Corrective Action Plans

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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
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
Finding 402363 (2021-007)
Significant Deficiency 2021
California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding...
California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding identifies lack of communication of required subaward information to Cal ICH subrecipients of the Coronavirus Relief Fund (CRF) program at the time of the subaward, or when the State became aware of changes in subaward information, including identification that the subaward funds represented federal funding. Cal ICH agrees with this finding and the recommendation to review all subawards provided which were funded using CRF program funds and determine whether the subrecipients properly reported their CRF awards and related expenditures in their respective schedule of expenditures of federal awards pursuant to Title 2 Code of the Federal Regulations 200.502. Additionally, while formal communication identifying that the subaward fund represented federal funding was not provided, many informal conversations were had with CRF grantees. These conversations were held during bi-weekly online Office Hours and through one-on-one calls with individual subrecipients and discussions of the substitution of federal awards with grantees originally provided with State funds could have occurred. Cal ICH will conduct review of the CRF subawards during mandatory desk reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Additionally, Cal ICH has developed an improved communication system between leadership and program staff that will ensure changes are clearly communicated. This will also ensure the Council’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Additionally, if in the future funding is changed, CDE will provide updated information to all recipients; this will ensure that expenditures are in line with the terms and conditions of the grant and/or funding source. Estimated Implementation Date: May 2023 Contact: Ellen Meuchel, Monitoring Unit Cal ICH Grant Operations and Suppor California Department of Education Concur. Education will review the relevant subawards funded under the CRF program and determine whether the subrecipients properly reported their CRF awards pursuant to 2 CFR 200.501. Estimated Implementation Date: July 31, 2023 Contact: Kelly Levario, External Audits Coordinator Audits and Investigations Division California Department of Social Services The California Department of Social Services (CDSS) acknowledges the Single Audit finding regarding the delayed communication of subaward information to the Department’s subrecipients of the Coronavirus Relief Fund (CRF) program. On December 21, 2022, CDSS released County Fiscal Letter 22/23-31 on the subject of “Federal Coronavirus Relief Funds That Replaced General Fund for COVID-19 Related Activities for Fiscal Years 2019-20 and 2020-21” to County Welfare Departments (CWDs) and federally recognized Tribal governments in California. This letter served as a formal documentation of the portion of expenditures that were funded with federal CRF. Additionally, although formal notice was not provided until December 21, 2022, informal notices and conversations took place between CDSS and the County Welfare Directors Association, as well as with CWDs, regarding possible situations in which the substitution of federal awards with grants originally provided with State funds could occur. On September 21, 2021, CDSS sent a notice to subrecipients requesting for their Data Universal Number System for the purpose of CRF federal subawards; thereby, communicating the use of CRF on the subrecipients’ behalf. CDSS will conduct a review of the CRF subawards during on-site fiscal monitoring reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Moreover, CDSS will ensure that the Department’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Estimated Implementation Date: April 2023 through June 2024 Contact: Elisa Tsujihara, Chief Fiscal Policy and Analysis Bureau
The EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete any remaining retroactive workload by April 30, 2023. Estimated Implementation Date: January 2021 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California ...
The EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete any remaining retroactive workload by April 30, 2023. Estimated Implementation Date: January 2021 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 309913 Questioned Costs: $1
Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condit...
Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board (FTB) records in November 2020 to assist in verifying the income of PUA claimants. Claimants who could not be automatically verified through the FTB wage record match were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California weekly benefit amount (WBA) of $167, in June 2022, the EDD submitted a blanket waiver application to the U.S. Department of Labor (DOL), pursuant to the DOL Unemployment Insurance Program Letter 20-21, Change 1. EDD’s application is pending the DOL’s determination. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, failed to provide proof of income substantiation to support the increase or whose WBA will be decreased because the proof they provided was insufficient. Regarding the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), this verification process is being implemented in two phases. Phase 1 of the SEES effort was implemented on November 10, 2021, and involved notifying claimants registered in California’s UI Online (UIO) system by email and text of their requirement to provide SEES documentation. Phase 2 will involve notifying claimants who did not respond to the UIO request for SEES documentation, and those who are not registered in UIO, via a paper notice mailed through the United States Postal Service (USPS). EDD submitted a blanket overpayment waiver application in June 2022 to DOL regarding this issue. EDD will assess further implementation based on the DOL’s decision. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, provided insufficient documentation or did not provide any documentation. Estimated Implementation Date: To be determined once the DOL provides a decision on the waiver application. Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 309913 Questioned Costs: $1
Public Health’s Accounting Office will generate the FI$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$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will update the procedures to document the SEFA reporting for the ELC program.
EDD agrees with this finding. The deferred transition to FI$Cal and the difficulties experienced thereafter have continued to cause EDD to be late with submitting year-end financials and its ability to submit timely the cash basis expenditures into the Single Audit Expenditures Reporting Database (...
EDD agrees with this finding. The deferred transition to FI$Cal and the difficulties experienced thereafter have continued to cause EDD to be late with submitting year-end financials and its ability to submit timely the cash basis expenditures into the Single Audit Expenditures Reporting Database (Database). In addition, the onset of the COVID-19 pandemic created additional issues which ultimately impacted the EDD’s ability to submit timely year-end financials. However, the EDD is making progress and continues to gain ground in the department’s efforts to follow the State’s deadlines for submitting year-end financials and entering the cash basis expenditures into the Database. By the end of fiscal year 2021-22 and into fiscal year 2022-23, the EDD did a restructuring within the accounting area which realigned workload amongst the units and provided additional resources in critical areas. These changes will have a lasting effect and help the department to be better positioned going forward in processing the accounting workload and ultimately be able to catch up and submit year-end financials and enter the cash basis expenditures into the Database by the State’s deadlines. In addition, the EDD took lessons learned from the fiscal year 2019-20 financial audit to update processes and procedures and applied that knowledge going forward. Also, staff have been participating in various trainings offered by Finance and the Department of FISCal and staff continue to work with the control agencies when issues arise that would impact our accounting functions. While the EDD is still behind, the department is making great progress on catching up. The EDD submitted the last of its fiscal year 2020-21 financials in July 2022 and is targeting to submit the last of its fiscal year 2021-22 financials by the end of March 2023. The EDD’s goal is to submit fiscal year 2022-23 financials by the end of December 2023. Similar to the 2019-20 financial audit, the EDD will take the knowledge learned during the 2020-21 audit season, continue to engage with the control agencies, and continue to train and develop staff in order to keep progressing towards the department’s goal of becoming timely with the submission of the year-end financials and entering of the cash basis expenditures into the Database.
Reportable Condition: The Institute did not submit the Data Collection Form and Reporting Package to the Federal Audit Clearinghouse of the fiscal year in June 30, 2021 during the required period. Recommendation: We recommend the institute to maintain adeq...
Reportable Condition: The Institute did not submit the Data Collection Form and Reporting Package to the Federal Audit Clearinghouse of the fiscal year in June 30, 2021 during the required period. Recommendation: We recommend the institute to maintain adequate accounting records related to the non-federal and federal funds in order to properly prepare the financial statements accurrate and in a timely manner. Action Taken: As previously stated, our new accounting system (MIP) will keep our accounting records on a precise manner, improving our internal controls and providing us the opportunity to prepare the financial statements with fulll correctness and accuracy, also complying with the terms established and regulated.
Department of Health and Human Services Presbyterian Homes of Tennessee, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is disc...
Department of Health and Human Services Presbyterian Homes of Tennessee, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Audit period: January 1, 2021 through December 31, 2021 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2021-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: The organization updated the submission related to its Period 1 reporting, which included an updated lost revenue calculation to support all provider relief fund payments received. The organization should ensure the proper review procedures are in place for any future submissions to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An amended Period 1 submission report, using the lost revenues, was submitted. Appropriate review procedures will be put in place to ensure accurate reporting on any future submissions. Name of the contact person responsible for corrective action: Erik Hockman, CFO Planned completion date for corrective action plan: May 2, 2023 If the Department of Health and Human Services has questions regarding this plan, please call Erik Hockman at 865-243-3613.
Finding 2021-002 Responsible Official: Donnie Gosnell, Controller Views of Responsible Officials: With the volume of new COVID-19 federal programs, it was more challenging to completely prepare the SEFA. Processes will be put in place to compile the SEFA, reconcile to support and perform a related r...
Finding 2021-002 Responsible Official: Donnie Gosnell, Controller Views of Responsible Officials: With the volume of new COVID-19 federal programs, it was more challenging to completely prepare the SEFA. Processes will be put in place to compile the SEFA, reconcile to support and perform a related review prior to audit. In addition, grant agreements will be required to go through the contract approval process. This will allow all grants to be identified and tracked, ensuring completeness. This has been implemented as of March 2024
Finding 2021-001 Responsible Official: Matthew Vaughn, Regional Director of Financial Planning & Analysis Views of Responsible Officials: The District believed they were in compliance with the reporting requirements at the time of submission based on the guidance available. Guidance among the differ...
Finding 2021-001 Responsible Official: Matthew Vaughn, Regional Director of Financial Planning & Analysis Views of Responsible Officials: The District believed they were in compliance with the reporting requirements at the time of submission based on the guidance available. Guidance among the different federal programs changed over the course of the Public Health Emergency in a manner that caused reconsideration of both the classification and estimate of expenses. Over the course of the pandemic, the district went through the process to more completely segregate the PRF support from other COVID-19 funding. While the allocations and classifications within the program reports would have changed based on that process, in total program expenditures for both periods in total were supported. All expenses under the Public Health Emergency period have currently been categorized in this manner, and any future expenses or expense adjustments will be kept with this categorization in-tact. This was completed over the course of the 2021 Single Audit review in November 2023
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the F...
Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
Views of Responsible Officials and Planned Corrective Action – Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and will file the single audit reporting package as soon as possible.
Views of Responsible Officials and Planned Corrective Action – Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and will file the single audit reporting package as soon as possible.
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...
Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately
Finding 400779 (2021-006)
Significant Deficiency 2021
The City has already started rebuilding its team in the Administrative Services Department and Finance Division. Further, the City has hired a consultant to assist with general duties of the Finance Division. Additionally, the City has started, and will continue to offer, robust internal trainings a...
The City has already started rebuilding its team in the Administrative Services Department and Finance Division. Further, the City has hired a consultant to assist with general duties of the Finance Division. Additionally, the City has started, and will continue to offer, robust internal trainings and protocols to ensure that all staff involved with financial activities are aware of, and comply with, any transactions or other activities associated with the timely preparation of the City’s annual financial audit.
Finding 400778 (2021-005)
Significant Deficiency 2021
The City will analyze the agency’s existing procedures associated with the preparation of the annual Schedule of Expenditures of Federal Awards (SEFA), make any necessary modifications, and ensure these procedures are both adequate and consistently followed.
The City will analyze the agency’s existing procedures associated with the preparation of the annual Schedule of Expenditures of Federal Awards (SEFA), make any necessary modifications, and ensure these procedures are both adequate and consistently followed.
While BREC currently does not have any questioned costs applicable to this finding, we have initiated the advertisement for professional level accountants to fill key staff positions to ensure monthly reconciliations of bank accounts in order for the single audit to be performed, which will ultimate...
While BREC currently does not have any questioned costs applicable to this finding, we have initiated the advertisement for professional level accountants to fill key staff positions to ensure monthly reconciliations of bank accounts in order for the single audit to be performed, which will ultimately allow for timely submission of the Single Audit Report moving forward. o Anticipated Completion Date: September 30, 2024 o Responsable Contact Person: Rhonda Williams
Condition The Health Center’s financial statement and compliance audits for the December 31, 2021 reporting period were not filed within the required timeline. Views of responsible officials and planned corrective actions Management will continue to monitor and enhance our internal controls to as...
Condition The Health Center’s financial statement and compliance audits for the December 31, 2021 reporting period were not filed within the required timeline. Views of responsible officials and planned corrective actions Management will continue to monitor and enhance our internal controls to assure all future reporting timelines are met. Anticipated completion date Ongoing
Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel...
Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel, we will continue to enhance our internal controls over the completion of the SEFA. Anticipated completion date Ongoing
Condition Management provided excel workbooks of costs they determined allowable under the PRF program. Although the workbook totals for some cost reporting categories did match the PRF reporting form, there were several categories that did not. Other reporting errors were also noted on the PRF po...
Condition Management provided excel workbooks of costs they determined allowable under the PRF program. Although the workbook totals for some cost reporting categories did match the PRF reporting form, there were several categories that did not. Other reporting errors were also noted on the PRF portal reporting document. Views of responsible officials and planned corrective actions We will review our current reporting processes and internal controls over PRF reporting to ensure all future reporting requirements are met. Anticipated completion date Ongoing
Condition Supporting expense workbooks provided by management did not agree with certain amounts reported in the PRF portal reporting form. Additionally, certain expenses reported were related to direct patient care costs and management was unable to provide sufficient supporting documentation the ...
Condition Supporting expense workbooks provided by management did not agree with certain amounts reported in the PRF portal reporting form. Additionally, certain expenses reported were related to direct patient care costs and management was unable to provide sufficient supporting documentation the amounts were related to providing care to COVID-19 patients. This resulted in the auditors reporting total questioned costs of $911,136. Views of responsible officials and planned corrective actions Management does not agree with the noted finding. The Health Center feels as though costs incurred did qualify under the provision of being prepared and treating COVID positive, and suspected COVID patients. The Health Center does have amounts that could have been reported as lost revenues that would cover some of the questioned costs. The Health Center was unable to include the lost revenue amounts in the original submission because the website did not allow submission of lost revenues if enough costs were reported to cover the PRF funds received. Anticipated completion date Ongoing
View Audit 308322 Questioned Costs: $1
Finding 2021-001 – Reporting - Submission of the Data Collection Form Contact: Terry L. Weaver, CFO Telephone Number: (301) 539-3629 Estimated Completion Date: June, 2024 Charles County Nursing and Rehabilitation Center, Inc. hereby acknowledges the Organization’s audit reporting package was not ...
Finding 2021-001 – Reporting - Submission of the Data Collection Form Contact: Terry L. Weaver, CFO Telephone Number: (301) 539-3629 Estimated Completion Date: June, 2024 Charles County Nursing and Rehabilitation Center, Inc. hereby acknowledges the Organization’s audit reporting package was not submitted by the filing deadline of September 30, 2022. The Organization will file the reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with our audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline. Anticipated Completion Date The Organization anticipates submission of the audit and data collection form immediately upon completion on May 16, 2024.
Finding 399399 (2021-009)
Material Weakness 2021
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.
View Audit 307906 Questioned Costs: $1
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