Corrective Action Plans

Finding 1168207 (2024-005)

Material Weakness 2024

Detroit Health Care for the Homeless Dba Advantage Health Centers

MI

Eligibility HUD Housing Programs Matching / Level of Effort / Earmarking § 200.303

AHC has revised its patient intake procedures to ensure that all required documentation is collected and verified at the point of service. An electronic eligibility checklist has been integrated into the EHR, and staff have been trained to collect alternative income documentation where appropriate. ...

AHC has revised its patient intake procedures to ensure that all required documentation is collected and verified at the point of service. An electronic eligibility checklist has been integrated into the EHR, and staff have been trained to collect alternative income documentation where appropriate. Monthly audits of ten patient files per site are conducted, and exceptions are logged and resolved within ten business days. Policies and procedures have been updated to reflect documentation and compliance standards. Ongoing monitoring and periodic staff retraining continue to support program integrity and compliance with federal requirements. Moving forward, responsibility for managing the sliding fee discount process will transition from front-desk personnel to the Revenue Cycle department to ensure stronger oversight and accountability.

View Audit 380010

Finding 1168190 (2024-001)

Material Weakness 2024

Historic South Initiative

OH

Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.318 § 200.320 § 200.324

Prospectively, Historic South will review best practices related to the contract awarding process and formal contracting arrangements for construction work. In addition, Historic South will implement policies of: 1. Requiring the solicitation of multiple bids for all construction work in excess of $...

Prospectively, Historic South will review best practices related to the contract awarding process and formal contracting arrangements for construction work. In addition, Historic South will implement policies of: 1. Requiring the solicitation of multiple bids for all construction work in excess of $10,000 2. Establishing criteria for awarding all construction work 3. Implementing formal contracting processes for all construction work

View Audit 379971

Finding 1167968 (2024-002)

Material Weakness 2024

Montana Cancer Consortium

MT

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

Finding #2024-002: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.599 – Lack Inadequate Documentation and Lack of Independent Review of Expenditures Corrective Action: We agree with th...

Finding #2024-002: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.599 – Lack Inadequate Documentation and Lack of Independent Review of Expenditures Corrective Action: We agree with the recommendation. We do currently require complete supporting documentation for all expenditures. MCC has updated the Financial Process Procedure to include language related to receipt management, and allowable and disallowed grant expenses. MCC has created a Travel Reimbursement Procedure that addresses approval of Director expenses. Timeline: This was implemented on December 1, 2025. Responsible Parties: MCC Director, Principal Investigators

View Audit 379617

Finding 1167415 (2024-007)

Material Weakness 2024

Mille Lacs County

MN

Allowable Costs / Cost Principles § 200.303 § 200.403

Finding Number: 2024-007 Finding Title: Allowable Costs/Cost Principles – Cost Allocation Plan Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: The County has contracted with a new vendor to prepare its Cost Allocation Plan effec...

Finding Number: 2024-007 Finding Title: Allowable Costs/Cost Principles – Cost Allocation Plan Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: The County has contracted with a new vendor to prepare its Cost Allocation Plan effective in 2025. Anticipated Completion Date: Completed August 2025

View Audit 378497

Finding 1167286 (2024-001)

Material Weakness 2024

Central Texas Electric Cooperative, Inc.

TX

Allowable Costs / Cost Principles Subrecipient Monitoring Equipment & Real Property Management § 200.303

The Cooperative submitted the reimbursement request to the Federal Emergency Management Agency (FEMA) for equipment costs based on a conservative (less cost) approach using actual mileage costs. The hourly data submitted to FEMA was identified as not used for the reimbursement request. This informat...

The Cooperative submitted the reimbursement request to the Federal Emergency Management Agency (FEMA) for equipment costs based on a conservative (less cost) approach using actual mileage costs. The hourly data submitted to FEMA was identified as not used for the reimbursement request. This information was only provided to demonstrate that the mileage-based cost was less than the hourly calculation. The hourly reimbursement data was a draft and it was indicated that the costs for aerial/digger equipment units were not included. FEMA opted to change the request to use the hourly calculation just prior to the submission deadline leaving no time for further discussion or analysis. A fully completed hourly based cost reimbursement request would have resulted in a higher requested amount and the hourly variance identified would have been negligible. Any future submissions will be based on the hourly approach and will be thoroughly reviewed.

View Audit 378311

Finding 1167122 (2024-007)

Material Weakness 2024

Pacific Forum International

HI

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320 § 200.326

Finding: Material weakness in internal control over procurement policies Questioned costs: ALN 81:113 ($31,120) ALN 19.901 ($15,000) Corrective action: While PFI accepts the finding and the rationale for identifying questioned costs based on Uniformed Guidance (UG) requirements for documentation reg...

Finding: Material weakness in internal control over procurement policies Questioned costs: ALN 81:113 ($31,120) ALN 19.901 ($15,000) Corrective action: While PFI accepts the finding and the rationale for identifying questioned costs based on Uniformed Guidance (UG) requirements for documentation regarding competitive bidding and contract types, it believes there is adequate documentation to justify incurred costs. PFI will update its procurement policy guidelines to reflect current UG requirements to include acquisition thresholds and competitive bidding procedures. Completion Date: February 1, 2026 Responsible Individual: Executive Director

View Audit 378170

Finding 1167121 (2024-006)

Material Weakness 2024

Pacific Forum International

HI

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

Finding: Significant deficiency in internal control over federal cash drawdowns Corrective action: Pacific Forum has adopted new financial controls policies to ensure federal cash drawdowns are completed in a timely manner and reviewed by management. The Director of Development prepares a financial ...

Finding: Significant deficiency in internal control over federal cash drawdowns Corrective action: Pacific Forum has adopted new financial controls policies to ensure federal cash drawdowns are completed in a timely manner and reviewed by management. The Director of Development prepares a financial report that shows the amount that can be invoiced/drawn down from federal funds based on actual expenditures. The Executive Director approves the request for funds prior to submission to the funding organization. These procedures will be incorporated into PFI cash management policy guidelines. Completion Date: February 1, 2026. Responsible Individual: Executive Director

View Audit 378170

Finding 1167120 (2024-005)

Material Weakness 2024

Pacific Forum International

HI

Allowable Costs / Cost Principles Subrecipient Monitoring Material Weakness § 200.303

Finding: Material weakness in internal control over period of performance Corrective action: Pacific Forum will incorporate policies into expense management and financial reporting guidelines to ensure all expenditure is completed within the period of performance and reviews by management are proper...

Finding: Material weakness in internal control over period of performance Corrective action: Pacific Forum will incorporate policies into expense management and financial reporting guidelines to ensure all expenditure is completed within the period of performance and reviews by management are properly documented. Completion Date: February 1, 2026 Responsible Individual: Executive Director

View Audit 378170

Finding 1167119 (2024-004)

Material Weakness 2024

Pacific Forum International

HI

Allowable Costs / Cost Principles Subrecipient Monitoring Material Weakness § 200.303

Finding: Material weakness in internal control over allowable costs and compliance with requirement for written documentation of transactions review required for federally funded awards Corrective action: PFI has adopted a policy to document transaction reviews. Email approval documentation is requi...

Finding: Material weakness in internal control over allowable costs and compliance with requirement for written documentation of transactions review required for federally funded awards Corrective action: PFI has adopted a policy to document transaction reviews. Email approval documentation is required for all transactions, including initial approval by the Program Director and final approval by the Executive Director. This policy will be incorporated into PFI expense management policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director

View Audit 378170

Finding 1166810 (2024-003)

Material Weakness 2024

AVDA dba Aid to Victims of Domestic Abuse

TX

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.303 § 200.430

09.744060 Basic Field Grant Grant Period: 1/1/2024 – 12/31/2024 Contract Number: 744060 U.S Department of Justice 16.575 Victims of Crime Act Grant Periods: 10/1/23-9/30/24 and 10/1/24 – 9/30/25 Contract Number: 4055104; 4055105 Supreme Court of Texas Basic Civil Legal Services Program Grant Period:...

09.744060 Basic Field Grant Grant Period: 1/1/2024 – 12/31/2024 Contract Number: 744060 U.S Department of Justice 16.575 Victims of Crime Act Grant Periods: 10/1/23-9/30/24 and 10/1/24 – 9/30/25 Contract Number: 4055104; 4055105 Supreme Court of Texas Basic Civil Legal Services Program Grant Period: 9/1/2023 – 8/31/2025 Contract Number: 26030 2024-003 Internal Controls and Compliance over Allowable Costs and Activities – Payroll (Material Weakness and Material Noncompliance) Recommendation: We recommend the Organization review its timekeeping policies and procedures and provide additional training to employees to ensure time sheets are retained for all payroll transactions to support the allocation of compensation. We also recommend the Organization review and refine its policies to reconcile the percentage of hours charged on the time sheets to the budget estimates used to bill Federal and State grantors. This should be done in conjunction with monthly or quarterly billings (or other determined regular interval), at fiscal year end, and at the end of the grant year (if different from the Organization’s fiscal year). Corrective Action: AVDA implemented a formal Timekeeping and Payroll Compliance Policy in June 2025. All employees funded by Federal or State grants are now required to complete bi-weekly electronic functional time sheets that identify time spent on tasks by budgeted grant(s). Supervisors must review and approve all time sheets prior to submission. The Director of Finance will reconcile budget estimates to actual hours monthly, and quarterly reviews will ensure accuracy in allocations. Training on grant timekeeping standards (2 CFR §200.430) was provided to all program directors and staff in July 2025. Responsible Parties: - Lisa Mikosh, Director of Finance - Marcello Gonzales, Bookkeeper - Maisha Colter, CEO (policy approval and oversight) Date Corrected: August 15, 2025

View Audit 377924

Finding 1166736 (2024-009)

Material Weakness 2024

GREAT PLAINS VETERANS SERVICES CENTER

MT

Internal Control / Segregation of Duties Cash Management Eligibility § 200.303

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There ...

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will reassign roles to ensure clear separation between allowability determinations and expenditure approvals. If staffing constraints prevent full segregation, management will ensure that the Finance Manager performs secondary reviews. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct periodic internal monitoring with documented review of approvals.

View Audit 377852

Finding 1166609 (2024-001)

Material Weakness 2024

Quitman County Board of Education

GA

Procurement, Suspension & Debarment School Nutrition Programs Subrecipient Monitoring § 200.303 § 200.318 § 200.320

FA 2024-001 Improve Controls over Procurement Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: AL Numbers and Titles: Federal Award Numbers: Questioned Costs: Procurement and Suspension and Debarment Material Weakness Material Noncompl...

FA 2024-001 Improve Controls over Procurement Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: AL Numbers and Titles: Federal Award Numbers: Questioned Costs: Procurement and Suspension and Debarment Material Weakness Material Noncompliance U.S. Department of Agriculture Georgia Department of Education 10.553 - School Breakfast Program 10.555 - National School Lunch Program COVID-19 - 10.555 - National School Lunch Program 10.582 - Fresh Fruit and Vegetable Program 245GA324N1199 (Year: 2024) 245GA324L1603 (Year: 2024) 245GA324l1603 (Year: 2024) $5,380.74 Description: A review of expenditures charged to the Child Nutrition Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that the School District's procurement procedures were followed. Corrective Action Plans: Implement a standardized procurement checklist that must be completed. Procurements will require two levels of review (program level review by child nutrition staff and District level) to confirm compliance before processing payments. District will provide staff training to ensure federal procurement regulations, district procurement policies along with documentation and recordkeeping requirements are being met. The finance department will conduct quarterly internal reviews of Child Nutrition expenditures to verify compliance. Estimated Completion Date: November 10, 2025 Contact Person: Jon Erik Jones, Superintendent Telephone: 229.321-1487 Email:jones@quitman.ki2.ga.us

View Audit 377591

Finding 1166577 (2024-019)

Material Weakness 2024

State of California

CA

Period of Performance § 200.303

California Department of Fish and Wildlife • The Accounting Services Branch (ASB) will document the process by updating the respective desk procedures to clearly direct staff to only approve vouchers with dates consistent with the Project ID start and end date as identified on the FI$Cal Crosswalk. ...

California Department of Fish and Wildlife • The Accounting Services Branch (ASB) will document the process by updating the respective desk procedures to clearly direct staff to only approve vouchers with dates consistent with the Project ID start and end date as identified on the FI$Cal Crosswalk. • Ensure new staff within ASB are trained on the desk procedures before they begin approving vouchers in FI$Cal. Estimated Implementation Date: March 31, 2026 Contact: Jing Lin, Branch Chief, Accounting Services Branch California Department of Transportation The Division of Research, Innovation and System Information staff have developed the following corrective actions in response to the audit finding: TEC Charging Guidance and Training To ensure research project Contract Managers properly code a Travel Expense Claim (TEC), the following guidance and training actions will be implemented. • The Division’s Contract Manager Handbook and Training documentation will be updated to provide staff with guidance ensuring that TEC charging information aligns with the fiscal year (FY) in which the travel expenses occurred. • DRISI Contract Managers and their first- and second-line supervisors will be trained on the change and will receive the annual reminder. A record of attendance of training will be maintained. • New hires will receive TEC charging practices training within 30 days of their start date. Annual TEC Coding Reminder To ensure TECs are coded accurately to the correct Federal Project Number, an annual email reminder will be sent to DRISI staff beginning in the month of May for coding/charging TECs. • The reminder will instruct staff to code and charge TECs to the fiscal year and federal project number in which the expense was incurred. • A list of tasks and project IDs will be attached to the email to minimize errors and ensure consistency. In addition, the program will send a reminder to the TEC/Accounting Office to: • Charge and post TECs and non-encumbered Operating Expense (OE) charges to the fiscal year in which they were incurred. • This process will help avoid audit findings related to charges being posted to the incorrect fiscal year or federal award number. Estimated Implementation Date: March 31, 2026 Contact: Chief, Division of Research, Innovation and System Information

View Audit 377562

Finding 1166576 (2024-020)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303

The Cal OES Recovery Financial Administration Branch (FAB), which oversees Public Assistance funds, has revised its existing FFATA reporting procedures and has taken several actions to strengthen internal controls, resolve discrepancies among reporting systems, and ensure staff are fully trained to ...

The Cal OES Recovery Financial Administration Branch (FAB), which oversees Public Assistance funds, has revised its existing FFATA reporting procedures and has taken several actions to strengthen internal controls, resolve discrepancies among reporting systems, and ensure staff are fully trained to maintain compliance with all FFATA reporting requirements. In March of 2025, the Cal OES FAB developed the FAB FFATA SOP (attachment #2) for FFATA reporting which outlines steps for collecting subrecipient data, preparing reports, and submitting reports within the required time frames. In addition, the Cal OES FAB enhanced their existing FFATA reporting procedures using Salesforce to provide accurate data reports for federally funded grant projects. These reports are then used to ensure accurate reporting and timely updates to existing FFATA records. Furthermore, in July of 2025, Cal OES FAB was provided a comprehensive FFATA training course to ensure staff understand the process and reporting requirements for FFATA. The Recovery FAB analysts are responsible for submitting FFATA reporting and ensuring that all required fields are completed accurately. FFATA reporting is performed by Cal OES FAB analysts and is reviewed and approved by their respective peer reviewers and manager to verify accuracy and complete reporting. Estimated Implementation Date: Implemented Contact: • Heidi Palchik, Chief • Recovery Financial Administration Branch lnteragency Recovery Coordination Section Recovery • California Governor's Office of Emergency Services

View Audit 377562

Finding 1166572 (2024-018)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring § 200.303 § 200.332

• In collaboration with the Watershed Restoration Grants Branch (WRGB), the Budget Branch, Federal Assistance Section (FAS) will revise the Subrecipient Risk Assessment (DFW 870) to capture all elements required by 2 CFR §200.332, including identifying which subrecipients are subject to Single Audit...

• In collaboration with the Watershed Restoration Grants Branch (WRGB), the Budget Branch, Federal Assistance Section (FAS) will revise the Subrecipient Risk Assessment (DFW 870) to capture all elements required by 2 CFR §200.332, including identifying which subrecipients are subject to Single Audit requirements, obtaining and reviewing their audit reports on an annual basis, documenting verification of compliance, and ensuring timely follow-up on any corrective actions related to audit findings, as well as identifying the Assistance Listing Number and whether the award is Research and Development. • In collaboration with WRGB, FAS will create a new form to document the annual follow-up, the Subrecipient Risk Assessment (DFW 870A) to capture all elements required by 2 CFR §200.332, obtaining and reviewing their audit reports on an annual basis, documenting verification of compliance, and ensuring timely follow-up on any corrective actions related to audit findings, as well as identifying the Assistance Listing Number and whether the award is Research and Development. • FAS will establish an annual process to issue a Budget Branch memorandum to Department staff notifying them of the requirements of the DFW 870 and the DFW 870A, along with the requirements to complete the applicable forms in order for FAS to approve the use of federal funds to fund the subrecipient agreements. Estimated Implementation Date: March 31, 2026 Contact: • Nicole Nelson, Branch Chief, Budget Branch • Matt Wells, Branch Chief, Watershed Restoration Grants Branch

View Audit 377562

Finding 1166571 (2024-017)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring § 200.303 § 200.332 § 200.513 § 200.521

The Program Quality Improvement Branch (PQIB) has resolved the risk assessment application finding. Risk assessment criteria is applied and documented on all agencies annually. Documentation of the applied risk assessment is in the caseload spreadsheet. The Continuous Improvement Plan (CIP) process ...

The Program Quality Improvement Branch (PQIB) has resolved the risk assessment application finding. Risk assessment criteria is applied and documented on all agencies annually. Documentation of the applied risk assessment is in the caseload spreadsheet. The Continuous Improvement Plan (CIP) process was implemented in FY 24-25. The updated procedures have been applied for tracking. The process ensures reports are received for all programs requiring follow-up from outstanding findings identified during Contract Monitoring. FY 25-26 will be the first full year of implementation of this practice and the PQIB will conduct internal monitoring to ensure procedures are followed. A spreadsheet tracks all areas of the monitoring tool that require follow up. Additionally, the CDSS has fully adopted a process for audit report monitoring responsibilities of Local Education Agencies (LEA) and certain non-LEAs receiving Child Care and Development Fund (CCDF) Cluster program funds. This process applies to monitoring of FY24-25 audit reports and includes notifying contractors and certified public accountant (CPA) firms that the CDSS must be reported as the pass-through entity for the CCDF cluster on the Schedule of Expenditures of Federal Awards (SEFA) in single audit reports. When the CDSS audit monitoring discovers the CDE as the pass-through entity on SEFA, the CDSS will directly request the CPA to revise the SEFA. Estimated Implementation Date: Fully Corrected. Contact: • Jeff Fowler, Child Care Administration Bureau Chief • Central Operations Branch • Child Care and Development Division • California Department of Social Services

View Audit 377562

Finding 1166569 (2024-016)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

The Child Care and Development Division is working towards compliance with federal requirements for license-exempt health and safety monitoring with an anticipated completion date of July 1, 2029, assuming additional resources are secured. This plan has been outlined in Appendix A of the Federal Fis...

The Child Care and Development Division is working towards compliance with federal requirements for license-exempt health and safety monitoring with an anticipated completion date of July 1, 2029, assuming additional resources are secured. This plan has been outlined in Appendix A of the Federal Fiscal Year 2025-27 State Plan for California with Administration of Children and Families (State Plan). The State Plan can be provided upon request. Estimated Implementation Date: July 1, 2029 Contact: • Jeff Fowler, Child Care Administration Bureau Chief • Central Operations Branch • Child Care and Development Division • California Department of Social Services

View Audit 377562

Finding 1166567 (2024-015)

Material Weakness 2024

State of California

CA

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

The difference in reporting deadlines between the ACF-696 and SEFA reports will consistently result in a known discrepancy. To address this, as of September 2025, CDSS started conducting year-end reconciliations between the two reports to validate and confirm these discrepancies. Estimated Implement...

The difference in reporting deadlines between the ACF-696 and SEFA reports will consistently result in a known discrepancy. To address this, as of September 2025, CDSS started conducting year-end reconciliations between the two reports to validate and confirm these discrepancies. Estimated Implementation Date: March 2026 Contact: • Daniel During, Federal Reporting Section Chief • Accounting and Fiscal Systems Branch • Finance and Accounting Division • California Department of Social Services

View Audit 377562

Finding 1166565 (2024-014)

Material Weakness 2024

State of California

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

To ensure timely reporting, the Federal Reporting Section (FRS) has ensured that all staff understand the final deadline and all key milestones along the way. The FRS has broken down the report into smaller, manageable tasks within individual deadlines which help avoid last-minute rushes and ensure ...

To ensure timely reporting, the Federal Reporting Section (FRS) has ensured that all staff understand the final deadline and all key milestones along the way. The FRS has broken down the report into smaller, manageable tasks within individual deadlines which help avoid last-minute rushes and ensure steady progress. The FRS conducts regular check-ins to discuss progress, address any challenges early, and adjust the plan as needed to prevent delays. Estimated Implementation Date: Implemented in November 2024. Contact: • Daniel During, Federal Reporting Section Chief • Accounting and Fiscal Systems Branch • Finance and Accounting Division • California Department of Social Services

View Audit 377562

Finding 1166563 (2024-013)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303

The corrective action has already been implemented. This includes CDA hiring an employee in April 2024 to fulfill the FFATA duties, and CDA has now been able to keep current on FFATA reporting. The staff member has created FFATA procedures and caught up on the late FFATA reporting. Estimated Impleme...

The corrective action has already been implemented. This includes CDA hiring an employee in April 2024 to fulfill the FFATA duties, and CDA has now been able to keep current on FFATA reporting. The staff member has created FFATA procedures and caught up on the late FFATA reporting. Estimated Implementation Date: Currently implemented. Contact: Kim Elliot

View Audit 377562

Finding 1166558 (2024-012)

Material Weakness 2024

State of California

CA

Internal Control / Segregation of Duties Eligibility Special Tests & Provisions § 200.303

CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including s...

CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including surveys conducted by Accrediting Organizations. CHCQ has already taken steps by reiterating this requirement at a recent statewide management meeting. CHCQ will continue reminding staff of expectations at appropriate meetings and provide additional training as needed to ensure all offices follow consistent procedures when completing the required CMS 1539 forms. Headquarters management will provide oversight and conduct periodic audits to ensure staff complete and sign all CMS 1539 forms according to expectations. Estimated Implementation Date: Fiscal Year 2025-26 Contact: Nate Gilmore, State Surveyors Branch Chief, CHCQ

View Audit 377562

Finding 1166553 (2024-011)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties § 200.303

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County p...

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Through the reinstatement of county performance standards and Focused Reviews, DHCS can identify and address eligibility concerns, such as the proper use of aid codes, and work with counties through the corrective action plan process to address staff training to ensure correct eligibility determinations for all Medi-Cal programs, including pregnancy programs. Estimated Implementation Date: Fully Implemented Contact: Sarah Crow, Medi-Cal Eligibility Division, Division Chief Harold Higgins, Medi-Cal Eligibility Division, Branch Chief Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 377562

Finding 1166548 (2024-010)

Material Weakness 2024

State of California

CA

Eligibility Internal Control / Segregation of Duties § 200.303

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County p...

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Additionally, DHCS resumed the Aid Code Cleanup effort in September 2025, as outlined in MEDIL I 25-19. The purpose of the aid code cleanup effort is to assist counties in identifying records that require eligibility re-evaluation to either transition individuals to the correct Medi-Cal aid code or appropriately discontinue coverage. Through these initiatives, DHCS can identify and address eligibility concerns, such as processing timeliness and proper aid code usage. Estimated Implementation Date: Fully Implemented Contact: Sarah Crow, Medi-Cal Eligibility Division, Division Chief Harold Higgins, Medi-Cal Eligibility Division, Branch Chief Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 377562

Finding 1166546 (2024-009)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.332 § 200.414

In response to the previous audit finding, CDPH submitted the required risk assessment as of January 2025, along with supporting documentation. Moving forward, CDPH will establish formal procedures to ensure that all required federal award information – such as the Assistance Listings Number, Title,...

In response to the previous audit finding, CDPH submitted the required risk assessment as of January 2025, along with supporting documentation. Moving forward, CDPH will establish formal procedures to ensure that all required federal award information – such as the Assistance Listings Number, Title, and FAIN – is clearly identified in all agreements with subrecipients. Estimated Implementation Date: March 2026 Contact: • Melissa Relles • Assistant Deputy Director • Center for Preparedness and Response

View Audit 377562

Finding 1166545 (2024-008)

Material Weakness 2024

State of California

CA

Procurement, Suspension & Debarment § 200.303

CDPH is reviewing its existing procedures for verifying the suspension and debarment status of vendors prior to entering into any agreements involving federal funds. CDPH will enhance these procedures as necessary to ensure full compliance. Estimated Implementation Date: March 2026 Contact: • Meliss...

CDPH is reviewing its existing procedures for verifying the suspension and debarment status of vendors prior to entering into any agreements involving federal funds. CDPH will enhance these procedures as necessary to ensure full compliance. Estimated Implementation Date: March 2026 Contact: • Melissa Relles • Assistant Deputy Director • Center for Preparedness and Response

View Audit 377562

Corrective Action Plans

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