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Corrective Action Plans

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Finding 1226482 (2025-007)
Material Weakness 2025
Reach Community Development, Inc.
OR
Questioned Costs Special Tests & Provisions HUD Housing Programs
REACH has policies in place for annual unit inspections. Management created a new unit inspection form to capture inspection, work orders, and re-inspection in 2025. Portfolio Managers reviewed these new forms with site teams and provided training on how to complete these forms. Property management ...
REACH has policies in place for annual unit inspections. Management created a new unit inspection form to capture inspection, work orders, and re-inspection in 2025. Portfolio Managers reviewed these new forms with site teams and provided training on how to complete these forms. Property management team also sent emails and Teams reminders to the site team to ensure unit inspection, work orders, and re-inspections are completed on time and properly. During the second quarter of 2026, REACH outsourced both property management and compliance functions to a third-party management company to address outstanding compliance issues.
View Audit 409109
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 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 1226446 (2025-004)
Material Weakness 2025
Phoenix Indian Center
AZ
Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512
At the start of each fiscal year, the Finance Director will prepare a submission timeline working backward from the March 31 FAC deadline, establishing interim milestones for year-end close, draft financial statement preparation, management review, and auditor fieldwork. Progress against the submiss...
At the start of each fiscal year, the Finance Director will prepare a submission timeline working backward from the March 31 FAC deadline, establishing interim milestones for year-end close, draft financial statement preparation, management review, and auditor fieldwork. Progress against the submission timeline will be monitored by the CEO and reported to the Board of Directors on a quarterly basis. Management will engage its external auditors earlier in the process and ensure adequate finance staffing is maintained prior to the fiscal yearend close.
View Audit 409082
Finding 1226428 (2025-001)
Material Weakness 2025
Valley Behavioral Health, Incorporated and Affiliates
UT
Reporting Significant Deficiency § 200.502
Corrective Action Plan FINDING - 2025-001 - Federal Award Program Name: 93.958 Senior Services Criteria: Federal awards are required to be reported on the Schedule of Expenditures of Federal Awards (SEFA) when expenditures are incurred (2CFR Part 200). Condition: The Organization had a federal award...
Corrective Action Plan FINDING - 2025-001 - Federal Award Program Name: 93.958 Senior Services Criteria: Federal awards are required to be reported on the Schedule of Expenditures of Federal Awards (SEFA) when expenditures are incurred (2CFR Part 200). Condition: The Organization had a federal award received in a prior year that was not originally included on the SEFA. Cause of Condition: The Organization did not have adequate procedures in place to identify all federal awards and ensure they were properly reflected on the SEFA. Potential Effect of Condition: The Organization’s federal award expenditures not being included in the audited SEFA. Views of Responsible Officials: Management has acknowledged the finding and added the award expenditures to the SEFA. Corrective Action: The Controller will implement formal federal grant management policies and procedures to ensure all federal awards are properly identified, tracked, and reported on the SEFA in accordance with 2 CFR Section 200.502. Key actions include: - Developing and implementing a written federal grant and loan management policy, subject to Board approval. - Establishing and maintaining a centralized electronic repository of all federal grant and loan documentation, including key award details necessary for SEFA reporting. - Providing training to accounting and program staff responsible for identifying and tracking federal awards. - Performing quarterly reviews of the federal awards repository to ensure completeness and accuracy of information used in SEFA preparation. - The Controller will perform quarterly reviews, and the CFO will review and approve the completeness of the federal awards listing. Procedures will be implemented immediately and in place for the next SEFA reporting cycle.
View Audit 409042
Finding 1226399 (2025-001)
Material Weakness 2025
The Housing Authority of the City of Oxford
MS
Questioned Costs Significant Deficiency Internal Control / Segregation of Duties
The issue was corrected before the audit concluded. A written invoice authorization proess is in place, and all invoices now require written approval before processing.
The issue was corrected before the audit concluded. A written invoice authorization proess is in place, and all invoices now require written approval before processing.
View Audit 408983
Finding 1226313 (2025-004)
Material Weakness 2025
Sangamon County, Illinois
IL
Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
County department personnel changes have been implemented which address this deficiency. Additional training from the Auditor’s office and state grantors has occurred and will continue for staff in departments that receive federal and state awards.
County department personnel changes have been implemented which address this deficiency. Additional training from the Auditor’s office and state grantors has occurred and will continue for staff in departments that receive federal and state awards.
View Audit 408963
Finding 1226312 (2025-005)
Material Weakness 2025
Sangamon County, Illinois
IL
Questioned Costs Reporting Significant Deficiency § 200.303
County department personnel changes have been implemented which address this deficiency. Additional training from the Auditor’s office and state grantors has occurred and will continue for staff in departments that receive federal and state awards.
County department personnel changes have been implemented which address this deficiency. Additional training from the Auditor’s office and state grantors has occurred and will continue for staff in departments that receive federal and state awards.
View Audit 408963
Finding 1226310 (2025-003)
Material Weakness 2025
Sangamon County, Illinois
IL
Questioned Costs Period of Performance Significant Deficiency § 200.303
County department personnel changes have been implemented which address this deficiency. Additional training from the Auditor’s office and state grantors has occurred and will continue for staff in departments that receive federal and state awards.
County department personnel changes have been implemented which address this deficiency. Additional training from the Auditor’s office and state grantors has occurred and will continue for staff in departments that receive federal and state awards.
View Audit 408963
Finding 1226263 (2025-001)
Material Weakness 2025
Pomona Community Health Center Dba Parktree Community Health Center
CA
Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties
Department of Health and Human Services: ParkTree Community Health Center (PCHC) respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: 01/1/25 – 12/31/25 The findings from the schedule of findings and questioned costs are discussed below. The f...
Department of Health and Human Services: ParkTree Community Health Center (PCHC) respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: 01/1/25 – 12/31/25 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2025-01 Health Center Cluster– Assistance Listing No. 93.HCP Recommendation: CLA recommends that PCHC implement a second-level, independent review of demographic data and income verification information entered into the patient billing system to help ensure each patient’s sliding fee classification and corresponding discount is accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Plan: ParkTree Community Health Center will implement a second-level independent review process for all new Sliding Fee Discount Program (SFDP) applications and annual renewals. Under this process, demographic information, household income documentation, family size, and the assigned sliding fee classification will be independently verified by a designated supervisor or other qualified staff member before the sliding fee discount is finalized in NextGen. Front desk receptionists and enrollment staff receive ongoing training and best practice reminders to ensure that all SFDP applications and supporting documentation are completed accurately and in a timely manner. Management has also implemented a weekly internal review process to verify that applications are complete, that appropriate supporting documentation is retained in each patient's file, and that assigned sliding fee classifications are accurate and consistent with PCHC's Board-approved SFDP policies and procedures. In addition, periodic quality assurance reviews will continue to be conducted to monitor compliance, identify trends, and provide corrective coaching when discrepancies are identified. These enhanced controls are designed to strengthen internal controls, improve compliance with the SFDP, and help ensure that each patient's sliding fee classification and corresponding discount are accurately applied in NextGen. Name of Contact Person Responsible for Corrective Action: Alfonso Aguilera Planned Completion Date: December 31, 2026 If the U.S Department of Health and Human Services has any questions regarding this Corrective Action Plan, please contact Alfonso Aguilera at (909)-865-9501, Ext. 3970.
View Audit 408927
Finding 1226237 (2025-001)
Material Weakness 2025
Western Montana Mental Health Center & Affiliate
MT
Questioned Costs Reporting Significant Deficiency
WMMHC issued additional review procedures for grant expenditures to all WMMHC employees on July 27, 2026, to ensure timely filing and compliance with federal requirements.
WMMHC issued additional review procedures for grant expenditures to all WMMHC employees on July 27, 2026, to ensure timely filing and compliance with federal requirements.
View Audit 408880
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 1226107 (2025-002)
Material Weakness 2025
City of Hempstead, Texas
TX
Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303 § 200.328
Finding 2025-002: Insufficient Documentation of Management Review of Section 3 Quarterly and Annual Reporting Planned Corrective Action: Management concurs with the finding. Although the related grant concluded during fiscal year 2025, the City will implement procedures to ensure that future federal...
Finding 2025-002: Insufficient Documentation of Management Review of Section 3 Quarterly and Annual Reporting Planned Corrective Action: Management concurs with the finding. Although the related grant concluded during fiscal year 2025, the City will implement procedures to ensure that future federal program reports, including any applicable Section 3 or similar compliance reports, are subject to documented management review and approval prior to submission. The procedures will require the preparer to provide each report and supporting documentation to City management for review, and evidence of approval, such as a signed review checklist, email approval, or electronic sign-off, will be retained in the grant files. The City Secretary will be responsible for ensuring that documented review and approval procedures are applied to future federal reporting requirements. Anticipated Completion Date: July 2026
View Audit 408755
Finding 1226088 (2025-005)
Material Weakness 2025
Westerly Area Rest Meals (warm) INC
RI
Procurement, Suspension & Debarment Significant Deficiency
The Organization lacked a formal procurement policy that was effective for the fiscal year ended June 30, 2025. A procurement policy which included all required elements was drafted and implemented with an effective date of July 1, 2025.
The Organization lacked a formal procurement policy that was effective for the fiscal year ended June 30, 2025. A procurement policy which included all required elements was drafted and implemented with an effective date of July 1, 2025.
View Audit 408740
Finding 1226087 (2025-004)
Material Weakness 2025
Westerly Area Rest Meals (warm) INC
RI
Significant Deficiency
The Organization lacked such a policy that was effective for the fiscal year ended June 30, 2025. A policy which included all required elements was drafted and implemented with an effective date of July 1, 2025.
The Organization lacked such a policy that was effective for the fiscal year ended June 30, 2025. A policy which included all required elements was drafted and implemented with an effective date of July 1, 2025.
View Audit 408740
Finding 1226085 (2025-026)
Material Weakness 2025
State of California
CA
Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303
Special Tests and Provisions California Governor’s Office of Emergency Services On December 10, 2025, Cal OES implemented communication protocol improvements by reemphasizing correct threshold applicability prior to payment during team meetings. In addition, by August 31, 2026, Cal OES will revise i...
Special Tests and Provisions California Governor’s Office of Emergency Services On December 10, 2025, Cal OES implemented communication protocol improvements by reemphasizing correct threshold applicability prior to payment during team meetings. In addition, by August 31, 2026, Cal OES will revise its Project Threshold standard operating procedure to include a review control that verifies the applicability of project thresholds, specifically the Large Project threshold, based on the appropriate timing criteria. Cal OES will also provide training to all grants processing and support staff on the revised procedure, including how to correctly identify and enter Large Project Thresholds, verify disaster data against approved sources, and apply the appropriate thresholds for specific declaration dates. Refresher training will be provided as needed thereafter. Furthermore, guidance on Large Project Thresholds will be incorporated into the onboarding process for all new staff. Estimated Implementation Date: August 2026 Contact: - Heidi Palchik, Chief, Recovery Financial Administration Branch, lnteragency Recovery Coordination Section
View Audit 408731
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 1226078 (2025-021)
Material Weakness 2025
State of California
CA
Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions § 200.303
Special Tests and Provisions California Department of Public Health Public Health concurs with the finding that a portion of the federally-required Skilled Nursing Facility (SNF) and Intermediate Care Facility (ICF) recertification surveys were not completed within the 15.9-month requirement. Public...
Special Tests and Provisions California Department of Public Health Public Health concurs with the finding that a portion of the federally-required Skilled Nursing Facility (SNF) and Intermediate Care Facility (ICF) recertification surveys were not completed within the 15.9-month requirement. Public Health’s ability to meet survey workload was hindered by the nearly three-month federal shutdown, reduced staffing capacity due to budget constraints, and competing high-priority workloads. Surveys that were overdue in FFY 2024-25 have been prioritized in FFY 2025-26, focusing first on facilities presenting the highest risk and those with the longest intervals since their last survey. Public Health will continue prioritizing the highest-risk federal workload within the limits of available staffing and budget. The federal contract allotment has remained stagnant despite increased expectations, and reductions in state funding during SFY 2024-25 and continuing through SFY 2025-26 limit Public Health’s ability to backfill gaps with state resources. As a result, Public Health will focus surveyor efforts on Immediate Jeopardy (IJ) investigations, quality-of-care issues, access-to-careconcer, and Tier 1 workload (including SNFs and ICFs). This approach aligns with CMS’s shift toward prioritizing IJ and high-risk intakes over lower-tier recertification surveys. Public Health remains committed to completing all federal workload assignments and will strive to meet Mission and Priorities Document (MPD) and State Performance Standards Systems (SPSS) requirements to the fullest extent possible given current staffing and budget limitations. Estimated Implementation Date June 2027 Contact - Andy Barbusca, State Surveyors Branch Chief, Center for Health Care Quality, California Department of Public Health
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 1226068 (2025-019)
Material Weakness 2025
State of California
CA
Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.328 § 200.329
Reporting California Department of Social Services CDSS will implement improved procedures and consider if a grant management solution would be feasible and necessary. CDSS has already begun establishing a process that determines and documents whether funding actions are reportable subrecipients or ...
Reporting California Department of Social Services CDSS will implement improved procedures and consider if a grant management solution would be feasible and necessary. CDSS has already begun establishing a process that determines and documents whether funding actions are reportable subrecipients or contractors. CDSS has also begun establishing a field within the CDSS accounting system that identifies subrecipients at the contract level so this data is automatically included when extracted for FFATA reporting, which will ensure reports are submitted accurately and timely. CDSS is also developing a Federal Reporting Dashboard to track all grants with FFATA reporting requirements, including due dates and completion status. Additionally, CDSS will designate a primary point and a backup person within the Federal Reporting Section to monitor all FFATA reporting deadlines. This designated staff member will issue 45 days advance notifications to the grant owner and reviewing manager, set calendar reminders for grant owners, and provide regular status updates to Accounting Management. To strengthen timely compliance, these reminders will also instruct grant owners to complete the FFATA submission 10 days before the federal deadline, ensuring sufficient time to resolve any errors that may occur during the upload process. Estimated Implementation Date: November 2026 Contact: - Rosali Bautista, Chief, Accounting and Reporting Bureau, Accounting and Fiscal Systems Branch, Finance and Accounting Division
View Audit 408731
Finding 1226037 (2025-006)
Material Weakness 2025
State of California
CA
Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303
Special Tests and Provisions Employment Development Department EDD has current policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the ...
Special Tests and Provisions Employment Development Department EDD has current policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the employee did not follow proper procedure to include the penalty. EDD accepts this oversight and is committed to reviewing its applicable policies and procedures to ensure they are clear, and the penalty requirements are emphasized. Regarding internal controls, EDD leverages a process known as the Field Office Basic Evaluation System (FOBES). This process includes a standardized form that is utilized by leadership to evaluate the quality of their employees’ work in a variety of processes, including overpayment processing. EDD continues to review and modernize the existing assessment form and FOBES process to ensure effectiveness and consistency while evaluating employee compliance with policies and procedures. EDD will enhance current procedures to outline the steps for reviewing claimant eligibility and applying disqualification penalties by: - Updating procedures in the various resources available for our determination false statement processes to include more comprehensive guidance. - Providing updated training for employees on any changes to procedures. Milestones: - Update UI Manuals by 8/14/2026. - Engage with UIB training team to update overpayment-related training and create a new refresher training by 8/14/2026. - Evaluate when a refresher training can be presented to determination trained employees by 8/14/2026. - Provide updated milestone to DOL by 9/30/2026. Estimated Implementation Date: September 2026 Contact: - Diane Underwood, Division Chief, Unemployment Insurance Branch
View Audit 408731
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