Corrective Action Plans

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Finding Number: 2024-006 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: LaRae Kuhfal, Fiscal Officer and Deb Sjostrom, Director. Corrective Action P...
Finding Number: 2024-006 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: LaRae Kuhfal, Fiscal Officer and Deb Sjostrom, Director. Corrective Action Planned: LaRae has taken over the report starting with quarter 4 of 2025 and is keeping all records used for the LCTS report. We plan to make sure that the quarterly reports are reviewed and approved by the director. Anticipated Completion Date: Completed as of quarter 4, 2025 and continuing.
Finding Number: 2024-008 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Tarah Yaggie Corrective Action Planned: We understand we need to look at sam.gov and will do so goin...
Finding Number: 2024-008 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Tarah Yaggie Corrective Action Planned: We understand we need to look at sam.gov and will do so going forward. Anticipated Completion Date: 6/12/2026
Finding Number: 2024-007 Finding Title: Eligibility – MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cindy Noetzelman Corrective Action Planned: Cases have been corrected and there was a discussion with staff on the process and the need ...
Finding Number: 2024-007 Finding Title: Eligibility – MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cindy Noetzelman Corrective Action Planned: Cases have been corrected and there was a discussion with staff on the process and the need for correct entries. We will continue to review at monthly staffing meetings to ensure correct procedures continue to be followed. Anticipated Completion Date: Cases have been corrected as of Dec 31, 2025
U.S. Department of Housing and Urban Development Community Development Block Grant – Assistance Listing No. 14.218 Recommendation: We recommend the City implement policies and procedures to ensure that the Federal Funding Accountability and Transparency Act (FFATA) reporting occurs for all subawards...
U.S. Department of Housing and Urban Development Community Development Block Grant – Assistance Listing No. 14.218 Recommendation: We recommend the City implement policies and procedures to ensure that the Federal Funding Accountability and Transparency Act (FFATA) reporting occurs for all subawards of $30,000 or more for all federal awards and that the reporting be performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Finance Department will ensure that all departments are aware of this compliance requirement and ensure reporting requirements are performed timely in relation to subawards. Name(s) of the contact person(s) responsible for corrective action: Rebecca Campbell, Finance Director Planned completion date for corrective action plan: July 2026
2024-004 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA111008 and 2021 Compliance Requirements: Reporting Type of Finding:...
2024-004 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA111008 and 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: ICWDO acknowledges the recommendation and is actively working on a remedy and on the development of formal policies as recommended, which will assist ICWDO’s fiscal team in ensuring that all reports are appropriately reconciled. ICWDO acknowledges the recommendations from finding 2021-010 related to a formalization of the Administrative/fiscal processes and protocols to ensure that procedures are consistently followed to guarantee that reports agree to the amounts recorded in the general ledger and SEFA. Additionally, the recommendation specifics that protocols to ensure the separation of duties are featured in the policy. ICWDO operates under WIOA guidelines and follows County fiscal/administrative policies. Internal policies that include formal controls and procedures to ensure that monthly reports and general ledgers are consistent, with clear segregation of duties will be formally adopted. Aspects of these policies will include: • Protocol for preparation of monthly reports by the fiscal manager, and approval and signature by ICWDO Director • Protocol for preparation of closeouts that will provide the hierarchy of development, review, and approval for future reference. • Schedule monthly closeout meetings with the fiscal department and administration to ensure that documents are reviewed separately, and issues are addressed promptly. • Protocol for Policy Committee review, comment and direction, and approval for implementation by vote of the full workforce development board. ICWDO anticipates to implement the corrective action by December 31, 2025. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2025
2024-003 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Ty...
2024-003 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Type of Finding: Material Weakness Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: The questions from finding 2021-008 relate to a formalization of the fiscal processes and protocols. ICWDO operates under WIOA guidelines and follows Imperial County’s fiscal policies. Internal policy will be formally updated to reflect compliance with WIOA regulations, as well as Imperial County policies. These policies will include formal controls and procedures to evaluate each subrecipient’s risk of noncompliance. Once the formal procedure is drafted, it will go through the ICWDO Policy Committee for comment and direction, and then finally reviewed and approved for implementation by the full Workforce Development Board. Additionally, for any future Memorandums of Understanding (MOUs) between this Imperial County department and any outside agency, there will be an additional step to include review by Imperial County Counsel to reflect that recital around the funding source will specify the following required information: • Federal Award Identification Number • Federal award date of award to recipient by the Federal agency • Name of Federal awarding agency • CFDA Number • Specific identification of whether the award is research and development ICWDO will develop internal policies for formalizing all subrecipient monitoring process. ICWDO operates under WIOA guidelines for monitoring; therefore a formal internal policy for future contracts will be developed and implemented using the usual review and approval procedures followed by the department. ICWDO will develop a formal internal documentation system, with appropriate checks and signatures, for the evaluation and assessment of each subrecipient’s risk of noncompliance. ICWDO will utilize this formal process to properly document the risk assessment of all subrecipients. ICWDO anticipates to implement the corrective action by December 31, 2025. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2025
Concur: · 8 instances where the Government was unable to obtain Quarterly Progress Reports. As a result of the audit finding and in accordance with grant requirement, a Governor's Authorized Representative (GAR) Memo is being implemented, requiring Subrecipients to submit Quarterly Progress Reports ...
Concur: · 8 instances where the Government was unable to obtain Quarterly Progress Reports. As a result of the audit finding and in accordance with grant requirement, a Governor's Authorized Representative (GAR) Memo is being implemented, requiring Subrecipients to submit Quarterly Progress Reports within 10 days of quarter end. All reports are reviewed and retained in a centralized location for documentation and audit compliance. · 8 instances where the Government was unable to obtain completion/inspection certificate. Project inspection/certification report(s) are now required for all payment request federal fund drawdowns. The reports must now be uploaded to the Enterprise Resource Planning System (ERP) and retained in centralized location for documentation and record keeping purposes. · 8 subrecipients with no supporting documentation that VITEMA verified that subrecipients expected to be audited as required by 2 CFR part 200, subpart F. The Program will annually notify subrecipients of their audit responsibilities, monitor compliance, obtain required audit reports, and maintain documentation in a centralized location for audit and recordkeeping purposes.
The Program agrees and has established internal controls to ensure that all Federal Funding Accountability and Transparency Act (FFATA) subaward reports exceeding 30,000 are submitted timely and reviewed by the Territorial Public Assistance Officer. Although the SAM.GOV system implemented in FY 2024...
The Program agrees and has established internal controls to ensure that all Federal Funding Accountability and Transparency Act (FFATA) subaward reports exceeding 30,000 are submitted timely and reviewed by the Territorial Public Assistance Officer. Although the SAM.GOV system implemented in FY 2024 does not track individual FFATA filing dates, VITEMA remains committed to submitting all required reports by the last day of the month following each award. A certification process has also been implemented to verify the date reports are filed and reviewed.
The Program Integrity Unit has established SOPPs which identifies the method for identifying fraud cases, investigating cases, and developed procedures in collaborating and cooperating with legal authorities, for referring credible allegations of fraud cases to law enforcement officials.
The Program Integrity Unit has established SOPPs which identifies the method for identifying fraud cases, investigating cases, and developed procedures in collaborating and cooperating with legal authorities, for referring credible allegations of fraud cases to law enforcement officials.
To address these challenges and strengthen program integrity, DHS implemented the Provider Enrollment Application (PEA) Portal on March 2, 2026. The PEA Portal modernizes provider enrollment and revalidation by electronically collecting, storing, and maintaining required documentation in a centraliz...
To address these challenges and strengthen program integrity, DHS implemented the Provider Enrollment Application (PEA) Portal on March 2, 2026. The PEA Portal modernizes provider enrollment and revalidation by electronically collecting, storing, and maintaining required documentation in a centralized system. The portal supports retention of Medicaid Provider Agreements, screening documentation, ownership disclosures, licensure information, and other enrollment records within a single electronic repository. The PEA Portal improves document retention and accessibility, creates an electronic audit trail, and enables staff to retrieve enrollment and screening records more efficiently. It also strengthens oversight by standardizing enrollment workflows, reducing reliance on paper files, and improving documentation consistency. These enhancements better position DHS to demonstrate compliance during future audits and monitoring reviews. DHS recognizes the importance of maintaining complete, accurate, and accessible provider enrollment records. In addition to implementing the PEA Portal, DHS is strengthening policies and procedures related to provider file maintenance, document retention, and quality assurance reviews. Staff training and periodic monitoring will help ensure required enrollment documents and exclusion screening records are consistently maintained and available for inspection. DHS is committed to maintaining compliance with federal Medicaid and CHIP provider enrollment requirements and believes the corrective actions implemented, including deployment of the PEA Portal, will improve documentation controls, strengthen program integrity, and reduce the risk of similar findings in the future.
During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To add...
During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To address this finding, the Department recently issued Requests for Qualifications (RFQs) to seven qualified vendors to perform comprehensive security risk assessments of the Medicaid Enterprise Systems (MES), including the VIBES Eligibility and Enrollment System, Provider Enrollment Application (PEA), Pharmacy Benefit Management (PBM) solution, and related supporting systems. Vendor responses are due within three weeks, after which the Department will evaluate submissions and proceed with the procurement process. The selected vendor will conduct the required risk assessments, identify control deficiencies and security vulnerabilities, and provide recommendations to strengthen the Department's security posture and compliance framework. The Department will work collaboratively with its technology partners, system vendors, and oversight entities to implement corrective actions identified through the assessments and enhance monitoring controls to ensure ongoing compliance with applicable federal requirements.
The Department has strengthened its oversight of Medicaid financial reporting through the establishment of a Director of Audits position in September 2025. The Director of Audits will work collaboratively with the Medicaid Program, Fiscal Office, and other applicable stakeholders to monitor complian...
The Department has strengthened its oversight of Medicaid financial reporting through the establishment of a Director of Audits position in September 2025. The Director of Audits will work collaboratively with the Medicaid Program, Fiscal Office, and other applicable stakeholders to monitor compliance with federal reporting requirements and ensure that adequate supporting documentation is maintained for Medicaid cost reporting activities.
Currently, reports are submitted for review via email. The CMS-64 as well as the CMS-37 is prepared by a consulting firm who submits the copy of the reports for review and approval. Once the Medicaid Director is satisfied, an email is sent approving the report, for further entering into the MBES (CM...
Currently, reports are submitted for review via email. The CMS-64 as well as the CMS-37 is prepared by a consulting firm who submits the copy of the reports for review and approval. Once the Medicaid Director is satisfied, an email is sent approving the report, for further entering into the MBES (CMS system of record) and certification. To ensure access for audit purposes, the Department has implemented a shared folder where copies of approval emails and any time extension requests are stored, since the submission portal does not allow for attachments. Additionally, a Director of Federal Grants has been on-boarded who will assume the role of preparing the reports.
Conversion from VIMS to VIBES allowed system generated ex parte extensions beyond 12 months without requiring updated member contact or documentation. No process was in place to proactively require updated documentation when extensions exceeded one year, resulting in eligibility continuing without c...
Conversion from VIMS to VIBES allowed system generated ex parte extensions beyond 12 months without requiring updated member contact or documentation. No process was in place to proactively require updated documentation when extensions exceeded one year, resulting in eligibility continuing without current proof in file. DHS will: 1. Implementation of Annual In Person/Active Renewal for Extended Cases 2. If members fail to provide required documentation or complete the renewal process, the case is closed for failure to verify eligibility. Appropriate adverse action notices are issued in accordance with policy and timelines. 3. Staff have been instructed that eligibility determinations must not be maintained solely on a system generated extension; supporting documentation must be present in the electronic case record and/or document management system. A brief standard note template is used in VIBES to reference what documents were received, and the date eligibility was rerun. 4. System Configuration Changes with Vendor (RedMane). Worked with RedMane to adjust system logic so that eligibility cannot be approved or extended if no completed application (or renewal) is on record. 5. Updated written procedure includes, staff must confirm that a completed application (paper, phone, online, or converted electronic record) is present and imaged/recorded before approving eligibility. If the individual fails to submit required information by the due date, staff must proceed with denial/closure and document the action in case notes. 6. Conducted targeted staff training on, requirement for a completed application before approval/extension; proper use of pending status and timeframes; correct closure/denial procedures. Provided written job aids illustrating compliant workflows. 7. Implementation of Review Tracking in SharePoint, as of July 2025, an Excel tracking file housed on SharePoint is used to document: case worker name; member name and address; case number; type of case (new application, renewal, newborn, etc.). Each case is entered when assigned to the worker. 8. The supervisor reviews the case directly in VIBES, confirms eligibility determinations, and applies any needed updates. VIBES records the supervisor’s actions with date, time stamp, and staff ID to show who reviewed and approved the case. The supervisor also applies changes and documents a brief note in the VIBES notes section (e.g., “Supervisor [Name/ID] reviewed and approved eligibility determination; OK to issue Notice of Decision.”). After review, the supervisor updates the SharePoint tracker to reflect that review is complete.
The exceptions identified were limited in nature and did not result in questioned costs. In the instance where the project code on the employee's Notice of Personnel Action (NOPA) had not been updated, program personnel made the necessary adjustments to ensure payroll costs were charged to the appro...
The exceptions identified were limited in nature and did not result in questioned costs. In the instance where the project code on the employee's Notice of Personnel Action (NOPA) had not been updated, program personnel made the necessary adjustments to ensure payroll costs were charged to the appropriate grant. To strengthen internal controls, the Department transitioned from manual timekeeping to a biometric finger-punch time and attendance system utilizing TimeForce in the fall of 2024. This system provides enhanced tracking, reporting, and record retention capabilities and reduces the risk of discrepancies associated with manual timekeeping processes. The Department will continue to strengthen its review and documentation procedures to ensure compliance with federal requirements. The Department of Human Services (DHS) adopted the electronic Timeforce (STATS) system for payroll, replacing manual processes. Time and attendance are approved through management levels, with payroll based on Notice of Personnel Action (NOPA) cost centers. Financial Analysts now assigned to the grant reconciles the payroll. Additionally, in order to ensure that Notices of Personnel Actions are updated on a timely basis, ensuring that salaries are charged to the respective account, DHS has implemented the following process: - Provisional Payroll Codes are requested prior to the close of the Fiscal Year by the Department of Finance through the Office of Management and Budget through the established process. - Once the codes are received, the Division of Human Resources will update the most current Personnel Distribution Sheets to reflect active employees. - The sheets will be submitted to Fiscal for certification by the CFO. - NOPA’s are updated with the provisional codes.
DHS remains in collaboration with Federal Partners relative to the required change to reflect a consolidated report for both ACL and ACF in the Payment Management System financial reporting module. All parties are in agreement that one report is required representing the financial expenditure report...
DHS remains in collaboration with Federal Partners relative to the required change to reflect a consolidated report for both ACL and ACF in the Payment Management System financial reporting module. All parties are in agreement that one report is required representing the financial expenditure reporting mirroring the core concept of the consolidation of the various grants. Relative to the pre and post expenditures, reports are submitted through the portal, represented by a submission log. There are no provisions for approval or acceptance by the Federal partners apparent in said portal. While email notices are received acknowledging receipt, a formal acceptance is not received. Conversations are ongoing with the Federal partners relative to receiving a formal notification. A Federal Grants Financial Analyst has been onboarded dedicated to the SSBG. Monthly and quarterly reports are prepared to allow for a match to all reports inclusive of Federal draws.
Once payroll is processed by the Department of Finance (DOF), a Flex Earnings Report is generated by the Analyst on each payday. A reconciliation is then performed to ensure that all employees, along with their respective fringe benefits, are accurately captured and drawn. Following this process, DO...
Once payroll is processed by the Department of Finance (DOF), a Flex Earnings Report is generated by the Analyst on each payday. A reconciliation is then performed to ensure that all employees, along with their respective fringe benefits, are accurately captured and drawn. Following this process, DOF posts the payroll to the accounting system. However, staffing has identified that deficiencies can occur in DOF’s postings, sometimes arising in periods subsequent to the actual payday. To address this, the Department of Human Services (DHS) has incorporated an internal control requiring retrospective reconciliation of accounts against the Flex Earnings Report to verify accuracy. Additionally, DHS plans to engage with DOF to better understand the underlying factors and nuances that result in discrepancies between DOF postings and the account coding reflected in the Flex Earnings Report. The Federal Grants Financial Analyst also plays a key role in ensuring that transactions are recorded in the appropriate accounting period and that costs are properly allocated. In this particular instance, no federal funds were drawn.
The Government concurs with the auditor’s findings and recommendations. Management will conduct a comprehensive review of existing internal controls related to non-payroll expenditures. DHS will update policies and procedures to ensure all costs are properly documented and comply with federal allowa...
The Government concurs with the auditor’s findings and recommendations. Management will conduct a comprehensive review of existing internal controls related to non-payroll expenditures. DHS will update policies and procedures to ensure all costs are properly documented and comply with federal allowable cost principles. DHS is committed to addressing the identified issues and maintaining ongoing compliance with federal regulations. DHS will conduct a thorough review of current internal controls and procedures related to non-payroll expenditures to identify gaps and areas for improvement. Policies will be updated to ensure all costs are properly documented and comply with federal allowable cost principles. Staff responsible for processing and approving expenditures will receive targeted training on documentation and compliance requirements. DHS will implement periodic internal audits to monitor adherence to updated procedures and promptly address any exceptions.
The Government concurs with the auditor’s findings and recommendations. Management will review current procedures to strengthen monitoring and documentation of provider eligibility for ARP Act stabilization funds. DHS is committed to improving internal controls and ensuring compliance with all progr...
The Government concurs with the auditor’s findings and recommendations. Management will review current procedures to strengthen monitoring and documentation of provider eligibility for ARP Act stabilization funds. DHS is committed to improving internal controls and ensuring compliance with all program requirements. An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, internal audits will be conducted to ensure alignment with the Federal mandates in addition to ensuring overall compliance.
Internal audits will be conducted quarterly by having OCCRS subsidy staff and Administrators review files for accuracy of eligibility and subsidy determinations. Quality staff will conduct at least 2 unannounced visits per child care facility to monitor attendance. DHS will implement a centralized, ...
Internal audits will be conducted quarterly by having OCCRS subsidy staff and Administrators review files for accuracy of eligibility and subsidy determinations. Quality staff will conduct at least 2 unannounced visits per child care facility to monitor attendance. DHS will implement a centralized, secure tracking matrix. This log will track all fraud referrals, audit start/end dates, findings, total funds identified for recovery, amounts recovered to date, and case closure signatures.
DHS has onboarded additional licensing staff which has built increased capacity to conduct provider visits for the purpose of assessing compliance with health and safety requirements. Efforts to recruit additional staff continue. A visual tracker of provider visits will be utilized to ensure visits ...
DHS has onboarded additional licensing staff which has built increased capacity to conduct provider visits for the purpose of assessing compliance with health and safety requirements. Efforts to recruit additional staff continue. A visual tracker of provider visits will be utilized to ensure visits are conducted across all providers.
A Federal Grants Financial Analyst for CCDF program has been hired and is tasked with ensuring the accuracy and submission of financial reports. Additionally, a Director of Federal Grants has been added to oversee the reporting process. Internal controls have been established, requiring final review...
A Federal Grants Financial Analyst for CCDF program has been hired and is tasked with ensuring the accuracy and submission of financial reports. Additionally, a Director of Federal Grants has been added to oversee the reporting process. Internal controls have been established, requiring final review and approval by the supervisor with final approval by the CFO or designee. Additionally, an Audit and Compliance unit has been established. Once staffed, regular monitoring will occur within the various divisions.
A Federal Grants Financial Analyst for CCDF program has been hired and is tasked with ensuring the accuracy and submission of financial reports to ensure compliance with earmarking. Additionally, a Director of Federal Grants has been added to oversee the reporting and earmarking process. Internal co...
A Federal Grants Financial Analyst for CCDF program has been hired and is tasked with ensuring the accuracy and submission of financial reports to ensure compliance with earmarking. Additionally, a Director of Federal Grants has been added to oversee the reporting and earmarking process. Internal controls have been established, requiring final review and approval by the supervisor with final approval by the CFO or designee. Additionally, an Audit and Compliance unit has been established. Once staffed, regular monitoring will occur within the various divisions.
DHS, has upgraded the child care database to more efficiently produce monthly vouchers without the historical connectivity disruptions that prevented an uninterrupted listing of provider vouchers and the associated subsidy payments. An independent audit will be conducted to verify processes, review ...
DHS, has upgraded the child care database to more efficiently produce monthly vouchers without the historical connectivity disruptions that prevented an uninterrupted listing of provider vouchers and the associated subsidy payments. An independent audit will be conducted to verify processes, review files and make recommendations. Additionally, An Audit and Compliance Unit has been established within the Fiscal Division. Staffing will include a program compliance monitor to work with the Child Care program to ensure compliance to Federal mandates.
To address the non-compliance related to the failure DHS will strengthen internal controls and governance oversight processes to ensure full compliance with Head Start Act requirements and Uniform Guidance. Specifically, DHS will: 1. Implement Monthly Financial Reporting • Develop and implement a st...
To address the non-compliance related to the failure DHS will strengthen internal controls and governance oversight processes to ensure full compliance with Head Start Act requirements and Uniform Guidance. Specifically, DHS will: 1. Implement Monthly Financial Reporting • Develop and implement a standardized process requiring monthly financial statements, including credit card expenditures, to be prepared and presented to both the Governing Board and Policy Council • Establish a recurring meeting schedule to ensure timely review • Maintain meeting minutes documenting review and approval 2. Establish Governance Training Program • Develop and implement an annual training plan for the governing body and Policy Council covering: • Financial statements and reporting • Roles and responsibilities under Head Start regulations • Oversight of Federal funds and internal controls • Maintain sign-in sheets, agendas, and training materials as documentation 3. Strengthen Audit Oversight Procedures • Require documented discussion in governing body meeting minutes demonstrating active monitoring and oversight to include: • Audit findings • Status of corrective actions
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