Corrective Action Plans

Finding 481174 (2021-003)

Significant Deficiency 2021

IL

Subrecipient Monitoring § 200.303 § 200.332

FINDING 2021-003 – Subrecipients Monitoring (Repeated from Prior Year Findings 20-004, 19-005, 18-004, and 17-003) CONDITION: The ROE does not have effective internal controls over subrecipient monitoring. Furthermore, ROE #47 was not properly monitoring subrecipients in accordance with the Unif...

FINDING 2021-003 – Subrecipients Monitoring (Repeated from Prior Year Findings 20-004, 19-005, 18-004, and 17-003) CONDITION: The ROE does not have effective internal controls over subrecipient monitoring. Furthermore, ROE #47 was not properly monitoring subrecipients in accordance with the Uniform Guidance standards. During audit testing procedures it was determined that ROE #47: Number of Subrecipients a. Did not evaluate the risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward. 2 of 2 b. Did not conduct subrecipient monitoring procedures 2 of 2 c. Did not determine whether the subrecipient met the 2 CFR 200 Subpart F Audit Requirements criteria for a single audit. 2 of 2 PLAN: Regional Office of Education will implement the following internal controls over Federal awards to ensure subrecipients are properly monitored as required by 2 CFR 200.332. This includes: a. Evaluating the risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward; b. Conducting subrecipient monitoring procedures; and c. Determining whether the subrecipient met the requirement criteria of 2 CFR 200 Subpart F Audit requirements for a single audit. ANTICIPATED DATE OF COMPLETION: Fiscal Year 2021 CONTACT PERSON: Mr. Chris Tennyson, Regional Superintendent for Lee, Ogle, and Whiteside Counties.

View Audit 317271

Finding 480952 (2021-004)

Significant Deficiency 2021

Luna County

NM

Questioned Costs Subrecipient Monitoring Significant Deficiency

2021-004 – High Intensity Drug Trafficking Areas (HIDTA) Overtime Violation (Signficant Deficiency) (Repeated finding FS 2020-005) - During the FY 2020 audit process it was discovered that Luna County had one employees which did not adhere to the HIDTA Program Policy on limitations of overtime. Luna...

2021-004 – High Intensity Drug Trafficking Areas (HIDTA) Overtime Violation (Signficant Deficiency) (Repeated finding FS 2020-005) - During the FY 2020 audit process it was discovered that Luna County had one employees which did not adhere to the HIDTA Program Policy on limitations of overtime. Luna County management along with the Program Commander and Luna County Sheriff will monitor OT more closely to ensure that no employee exceeds the maximum allowable earnings. Luna County will be monitoring all Federal programs to ensure compliance with contract/award guidelines on combined OT limits. In addition, the one employee this affected is no longer employed, however Luna County will continue due diligence to ensure that OT limits are strictly adhered to.

View Audit 317065 Questioned Costs: $1

Finding 480927 (2021-009)

Material Weakness 2021

Puerto Rico Electric Power Authority

PR

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Management acknowledges the findings and has implemented a corrective action plan to develop Standard Operating Procedures (SOPs) for current Grant management activities in order to assure that only expenditures incurred in each approved Project Worksheet (PW) that are not subsequently disallowed by...

Management acknowledges the findings and has implemented a corrective action plan to develop Standard Operating Procedures (SOPs) for current Grant management activities in order to assure that only expenditures incurred in each approved Project Worksheet (PW) that are not subsequently disallowed by the Federal Agency are included in the SEFA. In addition, the SEFA was amended to reflect PW expenditure in the accrual basis of accounting. Effective June 1, 2021, the Authority transitioned the management and operation of its transmission and distribution network as well as certain back- office functions, including billing, collections and accounting, to a third party. The third-party operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. Management will work to address these findings with the assistance of the third-party operators, where applicable. Also, effective July 1, 2023, the Authority transitioned the management and operation of its generation assets as well as certain back- office functions to a third party. The thirdparty operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. In addition, the Authority will also be implementing and monitoring corrective actions taken by the new generation segment operator. Contact Name Responsible for Corrective Action Plan - Nelson Morales Estimated Completion Date - July 2025

View Audit 317030

Finding 480926 (2021-008)

Material Weakness 2021

Puerto Rico Electric Power Authority

PR

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.302 § 200.303

Management acknowledges the findings and has implemented a corrective action plan to enhance compliance with Federal awards. This plan includes developing Standard Operating Procedures (SOPs) for grant management activities, identifying and documenting existing internal controls, and maintaining con...

Management acknowledges the findings and has implemented a corrective action plan to enhance compliance with Federal awards. This plan includes developing Standard Operating Procedures (SOPs) for grant management activities, identifying and documenting existing internal controls, and maintaining constant communication with stakeholders to prevent material noncompliance. Additionally, PREPA will provide training to staff on the new SOPs and establish a monitoring mechanism to continuously assess and improve the effectiveness of these controls. The corrective action plan, supervised by Mr. Ezequiel Nieves from the PREPA Disaster Funding Management Office, is expected to be completed by July 2025. Management is committed to addressing deficiencies, ensuring that processes and controls are robust and effective, and that Federal awards are managed transparently and in full compliance with all regulatory requirements. Effective June 1, 2021, the Authority transitioned the management and operation of its transmission and distribution network as well as certain back- office functions, including billing, collections and accounting, to a third party. The third-party operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. Management will work to address these findings with the assistance of the third-party operators, where applicable. Also, effective July 1, 2023, the Authority transitioned the management and operation of its generation assets as well as certain back- office functions to a third party. The thirdparty operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. In addition, the Authority will also be implementing and monitoring corrective actions taken by the new generation segment operator. Contact Name Responsible for Corrective Action Plan - Ezequiel Nieves Estimated Completion Date - July 2025

View Audit 317030

Finding 480860 (2021-006)

Significant Deficiency 2021

American Association of Physics Teachers, Inc.

MD

Subrecipient Monitoring Period of Performance § 200.331

Finding 2021-006: Subrecipient Monitoring Federal Programs: Research and Development Cluster: Stem +C Cause: AAPT's internal policies and procedures governing risk assessment on subrecipient was not performed. Views of Responsible Officials and Planned Corrective Actions: Management will continue to...

Finding 2021-006: Subrecipient Monitoring Federal Programs: Research and Development Cluster: Stem +C Cause: AAPT's internal policies and procedures governing risk assessment on subrecipient was not performed. Views of Responsible Officials and Planned Corrective Actions: Management will continue to perform risk assessment procedures and will thoroughly document the processes and evaluations. Anticipated Completion Date: December 17, 2021 Responsible Official: Michael Brosnan CFO

View Audit 316985

Finding 480685 (2021-001)

Significant Deficiency 2021

Puerto Rico Office Management and Budget

PR

Subrecipient Monitoring Reporting Significant Deficiency

3 de julio de 2024 Section II – Federal Award Findings and Questioned Costs Finding Number: 2021-001 Agency: Puerto Rico Office of Management and Budget Federal Program: Coronaviru...

3 de julio de 2024 Section II – Federal Award Findings and Questioned Costs Finding Number: 2021-001 Agency: Puerto Rico Office of Management and Budget Federal Program: Coronavirus Relief Fund Assistant listing number: 21.019 Grant Number: N/AV Grant Period: July 1, 2020 through June 30, 2021 Compliance Requirement: Reporting Category: Significant Deficiency and noncompliance over federal program Condition: During our audit of June 30, 2021 financial statement, we noted that single audit report for fiscal year 2020-2021 was not submitted by September 30, 2022. Cause: Missing of internal controls over financial reporting to produce financial statement on timely basis to comply with OMB reporting deadlines. Effect: Non-compliance with the above-mentioned requirement could lead to administrative actions by the grantor. It could also be interpreted as a failure to manage federal awards in compliance with laws, regulations, and provisions of contracts and grant agreements. Recommendation: To improve, execute and monitors accounting periods end closings as planned in order to get a financial statement on time to comply with required deadlines. Also, keep track and communication of federal programs compliances with regulatory parties and among agency’s responsible departments involve and establish a program deadline calendar. Questioned Costs: None Perspective of the information: Single audit report was issued after due date. The information was not drawn from a statistical sample. Calle Cruz #254 Esq. Tetuán, San Juan, PR / PO Box 9023228, San Juan, PR 00902-3228 Management response: 3 de julio de 2024 Section II – Federal Award Findings and Questioned Costs Finding Number: 2021-001 Agency: Puerto Rico Office of Management and Budget Federal Program: Coronavirus Relief Fund Assistant listing number: 21.019 Grant Number: N/AV Grant Period: July 1, 2020 through June 30, 2021 Compliance Requirement: Reporting Category: Significant Deficiency and noncompliance over federal program Condition: During our audit of June 30, 2021 financial statement, we noted that single audit report for fiscal year 2020-2021 was not submitted by September 30, 2022. Cause: Missing of internal controls over financial reporting to produce financial statement on timely basis to comply with OMB reporting deadlines. Effect: Non-compliance with the above-mentioned requirement could lead to administrative actions by the grantor. It could also be interpreted as a failure to manage federal awards in compliance with laws, regulations, and provisions of contracts and grant agreements. Recommendation: To improve, execute and monitors accounting periods end closings as planned in order to get a financial statement on time to comply with required deadlines. Also, keep track and communication of federal programs compliances with regulatory parties and among agency’s responsible departments involve and establish a program deadline calendar. Questioned Costs: None Perspective of the information: Single audit report was issued after due date. The information was not drawn from a statistical sample. Calle Cruz #254 Esq. Tetuán, San Juan, PR / PO Box 9023228, San Juan, PR 00902-3228 Management response: The Puerto Rico Office of Management and Budget (OMB) acknowledges the finding and the importance of complying with the OMB Uniform Guidance for single audits. The following actions have been taken and will continue to be implemented to ensure compliance: 1. Contracting External Audit Firms: o Action Taken: OMB has contracted qualified external audit firms to conduct the single audits to ensure compliance with federal requirements. o Outcome: This measure has resolved the immediate issue of non- compliance by ensuring timely submission of audit reports. The OMB complied with instructions from the Puerto Rico Fiscal Agency and Financial Advisory Authority (AAFAF) regarding reports related to these funds. The OMB presumed that AAFAF was responsible for the final report and audit to the federal government. The OMB will continue monitoring the use and disbursement of federal funds to comply with state and federal regulations. Responsible Officer: Mrs. Nivis González Rodríguez Estimated Completion Date: July 2024

View Audit 316913

Finding 480517 (2021-001)

Material Weakness 2021

Virginia Commonwealth University Health System

VA

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking

Timely Preparation of Schedule of Expenditures of Federal Awards (SEFA) COVID – 19 – Coronavirus Relief Fund (Assistance Listing # 21.019); COVID – 19 – Provider Relief Fund (Assistance Listing #93.498) Recommendation: The Authority’s policy and procedure should be designed to ensure timely reportin...

Timely Preparation of Schedule of Expenditures of Federal Awards (SEFA) COVID – 19 – Coronavirus Relief Fund (Assistance Listing # 21.019); COVID – 19 – Provider Relief Fund (Assistance Listing #93.498) Recommendation: The Authority’s policy and procedure should be designed to ensure timely reporting as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management will enhance its procedures around the preparation of the SEFA to include a timely year-end reconciliation between the general ledger and all source documentation to ensure that all Federal expenditures are complete and accurately reported in the SEFA in fiscal 2024. Name(s) of the contact person(s) responsible for corrective action: Min Cummings, VP of Finance and Accounting, 703-629-8155. Planned completion date for corrective action plan: For the creation of the Schedule for FY2023.

View Audit 316713

Finding 479728 (2021-005)

Material Weakness 2021

Cambria Heights School District

PA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.302

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office o...

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations. CRITERIA: The Pennsylvania Department of Education (PDE), through the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts requires School Districts to utilize specific funding source codes for federal program expenditures. In addition, Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to 1) enhance internal controls for tracking and monitoring federal program expenditures and 2) comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to enhance its internal controls for tracking and monitoring federal program expenditures and to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

View Audit 316302

Finding 478867 (2021-005)

Significant Deficiency 2021

Detroit Central City Cmh, Inc.

MI

Questioned Costs Program Income Subrecipient Monitoring § 200.307

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants...

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants M10071L5F011912 and Ml0439L5F011903, respectively. Management Response: Management acknowledges that program income generated from specific programs is to be used to cover net allowable program costs or to meet matching requirements. DCCCMH will implement measures to track program income for grant programs and will use program income to offset allowable program costs when preparing financial status reports. A final review of the use of program income will be performed by the Finance team before the annual audit commences. These measures will be incorporated into the updates to the financial policies and procedures for grant programs.

View Audit 315464 Questioned Costs: $1

Finding 478559 (2021-007)

Material Weakness 2021

City of Adelanto

CA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.

View Audit 315185

Finding 478312 (2021-006)

Significant Deficiency 2021

City of Compton

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate ...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate calculations in the future. Planned Implementation Date: Implemented as of April 2024 Responsible Person(s): City Controller

View Audit 314981 Questioned Costs: $1

Finding 478311 (2021-008)

Significant Deficiency 2021

City of Compton

CA

Allowable Costs / Cost Principles Subrecipient Monitoring HUD Housing Programs

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy will also be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller

View Audit 314981

Finding 478306 (2021-002)

Material Weakness 2021

City of Compton

CA

HUD Housing Programs Material Weakness Reporting

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in pl...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: December 31, 2024 Responsible Person(s): City Manager, Community Development Director, and City Controller

View Audit 314981

Finding 406040 (2021-003)

Significant Deficiency 2021

Hospital Damas INC

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

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

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

View Audit 311582

Finding 406039 (2021-002)

Significant Deficiency 2021

Hospital Damas INC

PR

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

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

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

View Audit 311582

Finding 406038 (2021-001)

Significant Deficiency 2021

Hospital Damas INC

PR

Eligibility Subrecipient Monitoring Significant Deficiency

Finding No. 2021-001 - Activities Allowed or Unallowed - Hazard Pay Eligibility Corrective Action Plan On March 2, 2022, payments to ineligible employees were recharacterized as additional compensation paid from the Entity’s own resources, instead of federal awards. Such federal awards remain availa...

Finding No. 2021-001 - Activities Allowed or Unallowed - Hazard Pay Eligibility Corrective Action Plan On March 2, 2022, payments to ineligible employees were recharacterized as additional compensation paid from the Entity’s own resources, instead of federal awards. Such federal awards remain available for use under other assistance programs provided by the CARES Act through December 2020. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on March 2, 2022

View Audit 311582

Finding 404941 (2021-008)

None 2021

Clark County Fiscal Court

KY

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

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

View Audit 311338

Finding 403399 (2021-002)

Material Weakness 2021

Oficina Del Procurador De Las Personas De Edad Avanzada

PR

Subrecipient Monitoring

As established in the SA 2020 Corrective Action Plan, the OPPEA established a process to adapt to the reality of the office. The OPPEA implemented a Risk Assessment System. The actions taken by management regarding monitoring are based on a review of the policies and processes to carry out the monit...

As established in the SA 2020 Corrective Action Plan, the OPPEA established a process to adapt to the reality of the office. The OPPEA implemented a Risk Assessment System. The actions taken by management regarding monitoring are based on a review of the policies and processes to carry out the monitoring of subrecipients. Risk monitoring will be carried out to minimize evaluation efforts in the follow-up. With the purpose of streamlining their process and ensuring that they are completed effectively in less time. Some Risk categories were established so that in the event that a Monitor finds as a result of its evaluation that said project represents a risk in the management of funds, a more in-depth Monitoring can be carried out.

View Audit 310511

Finding 402379 (2021-014)

Material Weakness 2021

State of California

CA

Subrecipient Monitoring § 200.303 § 200.332 § 200.501 § 200.513 § 200.521

Public Health agrees with the recommendation. We will establish formal procedures for conducting risk assessments of our subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures and establish a process for obtaining single audit reports from out subrec...

Public Health agrees with the recommendation. We will establish formal procedures for conducting risk assessments of our subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures and establish a process for obtaining single audit reports from out subrecipients. Finally, we will develop a monitoring mechanism to track subrecipients' compliance with the single audit mandate. Estimated Implementation Date: December 2024 Contact: Melissa Relles, Assistant Deputy Director Division of Operations Center for Preparedness and Response California Department of Public Health

View Audit 309913

Finding 402375 (2021-013)

Significant Deficiency 2021

State of California

CA

Subrecipient Monitoring Material Weakness Reporting

Health Care Services understands the finding that amounts identified in the single audit as Medicaid and CHIP “pass through payments to subrecipients” could be subject to the FFATA. Pursuant to Office of Management and Budget (OMB) Guidance, Title 2 of the CFR, Parts 170 and 200.1, and the OMB Comp...

Health Care Services understands the finding that amounts identified in the single audit as Medicaid and CHIP “pass through payments to subrecipients” could be subject to the FFATA. Pursuant to Office of Management and Budget (OMB) Guidance, Title 2 of the CFR, Parts 170 and 200.1, and the OMB Compliance Supplement, a subrecipient is an entity “that receives a subaward from a pass-through entity to carry out part of a Federal award,” and a subaward “does not include payments to a contractor or payments to an individual that is a beneficiary of a Federal Program.” Health Care Services will review current practices for managing subawards and payment classifications to ensure payments subject to FFATA are appropriately reported and update current practices as applicable by June 2024. Estimated Implementation Date: June 2024 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913

Finding 402372 (2021-012)

Significant Deficiency 2021

State of California

CA

Subrecipient Monitoring Reporting Significant Deficiency

The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA re...

The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA reporting within the required timeframe. This individual has been trained and made aware of the expectations. Aging has begun updating the FFATA records and will continue this effort through the month of March until all reporting has been completed. Moving forward, the dedicated staff person will update the FFATA for each new federal funding award within the required timeframe. Estimated Implementation Date: March 2023 Contact: Kim Elliott, Chief Budget Officer Division of Administrative Services California Department of Aging

View Audit 309913

Finding 402371 (2021-011)

Material Weakness 2021

State of California

CA

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

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

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

View Audit 309913

Finding 402369 (2021-010)

Material Weakness 2021

State of California

CA

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

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

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

View Audit 309913 Questioned Costs: $1

Finding 402368 (2021-009)

Significant Deficiency 2021

State of California

CA

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

Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. T...

Office of AIDS (OA) agrees with the finding and has implemented solutions to meet the auditor's recommendation. OA has already taken steps to remedy the issue by using its Support Branch to realign staff and responsibilities to allow for a greater focus on fiscal reporting and invoice processing. The Care Branch has also put an increased emphasis on tracking and reviewing invoices for payment to prevent similar delays. Subsequently, the Ryan White Grant closeouts had all invoices processed and paid prior to the Federal Financial Report closeout deadlines to ensure that drawn cash for invoices was not held for extended timeframes. Estimated Implementation Date: July 1, 2021 Contact: Joseph Gonzales, Branch Chief Office of AIDS Support Branch California Department of Public Health

View Audit 309913

Finding 402364 (2021-008)

Material Weakness 2021

State of California

CA

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

Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law D...

Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law DHCS must enforce compliance with the terms of the DHCS’ contracts with Mental Health Plans and Drug Medi-Cal Organized Delivery System counties, as well as ensure compliance with applicable state and federal laws and regulations, in accordance with its authority and obligations under state and federal requirements.” Lastly, under the section titled ‘Exhibit A - Attachment 3’ of the County Mental Health Plan Contract counties are required to submit cost reports timely which would allow Health Care Services to impose sanctions on counties who do not submit cost reports in a timely manner. This BHIN resolves the finding. Additionally, Health Care Services will not be collecting cost reports for dates of service after State Fiscal Year 2022-23. Under the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and pursuant to Welfare and Institutions Code, Section 14184.403(b), Health Care Services will replace the current Certified Public Expenditures (CPE) reimbursement methodology with an intergovernmental transfer (IGT) reimbursement methodology. The IGT reimbursement methodology will make a single and final payment for services provided to the county, which includes the non-federal portion of the claims. This change will eliminate the requirement for the county submission of cost reports. Estimated Implementation Date: October 31, 2022 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913

Corrective Action Plans

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