formal internal control process for P&E Report preparation. Train all relevant staff on SLFRF reporting guidance. Correct prior inaccurate filings by submitting amended P&E Reports for fiscal year 2024 and fiscal year 2025 to ensure proper classification of expenditures. Conduct quarterly internal reviews of SLFRF expenditures to ensure correct categorization and timely reporting, with findings documented.

View Audit 378515

Finding 1167323 (2024-001)

Material Weakness 2024

Primary Care Health Services, Inc.

PA

Internal Control / Segregation of Duties

We concur with the audit finding and are committed to implementing corrective actions. Management will hire key financial staff and implement a month-end closing schedule to ensure the timely completion of its monthly financial statements. Additionally, balance sheet account reconciliations will be ...

We concur with the audit finding and are committed to implementing corrective actions. Management will hire key financial staff and implement a month-end closing schedule to ensure the timely completion of its monthly financial statements. Additionally, balance sheet account reconciliations will be prepared and reviewed on a timely basis to ensure all adjustments are recorded in the correct periods. A monthly financial statement package will be prepared and reviewed by Management to ensure appropriate presentation in accordance with U.S. Generally Accepted Accounting Principles (“GAAP”).

View Audit 378354

Finding 1167285 (2024-002)

Material Weakness 2024

Marie Wilkinson Food Pantry, Inc.

IL

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

Auditee Response and Corrective Action Plan: Management concurs with the finding. The Organization will update its year-end and audit procedures to designate a responsible party for monitoring and completing the FAC submission process. The Organization will also include the due date as part of its a...

Auditee Response and Corrective Action Plan: Management concurs with the finding. The Organization will update its year-end and audit procedures to designate a responsible party for monitoring and completing the FAC submission process. The Organization will also include the due date as part of its audit closing checklist to ensure future submissions are made timely.

View Audit 378291

Finding 1167284 (2024-001)

Material Weakness 2024

Marie Wilkinson Food Pantry, Inc.

IL

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Auditee Response and Corrective Action Plan: Management concurs with the finding. The Organization should design and implement a comprehensive review process for all significant general ledger accounts to ensure that they are reconciled to underlying supporting documentation in a continuous and time...

Auditee Response and Corrective Action Plan: Management concurs with the finding. The Organization should design and implement a comprehensive review process for all significant general ledger accounts to ensure that they are reconciled to underlying supporting documentation in a continuous and timely manner throughout the fiscal year.

View Audit 378291

Finding 1167125 (2024-010)

Material Weakness 2024

Pacific Forum International

HI

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.512

Finding: Significant deficiency in internal control for late submission of data control form and Single Audit report package. Corrective action: Pacific Forum has authorized its outsourced accounting service to take on a larger role in fulfilling auditor requests to ensure the information submitted ...

Finding: Significant deficiency in internal control for late submission of data control form and Single Audit report package. Corrective action: Pacific Forum has authorized its outsourced accounting service to take on a larger role in fulfilling auditor requests to ensure the information submitted is accurate and complete. PFI has also consolidated financial management policies and other required documentation in a secure cloud network. PFI has also adopted more features available through Bill.com, which has enhanced documentation of expenditures and management reviews. Procedures for filing documents and utilizing financial management procedures available through Bill.com will be integrated into PFI financial management policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director

View Audit 378170

Finding 1167121 (2024-006)

Material Weakness 2024

Pacific Forum International

HI

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

Finding: Significant deficiency in internal control over federal cash drawdowns Corrective action: Pacific Forum has adopted new financial controls policies to ensure federal cash drawdowns are completed in a timely manner and reviewed by management. The Director of Development prepares a financial ...

Finding: Significant deficiency in internal control over federal cash drawdowns Corrective action: Pacific Forum has adopted new financial controls policies to ensure federal cash drawdowns are completed in a timely manner and reviewed by management. The Director of Development prepares a financial report that shows the amount that can be invoiced/drawn down from federal funds based on actual expenditures. The Executive Director approves the request for funds prior to submission to the funding organization. These procedures will be incorporated into PFI cash management policy guidelines. Completion Date: February 1, 2026. Responsible Individual: Executive Director

View Audit 378170

Finding 1166830 (2024-004)

Material Weakness 2024

Supports to Encourage Low Income Families INC

OH

Reporting Internal Control / Segregation of Duties

In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiate...

In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiated. The new policy was approved shortly thereafter by the organization’s board. SELF also contracted with a digital security company to train all employees about digital threat awareness including fraud and phishing attempts, specifically via email. As part of these new practices, all employees are required to participate in monthly training.

View Audit 377976

Finding 1166799 (2024-001)

Material Weakness 2024

Eau Claire Cooperative Health Center, Inc.

SC

Reporting Internal Control / Segregation of Duties

To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals w...

To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals with adequate training and subject matter knowledge to perform assigned functions in accordance with appropriate standards and expectations. We are always receptive to positive constructive criticism in our effort to improve upon compliance and financial reporting. Sincerely yours, Rufus Wofford– Acting Chief Executive Officer

View Audit 377878

Finding 1166785 (2024-003)

Material Weakness 2024

Cayuga Home for Children, Inc. D/b/a Cayuga Centers

NY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management overrid...

Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management override, Cayuga Centers has implemented standardized procedures to ensure grant expenditures are properly classified in our financial system. Each transaction are supported by detailed documentation, including invoices, receipts, and grant-specific identifiers. Individuals responsible for grant oversight will undergo mandatory training to deepen their understanding of grant requirements, allowable costs, and reporting obligations. Additionally, Cayuga Centers is working to ensure open communication between staff and the Board. Under new leadership, the agency continues to enforce its Non-Retaliation Policy (Whistleblower). The Acting President’s office is establishing quarterly “Grant Compliance Forums” for employees to raise concerns related to grant administration.

View Audit 377870

Finding 1166740 (2024-002)

Material Weakness 2024

Laguna Housing Development and Management Enterprise

NM

Special Tests & Provisions Procurement, Suspension & Debarment Significant Deficiency

Department of Housing and Urban Development and Department of the Treasury 2024-002 Indian Housing Block Grant Program (IHBG) – Assistance Listing No. 14.867, Recommendation: We recommend that LHDME reviews all construction contracts to make sure they request certified payrolls for all contracts tha...

Department of Housing and Urban Development and Department of the Treasury 2024-002 Indian Housing Block Grant Program (IHBG) – Assistance Listing No. 14.867, Recommendation: We recommend that LHDME reviews all construction contracts to make sure they request certified payrolls for all contracts that exceed $2,000. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In the future all construction contracts will be reviewed on an monthly basis to determine what contracts total $2,000.00 or over to make sure we have a certified payroll for these contracts. Name(s) of the contact person(s) responsible for corrective action: Jamie Navenma, Executive Director and Cheryl Mullins, Controller Planned completion date for corrective action plan: December 1, 2025

View Audit 377864

Finding 1166736 (2024-009)

Material Weakness 2024

GREAT PLAINS VETERANS SERVICES CENTER

MT

Internal Control / Segregation of Duties Cash Management Eligibility § 200.303

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There ...

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will reassign roles to ensure clear separation between allowability determinations and expenditure approvals. If staffing constraints prevent full segregation, management will ensure that the Finance Manager performs secondary reviews. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct periodic internal monitoring with documented review of approvals.

View Audit 377852

Finding 1166734 (2024-007)

Material Weakness 2024

GREAT PLAINS VETERANS SERVICES CENTER

MT

Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties § 200.302

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-007: Activities Allowed or Unallowed / Allowable Costs - Insufficient Budget-to-Actual Reviews (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: Th...

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-007: Activities Allowed or Unallowed / Allowable Costs - Insufficient Budget-to-Actual Reviews (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: A monthly review checklist and variance analysis template will be adopted. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The internal audit function will conduct semiannual reviews to confirm adherence to established review procedures.

View Audit 377852

Finding 1166629 (2024-013)

Material Weakness 2024

City of Philadelphia

PA

Subrecipient Monitoring Internal Control / Segregation of Duties

Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Assistance Listing 93.354 Public Health Emergency Response Program Views of the Responsible Officials and...

Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Assistance Listing 93.354 Public Health Emergency Response Program Views of the Responsible Officials and Corrective Action Plan: ALN 93.136 – Injury Prevention and Control Research and State/Community Based Programs PDPH acknowledges that Federal Funding Accountability and Transparency Act (FFATA) reporting requirements were not consistently met during the audit period due to limited staff capacity and lack of clearly defined procedures for subaward reporting. In response, SUPHR will establish procedures to ensure timely and accurate FFATA reporting in accordance with federal requirements. These procedures include designating responsible staff, assigning appropriate SAM.gov access roles, and providing orientation and training on subaward reporting processes. Standardized documentation and retention practices will also be implemented to ensure proper recordkeeping and verification of all submissions. SUPHR is committed to maintaining compliance with FFATA requirements going forward and will continue to monitor adherence through routine oversight by the grants management team. Initial implementation of corrective measures will begin upon receipt of an approved Year 3 budget from the Centers of Disease Control. ALN 93.323 – Epidemiology and Lab Capacity Program PDPH acknowledges the error that occurred with FFATA reporting with respect to its incomplete reporting. This grant had previously been connected in the FSRS.gov system to a PDPH division that was created during the COVID pandemic that no longer exists. Although the grant was listed under the Division of Disease Control by FY24, the FFATA was overlooked and not completed. The Division of Disease Control will work toward implementing additional internal controls to support accurate and timely FFATA reporting going forward. ALN 93.354 – Public Health Emergency Response PDPH acknowledges that errors occurred with FFATA reporting with respect to both the timing of the reporting and the amounts of subawards reported. The Division of Disease Control will work toward implementing additional internal controls to support accurate and timely FFATA reporting going forward. Contact Persons: Daniel Teixeira da Silva, Director, Division of Substance Use Prevention and Harm Reduction (SUPHR), 267-760-0307 Jessica Caum, Public Health Preparedness Program Manager, Philadelphia Department of Public Health, 215-685-6731

View Audit 377616

Finding 1166625 (2024-012)

Material Weakness 2024

City of Philadelphia

PA

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.344

Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delay in liquidating obligations resulted from internal control procedures that appropriately identified a potenti...

Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delay in liquidating obligations resulted from internal control procedures that appropriately identified a potential contract concern involving the Resources for Human Development. In accordance with established financial oversight protocols, the Finance Department placed a temporary hold on related payments pending further review. Once the review was concluded, the payments were released. Additionally, limitations within the FAMIS system, specifically its inability to retain original voucher creation dates after rejection and resubmission, contributed to the appearance of delayed liquidation. To prevent recurrence, the Office of Homeless Services will strengthen its closeout procedures to ensure timely review and liquidation of all obligations in accordance with 2 CFR § 200.344. The Office will also initiate earlier coordination with the Finance Department when payment holds arise and reinforce staff training on grant closeout and escalation protocols. These corrective actions will enhance compliance and reduce the likelihood of future delays. Contact Person: Jerome Hill, Director of Compliance, OHS, 215-686-0371

View Audit 377616

Finding 1166613 (2024-001)

Material Weakness 2024

City of Charleston, South Carolina

SC

Internal Control / Segregation of Duties Period of Performance Reporting

Corrective Action Plan: The City of Charleston will implement internal controls and procedures to ensure all required reports are prepared, reviewed, and submitted within the program’s required timeframes, and with the correct amounts. Anticipated Completion Date: Fiscal Year 2025

View Audit 377599

Finding 1166569 (2024-016)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

The Child Care and Development Division is working towards compliance with federal requirements for license-exempt health and safety monitoring with an anticipated completion date of July 1, 2029, assuming additional resources are secured. This plan has been outlined in Appendix A of the Federal Fis...

The Child Care and Development Division is working towards compliance with federal requirements for license-exempt health and safety monitoring with an anticipated completion date of July 1, 2029, assuming additional resources are secured. This plan has been outlined in Appendix A of the Federal Fiscal Year 2025-27 State Plan for California with Administration of Children and Families (State Plan). The State Plan can be provided upon request. Estimated Implementation Date: July 1, 2029 Contact: • Jeff Fowler, Child Care Administration Bureau Chief • Central Operations Branch • Child Care and Development Division • California Department of Social Services

View Audit 377562

Finding 1166558 (2024-012)

Material Weakness 2024

State of California

CA

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

CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including s...

CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including surveys conducted by Accrediting Organizations. CHCQ has already taken steps by reiterating this requirement at a recent statewide management meeting. CHCQ will continue reminding staff of expectations at appropriate meetings and provide additional training as needed to ensure all offices follow consistent procedures when completing the required CMS 1539 forms. Headquarters management will provide oversight and conduct periodic audits to ensure staff complete and sign all CMS 1539 forms according to expectations. Estimated Implementation Date: Fiscal Year 2025-26 Contact: Nate Gilmore, State Surveyors Branch Chief, CHCQ

View Audit 377562

Finding 1166553 (2024-011)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties § 200.303

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County p...

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Through the reinstatement of county performance standards and Focused Reviews, DHCS can identify and address eligibility concerns, such as the proper use of aid codes, and work with counties through the corrective action plan process to address staff training to ensure correct eligibility determinations for all Medi-Cal programs, including pregnancy programs. 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 377562

Finding 1166548 (2024-010)

Material Weakness 2024

State of California

CA

Eligibility Internal Control / Segregation of Duties § 200.303

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County p...

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Additionally, DHCS resumed the Aid Code Cleanup effort in September 2025, as outlined in MEDIL I 25-19. The purpose of the aid code cleanup effort is to assist counties in identifying records that require eligibility re-evaluation to either transition individuals to the correct Medi-Cal aid code or appropriately discontinue coverage. Through these initiatives, DHCS can identify and address eligibility concerns, such as processing timeliness and proper aid code usage. 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 377562

Finding 1166544 (2024-007)

Material Weakness 2024

State of California

CA

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

SWRCB Program Manager acknowledges and understands the recommendation. During the December 2023 period, the SWRCB Program Manager held a meeting with staff and reviewed the information prior to approving the information being inputted into the CDOF Portal. Information being submitted to the CDOF Por...

SWRCB Program Manager acknowledges and understands the recommendation. During the December 2023 period, the SWRCB Program Manager held a meeting with staff and reviewed the information prior to approving the information being inputted into the CDOF Portal. Information being submitted to the CDOF Portal aligns with the FI$Cal KK Report per the direction of CDOF. For information provided by the SWRCB for the CDOF Quarterly Reporting, the SWRCB started formally documenting the approval of information starting the quarter after the December 2023 period. Corrective action plan: SWRCB Program Manager has implemented a process for the recommendation provided. As of the quarter following December 2023 period, a formal process that documents the information and approval of that information for CDOF portal updates is being used. The information submitted to the CDOF Portal aligns with the FI$Cal KK Report per the direction of CDOF. Estimated Implementation Date: March 2024 Contact: Selica Potter

View Audit 377562

Finding 1166541 (2024-005)

Material Weakness 2024

State of California

CA

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

The HQ Budgets OFR will update FPFT guidance and development documentation to include specific references to a new required secondary data validation for the more complex funding scenarios. A set of core FPFT standard templates will be modified to include an automated requirement for secondary data ...

The HQ Budgets OFR will update FPFT guidance and development documentation to include specific references to a new required secondary data validation for the more complex funding scenarios. A set of core FPFT standard templates will be modified to include an automated requirement for secondary data validation for any project that includes complex funding scenarios, including cooperative agreements, multiple funding priorities, multiple federal program codes, multiple state funding programs, and funding earmarks. Calculated data cells for federal reimbursement ratios will be added, as well as an automated check for the total sum of funding line percentages to ensure any rounding errors are eliminated. Consistent training will be provided for key HQ Budgets OFR staff on a regular basis, including live sessions for practical FPFT case reviews and FPFT development during monthly team meetings. Estimated Implementation Date: • Updated FPFT guidance documentation: 11/25/2025 • Updated FPFT template (automated secondary validation): 12/01/2025 • Monthly live training sessions (1st Thursday each month): 12/04/2025 Contact: • Raul Lerma, Chief, Program and Project Management Branch, Office of Federal Resources, HQ Division of Budgets • Keith Duncan, Division Chief, HQ Division of Budgets

View Audit 377562

Corrective Action Plans

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