Corrective Action Plans

Finding 480856 (2021-004)

Significant Deficiency 2021

American Association of Physics Teachers, Inc.

MD

Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Finding 2021-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Vie...

Finding 2021-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Views of Responsible Officials and Planned Corrective Actions: AAPT has made changes to correclty reflect the employee's assigned supervisor based on the position and job duties of the employees. Anticipated Completion Date: 04/01/2024 Responsible Official: Michael Brosnan, CFO

View Audit 316985

Finding 479433 (2021-002)

Material Weakness 2021

Unity Medical Center INC

TN

Reporting Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.507

2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal awar...

2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Section 200.507 of the Uniform Guidance states that the program-specific audit shall be completed, and reporting required submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the end of the audit, unless a longer period is specified in a program-specific audit guide. During 2023, we have strengthened internal controls related to review of the quarterly lost revenue calculations and reporting in the PRF reporting portal. Going forward, we will complete our audits and submit the required reports by the deadlines. We have taken appropriate steps to identify all other assistance received by quarter during the period of availability on the PRF report going forward.

View Audit 315964

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 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 404940 (2021-007)

Material Weakness 2021

Clark County Fiscal Court

KY

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure that expenses for Federal Reimbursement are eligible for reimbursement.

View Audit 311338 Questioned Costs: $1

Finding 404821 (2021-007)

Material Weakness 2021

Shattuck Hospital Authority D/b/a Newman Memorial Hospital, Inc.

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federa...

Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal, states, regulations and conditions of the federal award. Corrective Action Plan: We will modify internal control policies to ensure there is an understanding of reporting requirements to ensure that reports are accurate and amounts are not inadvertently claimed that are considered unallowable. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: June 2024

View Audit 311207

Finding 402820 (2021-001)

Significant Deficiency 2021

Brownfield Regional Medical Center

NM

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.403 § 200.430

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. ...

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. Action Taken: 1. Policy Revision and Development: o Develop or revise existing policies to clearly define the processes for documenting and retaining expenditure information related to federal awards. These policies should explicitly follow the requirements over 2 CFR Section 200.430(g)(i), ensuring that all expenditures are properly documented and justified as per federal award conditions. Specifically, approval of differential rates will be added to those policies. o Ensure that the policy includes guidelines for regularly reviewing employee pay rates against approved rates for compliance with federal award conditions. 2. Training and Awareness Programs: o Implement comprehensive training programs for all staff involved in charging costs to federal awards. This training should cover the importance of compliance with federal regulations, specifically focusing on the documentation and retention of expenditure information and adherence to approved pay rates. o Schedule regular refresher training sessions to ensure ongoing compliance and awareness. 3. Enhanced Monitoring and Audit Trails: o Introduce monitoring mechanisms to regularly review expenditures charged to federal awards for compliance with documented policies and federal requirements. o Develop an audit trail system that allows for the easy retrieval of documentation supporting expenditures and payroll compliance. This system should enable auditors to trace the documentation back to the federal award and the approved budget items. 4. Internal Control Improvements: o Review and strengthen internal controls related to the processing of expenditures and payroll to ensure that all transactions are authorized, recorded accurately, and in compliance with federal award requirements. o Implement segregation of duties where possible, to reduce the risk of errors or fraud in the charging of costs to federal awards. 5. Regular Compliance Reviews and Updates: o Conduct periodic internal reviews to assess compliance with federal award requirements and the effectiveness of the implemented corrective actions. o Ensure that any changes in federal regulations or award-specific requirements are promptly incorporated into the hospital's policies and training programs. 6. Documentation and Communication: o Maintain comprehensive records of all actions taken to address the audit findings, including policy revisions, training sessions, and internal review outcomes. Specifically, records for those these expenditures will remain onsite and not sent to long-term storage if the employee or vendor no longer has a relationship with the facilities. o Communicate regularly with federal awarding agencies to update them on the corrective actions taken and to seek guidance on compliance matters as needed. Implementation Timeline and Responsibility Assignment: • Management positions including the CEO, CFO and CNO for the 2021 fiscal year are no longer employed by Terry Memorial Hospital District. Administration employed in 2023 acknowledges these deficiencies and accepts responsibility for developing, applying and maintaining this corrective action plan going forward. • Assign specific responsibilities to designated staff members or departments for each component of the corrective action plan. • Set clear deadlines for the completion of each action item, with an initial goal to address all significant deficiencies within one to three months from the date of the audit report. Monitoring and Reporting: • Establish a mechanism for ongoing monitoring of the effectiveness of the corrective action plan, with periodic reports to senior management and the board of directors. Feedback Loop: • Create a feedback loop with employees and management to continuously improve internal controls and compliance processes based on practical experiences and challenges encountered during implementation. Responsible Person: Whitney Wilson, CFO

View Audit 310010 Questioned Costs: $1

Finding 402384 (2021-016)

Material Weakness 2021

State of California

CA

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference...

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference Number 2021-003. The other three claimants were receiving regular Unemployment Insurance (UI) benefits (one claimant) and Pandemic Emergency Unemployment Compensation (PEUC) benefits (two claimants). Those three claimants were paid pending the adjudication of potential eligibility issues, which were later found to be disqualifying. EDD has corrected both issues that resulted in the LWA payments being made to ineligible claimants. Regarding the issue of PUA claimants paid prior to the discovery of the potential identity issues, as outlined in the response to the finding for Reference Number 2021-003, during the years 2020 and 2021, the EDD implemented multiple new fraud prevention measures. Regarding the issue of the regular UI and PEUC claimants being paid prior to the adjudication of the potential eligibility issues, the EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete the remaining retroactive workload by April 30, 2023. Estimated Implementation Date: September 2020 (Fraud Enhancements) and January 2021 (Resumption of Adjudications) Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402380 (2021-015)

Significant Deficiency 2021

State of California

CA

Questioned Costs Reporting Special Tests & Provisions § 200.303

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assista...

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assistance Program vs. Children’s Health Insurance Program) for each overpayment account receivable set up after the effective date. The FFP rate and Budget Program information for each overpayment is provided on the Action Notices to the FI. The SDN also made updates to the California Omnibus Budget Reconciliation Act of 1985 (COBRA) system to enable the system to receive the FFP rate and Budget Program information for each overpayment set up by the FI and updated COBRA reports, thereby allowing Health Care Services to report the correct FFP rate for overpayments on the CMS-64 and CMS-21. Estimated Implementation Date: September 30, 2021 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913 Questioned Costs: $1

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 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

Finding 402363 (2021-007)

Significant Deficiency 2021

State of California

CA

Subrecipient Monitoring Reporting § 200.303 § 200.332 § 200.414 § 200.502

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

View Audit 309913

Finding 402361 (2021-006)

Material Weakness 2021

State of California

CA

Questioned Costs Eligibility Allowable Costs / Cost Principles § 200.303

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

Finding 402359 (2021-005)

Material Weakness 2021

State of California

CA

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

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

Finding 402357 (2021-004)

Material Weakness 2021

State of California

CA

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Since fiscal year 2020-21, EDD has implemented dozens of strict anti-fraud measures to continue to evaluate and enhance its fraud detection. These measures, described in last year’s response to finding Reference Number 2020-005, included, but were not limited to, cross matching claimant information ...

Since fiscal year 2020-21, EDD has implemented dozens of strict anti-fraud measures to continue to evaluate and enhance its fraud detection. These measures, described in last year’s response to finding Reference Number 2020-005, included, but were not limited to, cross matching claimant information against law enforcement and government databases and implementing rigorous new identity verification procedures. As a result, EDD caught and stopped multiple fraud attempts starting in September 2020. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating Pandemic Unemployment Assistance (PUA) claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. The EDD will continue to evaluate and enhance the fraud detection/prevention tools that have been put in place. Estimated Implementation Date: September 2020 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402355 (2021-003)

Material Weakness 2021

State of California

CA

Eligibility Allowable Costs / Cost Principles HUD Housing Programs § 200.303

The Women, Infants, and Children Division (WIC) of the California Department of Public Health (Public Health) agrees that the WIC WISE system does not currently store eligibility history that should be included in the “Cert History Report.” Currently, the initial eligibility data is overwritten when...

The Women, Infants, and Children Division (WIC) of the California Department of Public Health (Public Health) agrees that the WIC WISE system does not currently store eligibility history that should be included in the “Cert History Report.” Currently, the initial eligibility data is overwritten when subsequent eligibility information is keyed into WIC WISE. WIC WISE does include preventative internal stops or check points that do not allow ineligible individuals to be certified and issued benefits (e.g., over income, not a CA resident, no nutrition risk factor, etc.). User acceptance testing vetted these items prior to system implementation. The certification history condition will be remediated via a system Defect Correction to WIC WISE. WIC has entered Defect Correction #6972 in Team Foundation Services (TFS), the tracking system used to capture system changes and defects. This correction is included in a release that is currently being tested and is targeted for release into production by May 2023. The defect supports a system change to ensure initial eligibility information is retained when subsequent eligibility information is entered into WIC WISE. Estimated Implementation Date: May 2023 Contact: William Welch, Assistant Division Chief, Operations Women, Infants, and Children Division California Department of Public Health

View Audit 309913

Finding 402354 (2021-002)

Material Weakness 2021

State of California

CA

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.502 § 200.510

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.

View Audit 309913

Finding 402351 (2021-001)

Material Weakness 2021

State of California

CA

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

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.

View Audit 309913

Finding 401706 (2021-005)

Significant Deficiency 2021

Northwest Indian College

WA

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

Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the cha...

Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the challenge of hiring a Payroll Specialist. In September 2022, the College outsourced “Payroll” to Paycom. We continue to develop and communicate the unique needs of our College Payroll structure and Federal and private funding sources with Paycom and the College Human Resources to ensure that employees are paid properly. As such, the Business Office is undergoing a restructure and we have identified an internal candidate to take the lead on Payroll. Name of the contact person responsible for corrective action: Raquel Vigil, Chief Financial Officer, Clarissa Salhus, Finance Manager, Reatha Tom, Accounts Payable Specialist, Michelle Ferron-Guppy, Director – Human Resources, and Zoy Zamudio-Lane, Human Resources Generalist Planned completion date for corrective action plan: September 30, 2024

View Audit 309644

Finding 401704 (2021-004)

Significant Deficiency 2021

Northwest Indian College

WA

Equipment & Real Property Management Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.313

Recommendation: We recommend the College implement policies and procedures to ensure all property and equipment purchased with federal funds includes such information in the property records to comply with the requirement. Explanation of disagreement with audit finding: There is no disagreement with...

Recommendation: We recommend the College implement policies and procedures to ensure all property and equipment purchased with federal funds includes such information in the property records to comply with the requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has begun to explore the Asset Module in the Jenzabar platform, with the goal that Procurement is the first stage of our property tracking. Work continues to be a challenge in this area as we are short staffed. The Business Office Staff will continue to work with the Purchasing staff to identify how best to proceed with this requirement. The College currently has Policies that speak to Assets and the recording of such. The College will strengthen the specifics of what an Asset listing is to include. Name of the contact person responsible for corrective action: Raquel Vigil, Chief Financial Officer, Clarissa Salhus, Finance Manager, Charles Roberts, Purchasing Manager, and Paul Roberts, Fiscal Technician/Receiving Planned completion date for corrective action plan: March 31, 2025

View Audit 309644

Finding 401691 (2021-003)

Material Weakness 2021

Northwest Indian College

WA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control ...

Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control policies to document verification of vendors who may be listed in SAM for suspension and debarment. The College approved an updated procurement policy effective November 7, 2020, to adhere to Uniform Guidance. The College will strengthen (include) the suspension and debarment section to include a policy specific to Debarment and Suspension. Name of the contact person responsible for corrective action: Reatha Tom, Accounts Payable Specialist, and Clarissa Salhus, Finance Manager Planned completion date for corrective action plan: December 31, 2024

View Audit 309644

Finding 401146 (2021-001)

Significant Deficiency 2021

Public Hospital District No. 1 of Skagit County

WA

Matching / Level of Effort / Earmarking Reporting Significant Deficiency § 200.303

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

View Audit 309195

Corrective Action Plans

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