Corrective Action Plans

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Improve Controls over the Preparation of the Schedule of Expenditures of Federal of Awards Department’s Response: Management is in agreement with the recommendation and has updated their policy subsequent to year-end. Views of Responsible Offices and Corrective Action Plan: Management agrees with th...
Improve Controls over the Preparation of the Schedule of Expenditures of Federal of Awards Department’s Response: Management is in agreement with the recommendation and has updated their policy subsequent to year-end. Views of Responsible Offices and Corrective Action Plan: Management agrees with this and will implement the below to its financial policies and procedures manual: Post-Award Procedures - After an award has been made, the following steps shall be taken: 1.Verify the specifications of the grant or contract. The finance department shall review the terms, time periods, award amounts and expected expenditures associated with the award. A CFDA (Catalog of Federal Domestic Assistance) number shall be determined for each award. All reporting requirements under the contract or award shall be summarized. 2.Create new general ledger account numbers. New accounts shall be established for the receipt and expenditure categories in line with the grant or contract budget. 3.Gather documentation. A file is established for each grant or contract. The file contains the proposal, all correspondence regarding the grant or contract, the final signed award document and all reports submitted to the funding sources. 4.Management will prepare a SEFA and share with the auditor to determine when the schedule is presented fairly in all material respects in relation to the financial statements as a whole. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
2024-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and b...
2024-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and b) the School remained in compliance with federal requirements. Context: During our review of the school’s accounting records and internal controls, as well as through management inquiry, we noted the following: • For two of 25 accounts payable transactions tested out of the 15.044 grant, the School did provide adequate documentation to support the allowability of the expenditure. • For three of 25 accounts payable transactions tested out of the 15.046 grant, the School did provide adequate documentation to support the allowability of the expenditure. Repeat Finding: Repeated and modified. Action planned in response to the finding: The Principal will conduct an internal review of records management practices to verify that all accounts payable disbursements are properly supported. This evaluation will include random checks of purchase orders and their complete supporting documentation, once per month, to ensure accuracy, compliance, and integrity in financial operations. Keep all documents audit ready, at all times. Planned completion date for a corrective action plan: June 30, 2025 Name of the contact person responsible for corrective action: Marie Rose, Principal | Lynnette Greyeyes, Business Manager
Corrective Action Plan: Management acknowledges that federal grant revenue was recorded based on reimbursement timing rather than when related expenditures were incurred. To address this, the organization will implement procedures to ensure grant revenue is recognized in accordance with accrual acco...
Corrective Action Plan: Management acknowledges that federal grant revenue was recorded based on reimbursement timing rather than when related expenditures were incurred. To address this, the organization will implement procedures to ensure grant revenue is recognized in accordance with accrual accounting principles, aligning revenue with the period in which eligible expenditures are incurred. A year-end cutoff review will be performed to identify and record any receivables for incurred but unreimbursed costs. Additionally, grant tracking schedules and reconciliation processes will be enhanced to ensure accurate and timely revenue recognition. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: December 31, 2025
Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with ...
Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with federal cost principles. Actions include: • Enforcing segregation of duties within the AP workflow. • Implementing standardized invoice naming conventions. • Requiring secondary review for all grant-related invoices. • Conducting quarterly post-payment audits to detect and correct errors. • Implementing ERP system enhancements to flag potential duplicates. • Hiring an AP Manager to manage and improve the AP processes. Responsible Staff Chief Financial Officer (CFO) Target Completion Date June 30, 2026
􀀫􀁎􀁓􀁉􀁎􀁓􀁌􀀅􀀗􀀕􀀗􀀙􀑛􀀕􀀕􀀖􀀟 Significant deficiency in internal controls over financial reporting related to the recognition of grant and contract receivables and inventory Contact Person NAME: Keeley Foley PHONE: 206.381.0883 E-Mail: keeley.foley@aahi.org Explanation and Specific Reasons for Disagreement with...
􀀫􀁎􀁓􀁉􀁎􀁓􀁌􀀅􀀗􀀕􀀗􀀙􀑛􀀕􀀕􀀖􀀟 Significant deficiency in internal controls over financial reporting related to the recognition of grant and contract receivables and inventory Contact Person NAME: Keeley Foley PHONE: 206.381.0883 E-Mail: keeley.foley@aahi.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned Access to Advanced Health Institute’s (AAHI’s) response to the recommendation: 1. Engage Escalon Financial Services to review/update policies and procedures for grant receivable recognition per GAAP (FASB ASC 958) and Uniform Guidance (distinguish unconditional versus conditional grants, proper cutoff/revenue recognition) 2. Implement quarterly independent review of year-end receivable balances and revenue entries by Escalon. 3. Conduct training for finance staff on GAAP grant recognition (completion tracked via signed attendance sheets) (Escalon is GAAP trained and certified) 4. Test 100% of material grant receivables at next fiscal year-end close for proper recognition (Ensure process is full proof and no deviations of process in prior fiscal year occurred) 5. In addition, AAHI will implement controls over recognition of inventory Responsible party: Escalon with Operations Director and Keeley Foley(oversight) Anticipated Completion Date May 2026 􀀫􀁎􀁓􀁉􀁎􀁓􀁌􀀅􀀗􀀕􀀗􀀙􀑛􀀕􀀕􀀗􀀟 Significant deficiency in internal control over compliance and compliance as it relates to allowable costs and activities Contact Person NAME: Keeley Foley PHONE: 206.381.0883 E-Mail: keeley.foley@aahi.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned AAHI’s response to the recommendation: 1. Formalize written policies and procedures for allowable costs per 2CFR 200 Subpart E (necessary, 206.381.0883 222 5th Ave N, Seattle,WA 98109 www.aahi.org reasonable, allocable, documented). 2. Require pre-expenditure requisition approval by Principal Investigator (PI) for all grant-related expenses (tracked in project management system). 3. Mandate dual review and recertification of invoices and drawdowns: PI and Director of Operations (documented sign-off required before payment/submission) 4. Perform monthly compliance reconciliations (grant budget vs. actual expenditures) with variance resolution documented. 5. Deliver annual training, and otherwise as needed, to PIs and staff on allowable/unallowable costs (tracked via attendance and quiz scores above 80%) 6. Conduct quarterly internal monitoring of 25% sample of grant expenses for allowability and compliance. Responsible party: Keeley Foley (oversight), Director of Operations (daily enforcement), Escalon (support) Anticipated Completion Date May 2026
Audit Finding: 2024-001 Non-Material Non-Compliance – Allowable Costs and Activities; 2024-002 Revenue Recognition – Material Weakness Corrective Actions: This plan outlines the steps to address the staffing shortage and implement necessary controls to ensure financial statement accuracy and complia...
Audit Finding: 2024-001 Non-Material Non-Compliance – Allowable Costs and Activities; 2024-002 Revenue Recognition – Material Weakness Corrective Actions: This plan outlines the steps to address the staffing shortage and implement necessary controls to ensure financial statement accuracy and compliance. Phase 1: Immediate Actions Prioritize Key Hires: The immediate priority is to recruit and hire a Controller with significant non-profit accounting experience. This individual will be crucial in designing and implementing the necessary internal controls. 1. Interim Support (If Needed): While searching for permanent staff, explore options for interim accounting support through a consulting firm or temporary staffing agency specializing in non-profit organizations. This can provide immediate assistance with critical tasks and help bridge the gap until permanent staff are in place and sufficiently trained. 2. Documented Job Descriptions: Develop detailed job descriptions for the Controller, Senior Accountant, and Staff Accountant positions. These descriptions should clearly outline the required qualifications, responsibilities, and reporting lines. Emphasis should be placed on experience with non-profit accounting principles (GAAP), fund accounting, and relevant regulations. 3. Recruitment Strategy: Implement a robust recruitment strategy that includes: ○ Posting job openings on relevant job boards (e.g., Idealist, LinkedIn, specialized non-profit job sites). ○ Networking with professional organizations (e.g., state non-profit associations, accounting professional groups). ○ Partnering with recruitment agencies specializing in non-profit finance. Phase 2: Staffing and Implementation 1. Hire Controller: Complete the recruitment process and hire a qualified Controller with proven non-profit accounting experience. 2. Hire Senior Accountant: Once the Controller is in place, begin the recruitment process for a Senior Accountant to support the Controller and manage day-to-day accounting operations. Experience with fund accounting and grant management is highly desirable. 3. Hire Staff Accountants: Recruit and hire the necessary number of Staff Accountants to handle transaction processing, reconciliations, and other accounting tasks. 4. Control Design and Implementation: The Controller, in collaboration with the Senior Accountant, will be responsible for designing and implementing the necessary internal controls. This includes: ○ Segregation of duties (e.g., authorization, custody, recording). ○ Approval processes for expenditures and journal entries. ○ Regular reconciliations of bank accounts and other key accounts. ○ Documentation of accounting policies and procedures. Phase 3: Review and Monitoring (Ongoing) 1. Training: Provide comprehensive training to all finance staff on non-profit accounting principles, internal controls, and the organization's specific policies and procedures. 2. External Review (Optional): Consider engaging an external accounting firm to review the implemented controls and provide recommendations for improvement. This can provide an independent assessment of the effectiveness of the controls. 3. Regular Monitoring: The Controller will be responsible for regularly monitoring the effectiveness of the internal controls and reporting any deficiencies to the Executive Director and the Board of Directors. 4. Policy Updates: The Controller will ensure that accounting policies and procedures are reviewed and updated regularly to reflect changes in regulations and best practices. Responsible Parties: ● Executive Director (Todd Hixson) : Overall responsibility for implementation of the plan. ● Board of Directors: Oversight and approval of the plan and budget. ● Controller: Responsible for designing, implementing, and monitoring internal controls. Timeline: Phases 1 and 2 were completed as of January 2025. As noted above, phase 3 is an ongoing process. Regular progress updates have been and will continue to be provided to the Executive Director, Finance Steering Committee, and the Board of Directors as appropriate. This Corrective Action Plan demonstrates Safe Harbor Crisis Center’s commitment to addressing the identified control deficiencies and strengthening its financial management practices. By implementing this plan, the agency will be better positioned to ensure financial accountability, transparency, and compliance in service of the mission.
Finding 2024-001 Allowable Cost Principles and Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need for ...
Finding 2024-001 Allowable Cost Principles and Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need for a formalized, written policy governing expenditures charged to federal awards. To address identified material weaknesses, Wabash is committed to implementing a comprehensive written policy by June 30, 2026. This policy will formalize the coding, review, and reporting processes for all federal expenditures. Key improvements will include: • Enhanced Internal Controls: We will establish a clear segregation of duties to ensure oversight and accuracy. • Timely Reporting: We are refining our payroll allocation process. Previously, payroll expenditures were withheld pending budget verification, which occasionally led to reporting delays. New controls will ensure that all expenditures, including payroll, are reported within the required quarterly timeframes. • Monitoring: The Controller will oversee the development of these procedures and remain responsible for ongoing monitoring and compliance. These steps will ensure our financial practices meet federal standards and provide rigorous oversight of project funds. Contact person(s): Cheryl Gaither, Controller Justin Gephart, Chief Operating Officer
Management acknowledges that a formalized process to identify and track federal expenditures for SEFA preparation was not in place during the audit period. Steps have since been taken to improve tracking and reporting of federal expenditures throughout the year. With a stable accounting team in plac...
Management acknowledges that a formalized process to identify and track federal expenditures for SEFA preparation was not in place during the audit period. Steps have since been taken to improve tracking and reporting of federal expenditures throughout the year. With a stable accounting team in place since September 2024, management has increased oversight and accountability for grant coding and federal award identification. Additionally, the implementation of Blackbaud Financial Edge in FY2027 will allow for more precise tracking of funding sources, including the ability to segment federal and non-federal expenditures within programs and generate SEFA-ready reports. These improvements will enable the Organization to prepare a complete and accurate SEFA prior to the start of future audits and ensure compliance with Uniform Guidance requirements. Actions Taken - Established internal processes to identify and track federal expenditures throughout the fiscal year - Increased review procedures over grant coding and funding source classification - Assigned responsibility for SEFA preparation and review prior to audit fieldwork - Initiated implementation of Blackbaud Financial Edge to automate and enhance federal reporting capabilities
The City will design and implement controls to ensure that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles.
The City will design and implement controls to ensure that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
Significant deficiency in internal control over compliance and compliance as it relates to allowable costs and activities. Federal Agency: All awards within the Research and Development Cluster Program Title: All awards within the Research and Development Cluster Assistance Listing Number: All award...
Significant deficiency in internal control over compliance and compliance as it relates to allowable costs and activities. Federal Agency: All awards within the Research and Development Cluster Program Title: All awards within the Research and Development Cluster Assistance Listing Number: All awards within the Research and Development Cluster Award Number: All awards within the Research and Development Cluster Award Period: All awards within the Research and Development Cluster Criteria 2 U.S. Code of Federal Regulations (CFR) 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Section 200.303 requires that each recipient of federal awards “Establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” Condition/Context for Evaluation During our audit, we tested nonpayroll costs charged to the federal awards for adherence to necessary compliance requirements and internal control over compliance requirements. Out of 25 sample selections, we noted the following related to seven sample items: - Five of seven sample items selected involved overcharges to the grants. All five showed management approval for the incorrect amounts. - One of seven sample items selected had no supporting documentation. - One of seven sample items had no management approval. Questioned Costs $1,790 Effect or Potential Effect AAHI may have charged unallowable or incorrect costs to the federal awards. Repeat Finding No. Recommendation We recommend AAHI implement the necessary internal controls to (1) ensure documentation is retained to support costs spent on federal awards and (2) ensure all costs are properly approved and for the correct amounts. Views of Responsible Officials of Auditee Management concurs with the finding and has provided the accompanying corrective action plan.
Finding 2024-002 Information on the federal program: Federal Agency: Federal Transportation Administration Pass-Through Entity: N/A Federal Program: Federal Transit Cluster Assistance Listing Number: 20.507 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs – Cost Principles...
Finding 2024-002 Information on the federal program: Federal Agency: Federal Transportation Administration Pass-Through Entity: N/A Federal Program: Federal Transit Cluster Assistance Listing Number: 20.507 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs – Cost Principles Audit Findings: Material Weakness Criteria: 2 CFR 200.403 establishes principles and standards for determining costs for federal awards carried out through grants, cost reimbursement contracts, and other agreements with state and local governments. To be allowable, under federal awards, cost must meet certain criteria: a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles. b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. c) Be consistent with policies and procedures that apply uniformly to both federally financed and other activities of the non-Federal entity. d) Be accorded consistent treatment. A cost may not be assigned to a Federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated to the Federal award as an indirect cost. e) Be determined in accordance with generally accepted accounting principles (GAAP), except, for state and local governments and Indian tribes only, as otherwise provided for in this part. f) Not be included as a cost or used to meet cost sharing or matching requirements of any other federally financed program in either the current or a prior period. g) Be adequately documented. h) Cost must be incurred during the approved budget period. Additionally, 2 CFR 200.303 indicates that non-Federal Entities receiving Federal awards must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations and terms and conditions of the Federal award. The Corporation should have controls in place to document that salaries and overtime paid with federal funds were allowable. Timecards supporting hours worked should be approved and pay rates reviewed. Condition and Context: A summary of allowable charges for the grant was prepared for submission. Within the sample of 42, we noted that 9 timecards for bus operators did not have documented review. Documented review was implemented in September 2024. All instances of the error were prior to September 2024. We also noted 1 timecard showed 2 hours more than reflected on the pay register, resulting in a net underpayment. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. Each department is responsible for ensuring proper timecard records with approval are maintained. A documented review process for bus operators was implemented over timecard records in September 2025. Payroll is responsible for ensuring that the appropriate number of hours are paid to each employee. Additional review will be performed prior to issuance of pay checks to ensure that the appropriate number of hours are being paid.
Finding 2024-002: Allocation of Payroll Costs - Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance – Allowable Costs/Cost Principles Program: U.S. Department of Health and Human Services – Medicaid Cluster Response and Corrective Action Plan: Management acknowle...
Finding 2024-002: Allocation of Payroll Costs - Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance – Allowable Costs/Cost Principles Program: U.S. Department of Health and Human Services – Medicaid Cluster Response and Corrective Action Plan: Management acknowledges that documentation supporting payroll allocations for PATH CITED-related activities did not fully align with Uniform Guidance expectations for federal awards. However, similar to Finding 2024-001, the Organization was not aware that PATH CITED funding constituted federal assistance during FY2024 due to the absence of federal identifiers in grant documentation and related communications from DHCS. As such, payroll costs were managed under the Organization’s standard operational practices rather than federal compliance-specific requirements. The Organization applied a reasonable and consistent allocation methodology based on supervisory oversight and expected levels of effort, which management believes appropriately reflected the work performed, given the nature of the program at that time. Upon confirmation of the federal nature of the funding, management will take the following corrective actions which includes enhancing a time attestation/time studies process for personnel working on federal awards and strengthening policies requiring periodic after-the-fact review of payroll allocations and documentation retention requirements for supervisory approvals. Anticipated Completion Date: by June 30, 2026 Responsible Person: Virginia Lui VP, Controller
Planned Corrective Action: The Division will implement their control of ensuring that they only charge allowable costs incurred during the approved budget period of a federal award’s period of performance or will obtain authorization from the grantor for any costs incurred before the grant's approve...
Planned Corrective Action: The Division will implement their control of ensuring that they only charge allowable costs incurred during the approved budget period of a federal award’s period of performance or will obtain authorization from the grantor for any costs incurred before the grant's approved budget period. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Controller
Planned Corrective Action: The Division will design and implement a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Co...
Planned Corrective Action: The Division will design and implement a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Controller
VIDCOE will establish and document capitalization thresholds and procedures for identifying, recording, and depreciating capital assets, including maintaining a fixed asset register with periodic reconciliations. Procedures will also be implemented to ensure prepaid expenses are recorded appropriate...
VIDCOE will establish and document capitalization thresholds and procedures for identifying, recording, and depreciating capital assets, including maintaining a fixed asset register with periodic reconciliations. Procedures will also be implemented to ensure prepaid expenses are recorded appropriately and amortized over the periods benefited. In addition, grant accounting policies will be strengthened to ensure that funds received in advance are recorded as refundable advances and recognized as revenue only as allowable expenditures are incurred, in compliance with grant agreements and federal requirements. To further strengthen internal controls, VIDCOE will implement formal supervisory review and reconciliation procedures, including routine account reconciliations and financial statement reviews, to ensure transactions are properly classified, supported, and recorded. VIDCOEs’ Management expects to fully implement all corrective actions by July 30, 2026.
Finding No.: 2024-053 Special Test and Provisions – Project Accounting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures in compliance with applicable spec...
Finding No.: 2024-053 Special Test and Provisions – Project Accounting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures in compliance with applicable special tests and provision requirements. GHS will also identify department personnel responsible.
Finding No.: 2024-051 Period of Performance Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures over compliance with applicable period of Performance require...
Finding No.: 2024-051 Period of Performance Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures over compliance with applicable period of Performance requirements, as well as retention of all grant agreements. GHS will also identify department personnel responsible.
Finding No.: 2024-049 Activities Allowed or Unallowed: Allowable Costs/Cost Principles Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director Guam Homeland Security (GHS) will make sure that proper supporting documentation is available. GHS will also identify...
Finding No.: 2024-049 Activities Allowed or Unallowed: Allowable Costs/Cost Principles Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director Guam Homeland Security (GHS) will make sure that proper supporting documentation is available. GHS will also identify department personnel responsible.
Finding No.: 2024-046 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS disagrees with this finding and provided documentation of grantor approval to use the FY 2024 award to pay prior year obligati...
Finding No.: 2024-046 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS disagrees with this finding and provided documentation of grantor approval to use the FY 2024 award to pay prior year obligations. The enclosed communication from Linda Gee, CMS, dated July 1, 2021, provides more information. 45 CFR 95.7 (https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.95&rgn=div5#se45.1.95_17) provides that a state Medicaid agency (i.e. Guam Medicaid Agency) has up to two years to file for a claim that it made. DPHSS welcomes the opportunity to discuss and collaboratively identify the relevant information and guidance during an entrance conference for each year’s audit.
Finding No.: 2024-040 Activities Allowed or Unallowed: Allowable Costs/Cost Principles Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. The questioned tran...
Finding No.: 2024-040 Activities Allowed or Unallowed: Allowable Costs/Cost Principles Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. The questioned transactions relate to a major system migration from the AS400 to the D365 system, which temporarily impacted the traceability of certain records. During this transition, some data identifiers were reformatted to fit the new system's structure. However, this was a synchronization issue rather than a lack of oversight, and BCCS maintains that all costs are allowable, necessary, and reasonable under CCDF requirements. Supporting documents exist and were provided after a subsequent request on February 9, 2026, via One Drive link.
Finding No.: 2024-038 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS ELC Program disagrees with the findings. Condition 1: The questioned labor costs of $16,668 align with payment of Core funded ...
Finding No.: 2024-038 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS ELC Program disagrees with the findings. Condition 1: The questioned labor costs of $16,668 align with payment of Core funded staff during that approved budget period for BP01. The PPE coincides with two draws for the ending and beginning of those fiscal years. Supporting documents were submitted twice, once on February 9, 2026, and February 20, 2026, including the Notice of Award (NOA) for this grant with issue date of July 9, 2024. Condition 2: The question of compliance with period of performance was justified through supporting documentations as reflected in the NOAs and extensions of NOAs which were provided twice February 9, 20206 and February 23, 2026. Program also noted that core funds have expanded authority to be utilized in subsequent budget periods throughout the 5-year cycle of the Cooperative Agreement. Upon auditor’s review, a correspondence email noted that the documents were received and findings were removed for all but on expense. Although all supporting NOAs were submitted for every expenditure amount, a follow up email with the last NOA for 6NU50CK000561-05-00 was provided again as an attachment.
Finding No.: 2024-035 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Guam EPA has implemented processes relevant to the monitoring and reconciliation of program income. As part of our Correction Action for the FY2023 ...
Finding No.: 2024-035 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Guam EPA has implemented processes relevant to the monitoring and reconciliation of program income. As part of our Correction Action for the FY2023 audit, which is a repeat finding in FY2024, Guam EPA is attaching a sample report of all program income collected through the Transaction Processing System (TPS) to include external payments received by DOA. Also, variances not captured by this report, consisting of payments/transactions submitted directly to DOA via electronic method of payments, are being reconciled by our staff and DOA.
Finding No.: 2024-034 Period of Performance Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Request to DOA will require immediate collaboration between Guam EPA and DOA to gather, reconcile, and provide all supporting documentation t...
Finding No.: 2024-034 Period of Performance Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Request to DOA will require immediate collaboration between Guam EPA and DOA to gather, reconcile, and provide all supporting documentation to support compliance with the period of performance in question.
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