Corrective Action Plans

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Finding: The Housing Finance Commission did not have adequate internal controls over earmarking requirements for the Homeowner Assistance Fund program. Questioned Costs: Assistance Listing # 21.026 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Commission h...
Finding: The Housing Finance Commission did not have adequate internal controls over earmarking requirements for the Homeowner Assistance Fund program. Questioned Costs: Assistance Listing # 21.026 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Commission has taken the following corrective actions to strengthen controls over earmarking requirements for the Homeowner Assistance Fund (HAF) program: • Developed a system to track and monitor expenditures in relation to overall program expenditures to ensure earmarking requirements are within allowable parameters. • Selected an increased percentage of approved, denied, and withdrawn HAF applications that have previously been reviewed by the contractor, as part of the Quality Control process, for a secondary review by program staff. • Reviewed a selection of HAF applications independent of the Quality Control process performed by the contractor. • Reviewed a selection of approved HAF applications prior to disbursing funds to confirm eligibility determinations are proper. The conditions noted in this finding were previously reported in finding 2023-023. Completion Date: October 2024 Agency Contact: Lucas Loranger Senior Finance Director 1000 Second Ave, Suite 2700 Seattle, WA 98104-3601 (206) 464-7139 Lucas.Loranger@wshfc.org
Finding: The Employment Security Department did not have adequate internal controls over and did not comply with federal requirements to conduct case reviews for the Benefit Accuracy Measurement program of the Unemployment Insurance program in a timely manner. Questioned Costs: Assistance Listin...
Finding: The Employment Security Department did not have adequate internal controls over and did not comply with federal requirements to conduct case reviews for the Benefit Accuracy Measurement program of the Unemployment Insurance program in a timely manner. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department is committed to ensuring our Benefit Accuracy Measurement (BAM) program complies with federal regulations. Historically, the BAM unit has been challenged to maintain full levels of staffing. Staff turnover, lengthy training requirements, and unique skill sets make these positions difficult to maintain. The Department has implemented changes to position descriptions which have resulted in the hiring and retention of qualified staff. As a result, the unit has improved its case sampling timelines by implementing regular case reviews to ensure the 60-day, 90-day, and 120-day timelines are met. Additionally, the Department, in collaboration with the U.S. Department of Labor (USDOL), developed a State Quality Service Plan (SQSP) which includes metrics to improve program outcomes. The team has implemented additional internal communication to follow up on cases which are approaching the 120-day timeline. Although the 120-day timeline is not an improvement measure listed on the SQSP, the Department will continue to work with USDOL to implement guidance and processes to meet the 120-day requirement. The conditions noted in this finding were previously reported in findings 2023-009, 2022-006, 2021-005, and 2020-011. Completion Date: January 2025 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov
Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in Februar...
Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the hospital offline from processing claims. These two events resulted in the financial statement audit requiring significantly more time to complete resulting in the Hospital’s financial statements and compliance audits for June 30, 2024 reporting period not being filed within the required timeline. Views of responsible officials and planned corrective actions The financial statement and compliance audit will be filed with the Federal Audit Clearinghouse shortly after issuance. Anticipated completion date Ongoing
Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in Februar...
Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the hospital offline from processing claims. These two events had a negative and material impact on overall operating results as additional accounts receivable allowances for both contractual adjustments and bad debts were necessary at June 30, 2024. The negative impact on overall operations resulted in the Hospital not meeting the required 1.5 debt service coverage ratio and having less than 90 days of cash on hand at June 30, 2024. The Hospital did receive a waiver for from the USDA regarding not meeting these loan covenants for fiscal year 2024. Views of responsible officials and planned corrective actions The implementation of the new electronic health records created a delay in operational workflow processes which required vendor modifications and corrections to the system. This delayed submitting insurance claims for reimbursement continued throughout fiscal year 2024. Operations have now stabilized and the debt service coverage ratio is expected to be in compliance in fiscal year 2025. Hospital management notified its USDA representatives and received a waiver from the required 1.5 debt service coverage ratio and required 90 days of cash on hand for the period ended June 30, 2024. Anticipated completion date Ongoing
Finding 558311 (2024-062)
Significant Deficiency 2024
Each health plan reports TPL recoveries to EOHHS in its quarterly financial report (FDCR). These recoveries are used as a direct offset to medical expenses. As such, claims paid by the plans on behalf of a member with TPL will remain in the EOHHS encounter data warehouse. Health plans do not void...
Each health plan reports TPL recoveries to EOHHS in its quarterly financial report (FDCR). These recoveries are used as a direct offset to medical expenses. As such, claims paid by the plans on behalf of a member with TPL will remain in the EOHHS encounter data warehouse. Health plans do not void claims that have previously been paid to account for any TPL liability. Rather, they seek to recover from the third party any amount owed and report that amount to the state. In each of the last two fiscal years, this reduced medical expenditures by just under $8 million. 2025 Update: Following the process from 2023 and 2024, we are requesting a new TPL files from Gainwell that will be shared to each MCO. Anticipated Completion Date: Ongoing Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov
Management agrees with the finding regarding inaccurate calculations. Management disagrees with the finding regarding information about DCYF children in the system. The Office of Child Care (OCC) is continually reviewing available training materials related to CCAP eligibility and case processing ...
Management agrees with the finding regarding inaccurate calculations. Management disagrees with the finding regarding information about DCYF children in the system. The Office of Child Care (OCC) is continually reviewing available training materials related to CCAP eligibility and case processing and has identified certain gaps where additional training/clarification, and more frequent communication to processing staff is needed – specifically in income calculation/input of paystubs, confirming asset declarations, and confirming need hours. OCC is working with the DHS training department to create a CCAP-specific training to provide in-depth coverage of program requirements. OCC continues to present at quarterly meetings to highlight error findings and the critical importance of accurate documentation. In addition, the CCAP administrator works continuously with field staff and Deloitte through weekly theme meetings to identify areas where system changes can improve accuracy of eligibility determinations. OCC is currently reviewing the grace period/short-term approval policy, how it is applied to specific cases, and how it is implemented in RIBridges. The finding has been escalated from the CCAP administrator to the assistant director of the Office of Child Care to ensure continued collaboration from all facets of the eligibility work to continue to improve errors in determination. Anticipated Completion Date: Ongoing – will continue to see a decline in errors in eligibility approval. Contact Person: Nicole Chiello, Assistant Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov
View Audit 355126 Questioned Costs: $1
System changes to modify the time schedule that RIBridges interfaces with SWICA for processing tasks has already been submitted (RIB-141767). Currently, the interface occurs twice yearly. This will increase the frequency to quarterly. Anticipated Completion Date: October 31, 2025 Contact Person:...
System changes to modify the time schedule that RIBridges interfaces with SWICA for processing tasks has already been submitted (RIB-141767). Currently, the interface occurs twice yearly. This will increase the frequency to quarterly. Anticipated Completion Date: October 31, 2025 Contact Person: Donna Rook, Administrator, Family and Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov
View Audit 355126 Questioned Costs: $1
Finding 558218 (2024-036)
Significant Deficiency 2024
RIDE’s Office of School Health & Wellness will develop a guidance document for LEAs regarding Paid Lunch Equity calculations and send communication at least annually to ensure LEAs have complied with 7 CFR Sec. 210.14(e). Anticipated Completion Date: June 30, 2026 Contact Persons: Brandon Bohl, Fi...
RIDE’s Office of School Health & Wellness will develop a guidance document for LEAs regarding Paid Lunch Equity calculations and send communication at least annually to ensure LEAs have complied with 7 CFR Sec. 210.14(e). Anticipated Completion Date: June 30, 2026 Contact Persons: Brandon Bohl, Finance Director, Department of Elementary and Secondary Education brandon.bohl@ride.ri.gov Rosemary Reilly-Chammat, Director – Office of School Health & Wellness, Department of Elementary and Secondary Education rosemary.reilly-chammat@ride.ri.gov Jennifer Goodwin, School Health Specialist, Department of Elementary and Secondary Education jennifer.goodwin@ride.ri.gov
Finding 558213 (2024-035)
Significant Deficiency 2024
To eliminate the issue with stock discrepancies, the Central Distribution Center (CDC) will be incorporating updated software targeted toward minimizing inventory errors with the receipt, storage, and distribution of all commodities that come into the CDC. The CDC recently implemented handheld scan...
To eliminate the issue with stock discrepancies, the Central Distribution Center (CDC) will be incorporating updated software targeted toward minimizing inventory errors with the receipt, storage, and distribution of all commodities that come into the CDC. The CDC recently implemented handheld scanners for tracking purposes and stock management. The scanners have new upgrades that are designed to improve inventory picking procedures. The CDC is currently in the process of making this upgrade into our system and expects to have this fully implemented by May 31, 2025. In addition to the new software, we are at the beginning stages of a warehouse reorganization which will include a new storage location labeling system which is being designed with the intention of creating a more structured storage system for all products. In conjunction with the handheld scanners, the labeling system will include barcodes for inventory which will be matched to storage location. These labels are magnetic, durable, and removable and can be repositioned to any rack location in the warehouse as needed. We will immediately start automated cycle counts daily to detect and correct discrepancies early to ensure all issues with inventory are caught and addressed as early as possible. Similarly, the CDC will also be implementing a quarterly full inventory count with the first one occurring no later than May 31, 2025. Stock discrepancies are a major challenge but by incorporating the right strategies they can be eliminated. By leveraging automation, enforcing standard procedures, and continuously monitoring inventory we will improve our inventory efficiency. Anticipated Completion Date: May 31, 2025 Contact Persons: Terrence McNamara, Administrator Physical Resources, Department of Corrections terrence.mcnamara@doc.ri.gov Matthew Wiencis, Chief Distribution Officer, Department of Corrections matthew.wiencis@doc.ri.gov
2024-002: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging – Title III, Part B- Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part C1 – Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting (Sign...
2024-002: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging – Title III, Part B- Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part C1 – Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting (Significant Deficiency) Condition The 13th Aging Monthly Report required by the pass-through agency, Virginia Department of Aging and Rehabilitative Services (VDARS) contained inaccurate revenue and expenditure data which did not agree to the general ledger. Criteria VDARS requires the annual 13th Month Aging Monthly Report to be submitted by November 15th. The report must contain complete and accurate information as a restating of the monthly reporting for the fiscal year. Cause The 13th Aging Monthly Report was not reconciled to underlying financial records, resulting in unexplained differences between the report and trial balance provided as part of the audit. Inaccurate reporting of such revenues and expenditures did not impact the outcome of requirements of the Agency to meet level of effort metrics as required under the grant awards. Effect The submission of the 13th AMR included data that did not agree to underlying financial records. This should have been caught during the course of a review process before submission. Therefore, it is considered a significant deficiency of internal controls over compliance. Repeat Finding 2013-01 Recommendation Ensure reporting is submitted accurately by the deadline stated by VDARS. Implement a review process for each monthly submission, including documentation of the review. Reconcile the federal, state and local totals reported in the Aging Monthly Report to the underlying financial records as stated in the financial system to ensure accuracy before submission to VDARS. Planned Corrective Action Management agrees with the finding. Management plans to implement a process to ensure that the AMR report will be submitted accurately.
We have reviewed the control procedures around preparation and review of the schedule of expenditures of federal awards (SEFA) and implemented an independent review of the assistance listing numbers (ALN) per the grant agreements in the initial review of the SEFA. The improved procedures will provid...
We have reviewed the control procedures around preparation and review of the schedule of expenditures of federal awards (SEFA) and implemented an independent review of the assistance listing numbers (ALN) per the grant agreements in the initial review of the SEFA. The improved procedures will provide the needed structure to fulfill management's responsibility to accurately report the grantor agency / pass-through grantor, assistance listing number, federal program name and number, and expenditures. Identification of major programs, utilizing the guidelines in the Office of Management and Budget's (OMB) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) are the responsibility of the auditor.
Institutional Comments on Findings and Recommendations: The institution is fully aware of the Enrollment Reporting requirements and deadlines. The institution agrees with the auditor that there were two (2) cases where the enrollment status was reported late and three (3) cases where the auditors we...
Institutional Comments on Findings and Recommendations: The institution is fully aware of the Enrollment Reporting requirements and deadlines. The institution agrees with the auditor that there were two (2) cases where the enrollment status was reported late and three (3) cases where the auditors were unable to verify that changes in student status were reported. The institution informed the auditors that its current policy and procedure is to report all changes to student status monthly instead of every two months as established by the NSLDS reporting schedule to avoid cases on non or late reporting. Since the institution does not maintain copies of the report of enrollment changes that it submits to NSLDS and since the current NSLDS database does not maintain students that are inactive, it was unable to evidence the changes or updates that were made for these students to the auditors. Actions Taken or Planned: The institution has already discussed this issue as observed by the auditors with the officer in charge ofNDSLS Enrollment reporting. The institution would continue with its policy to submit Enrollment Reports monthly to update and notify changes to student's enrollment status more effectively and to avoid cases of late or non-compliance. Status of Corrective Actions on Prior Findings: Some of the issues related to this finding occurred in the past audit.
This finding is related to activities on our VOCA grants. This finding is related to Finding 2024-001. 4 invoices were not approved by management. FRLS’s AP policy that was adopted in September 2024 allowed us to skip separate management approval in cases of recurring invoices such as utilities and ...
This finding is related to activities on our VOCA grants. This finding is related to Finding 2024-001. 4 invoices were not approved by management. FRLS’s AP policy that was adopted in September 2024 allowed us to skip separate management approval in cases of recurring invoices such as utilities and in cases where we have approved contracts such as rent payments, software subscriptions etc. This was our policy before September 2024, but it was not formalized before that date. As in the case of 2024-001. FRLS will modify its AP Policy and Procedures to remove this recurring payment exception and will now require all invoices be approved by management by routing invoices to management for approvals through the Teams automated system. Invoices over $5,000 will also be required to be approved by the Executive Director or their temporary designee. Such designation must be made in writing. This change will be made within the next 60 days.
Finding 2024-005: U.S. Department of Housing and Urban Development – CFDA #14.155 Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Applicable Federal Award Number and Year – HUD loan under section 207/223(f), HUD Project No. 101-11316 Allowable Costs/ Allowab...
Finding 2024-005: U.S. Department of Housing and Urban Development – CFDA #14.155 Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Applicable Federal Award Number and Year – HUD loan under section 207/223(f), HUD Project No. 101-11316 Allowable Costs/ Allowable Activities Name of contact Person: Renee Gallegos, Finance Manager Anticipated completion date: Completed Planned Corrective Action: • Management has updated internal controls to include that all costs charged to the project are for allowable costs.
View Audit 354976 Questioned Costs: $1
The Smithsonian agrees with the finding. The Smithsonian would like to add that the reports were delivered to the sponsor and that the sponsor was satisfied with them. Furthermore, the sponsor has provided written acknowledgment that they were “verbally kept up to date” by the National Postal Museum...
The Smithsonian agrees with the finding. The Smithsonian would like to add that the reports were delivered to the sponsor and that the sponsor was satisfied with them. Furthermore, the sponsor has provided written acknowledgment that they were “verbally kept up to date” by the National Postal Museum (NPM) regarding this potential delay. Moving forward, NPM will strengthen senior management oversight of report delivery, review due dates more rigorously, and enhance internal controls to ensure timely submission. Any potential delays will be confirmed in writing to the sponsor ahead of the due date, and compliance updates will be provided by NPM senior management to the sponsor on a regular basis. Additionally, NPM will establish procedures to cross train staff to perform required responsibilities applicable to the NPM Project.
Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have th...
Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have the right to close purchase orders with federal fund sources to expedite this process. Also, the Provider Utilization Report has been updated with Key Performance Indicators (KPIs), Contract End Date Exceeds Period of Performance and Payments Exceed Period of Performance, that specifically address the period of performance as of December 2024.
View Audit 354902 Questioned Costs: $1
The monthly student reconciliations for the Direct Loan programs, including the SAS files, have resumed starting with the October 2024 SAS file. These reconciliations will continue on a monthly basis by the financial aid office, as required, and will be conducted without interruption. The reconcilia...
The monthly student reconciliations for the Direct Loan programs, including the SAS files, have resumed starting with the October 2024 SAS file. These reconciliations will continue on a monthly basis by the financial aid office, as required, and will be conducted without interruption. The reconciliation process will be closely monitored, reviewed, and approved monthly by management to ensure ongoing compliance. The loan processing team has been trained on the SAS file import process and direct loan reconciliation. They have also been provided with the necessary system resources to identify variances between Common Origination and Disbursement (COD) and Banner at the student level. Additionally, the direct loan reconciliation process documentation will undergo continuous review and monitoring by the loan processing team, with oversight from the Director of Student Financial Aid and Scholarships, to ensure accuracy and adherence to established policies with each new academic year. The loan processing team will have annual refresher training at the beginning of each academic year. Confirmation of employees, date of training, and current training process will be documented.
On July 29, 2024, Georgia State University (GSU) was made aware of a National Student Loan Data System (NSLDS) reporting defect in our student information system related to program level reporting. A system correction was installed on November 25, 2024. GSU will enhance monitoring procedures to ensu...
On July 29, 2024, Georgia State University (GSU) was made aware of a National Student Loan Data System (NSLDS) reporting defect in our student information system related to program level reporting. A system correction was installed on November 25, 2024. GSU will enhance monitoring procedures to ensure discrepancies in reporting to the NSLDS are identified and corrected in a timely manner.
The student in question had a lengthy break in enrollment (2015-2024). When the student returned, CGTC’s Banner rules differed from his previous enrollment and his status was not accurately updated within the correct term. To correct the issue, CGTC has worked with colleagues at the Technical Coll...
The student in question had a lengthy break in enrollment (2015-2024). When the student returned, CGTC’s Banner rules differed from his previous enrollment and his status was not accurately updated within the correct term. To correct the issue, CGTC has worked with colleagues at the Technical College System of Georgia to identify and correct any discrepancies in the Banner rules for the Satisfactory Academic Progress (SAP) process to prevent future occurrences of this issue. The College’s Financial Aid office has identified the “cutoff” year for changes in SAP rules and has developed a procedure to manually review any students with long breaks in enrollment whose last enrollment occurred prior to the identified cutoff. This review process will help to ensure that students’ SAP status is accurately updated in the correct term.
View Audit 354902 Questioned Costs: $1
The Financial Aid Office has worked with the Registrar's Office to streamline the collection, review and processing of student who are unofficial withdrawals. Streamlining the unofficial withdrawal process will allow for timely and accurate reporting, return to title IV, and reconciliation of funds ...
The Financial Aid Office has worked with the Registrar's Office to streamline the collection, review and processing of student who are unofficial withdrawals. Streamlining the unofficial withdrawal process will allow for timely and accurate reporting, return to title IV, and reconciliation of funds between Lanier Technical College and Common Origination and Disbursement (COD).
View Audit 354902 Questioned Costs: $1
The University of Georgia acknowledges the need for increased monitoring over the return to Title IV aid for students withdrawn from the University. UGA has taken immediate corrective action and has filled key staffing vacancies and implemented additional internal controls to monitor and ensure comp...
The University of Georgia acknowledges the need for increased monitoring over the return to Title IV aid for students withdrawn from the University. UGA has taken immediate corrective action and has filled key staffing vacancies and implemented additional internal controls to monitor and ensure compliance. A self-audit of Fall 2024 revealed no non-compliance issues.
To prevent future errors, staff will undergo training to ensure accurate processing of withdrawals that occur after the term has ended. Both official and unofficial withdrawals will be evaluated based on the student's last date of attendance when the withdrawal date is after the end of term. While...
To prevent future errors, staff will undergo training to ensure accurate processing of withdrawals that occur after the term has ended. Both official and unofficial withdrawals will be evaluated based on the student's last date of attendance when the withdrawal date is after the end of term. While the Financial Aid Office (FAO) staff have adhered to the current withdrawal procedures, we recognize the need for an update to address instances when the date a student initiates the official withdrawal process is earlier than when the withdrawal is completed. To address this, we will adopt the date the student begins the withdrawal process as the official withdrawal date, if this date precedes the completion of the withdrawal form. Additionally, we will implement automated and electronic system controls to ensure withdrawals are processed accurately and within the required timelines by monitoring the full withdrawal cycle. The withdrawal policy and administrative procedures documentation will be updated to reflect these changes. Staff will have annual refresher training at the beginning of each academic year. Confirmation of employees, date of training, and training process will be documented.
View Audit 354902 Questioned Costs: $1
Georgia State University (GSU) will ensure all team members are appropriately trained related to the return to title IV process. Procedures have been enhanced to ensure that unearned funds required to be returned to the program due to return to title IV calculations are immediately reconciled and re...
Georgia State University (GSU) will ensure all team members are appropriately trained related to the return to title IV process. Procedures have been enhanced to ensure that unearned funds required to be returned to the program due to return to title IV calculations are immediately reconciled and returned during the required window. GSU has established an Assistant Director over Electronic Processing to carry out these procedures.
Georgia State University (GSU) will ensure all team members are appropriately trained related to the process for locking student financial aid records and completing verifications after the term ends. Additionally, GSU has enhanced monitoring procedures to identify changes to institutional student i...
Georgia State University (GSU) will ensure all team members are appropriately trained related to the process for locking student financial aid records and completing verifications after the term ends. Additionally, GSU has enhanced monitoring procedures to identify changes to institutional student information records after term ends with a verification indicator to ensure these accounts are resolved in a timely manner.
View Audit 354902 Questioned Costs: $1
After the September 2023 quarter, controls were put in place to ensure accurate Federal quarterly reports. These controls included preparing the report based on our accounting records, e.g. the general ledger. Another control is that the Chief Financial Officer or her designee reviews all reports an...
After the September 2023 quarter, controls were put in place to ensure accurate Federal quarterly reports. These controls included preparing the report based on our accounting records, e.g. the general ledger. Another control is that the Chief Financial Officer or her designee reviews all reports and compares them to the general ledger prior to signature, approval and our submission to the grantor. Furthermore, periodic reviews by program fiscal staff during the performance period take place to closely monitor activity. GDOL will continue to follow the updated procedures and internal controls. As we transition to GA@Work, the system itself will control overspending and provide alerts.
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