Corrective Action Plans

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Assistance listing numbers and program names 93.268 Immunization Cooperative Agreements 93.268 COVID-19- Immunization Cooperative Agreements 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) ...
Assistance listing numbers and program names 93.268 Immunization Cooperative Agreements 93.268 COVID-19- Immunization Cooperative Agreements 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Agency: Department of Health Services (DHS) Name of contact person and title: Lora Andrikopoulos , Grants Administrator Anticipated completion date: June 30, 2026 Agency’s Response: Concur ADHS will continue to work with the CQI Team, Financial Services - Assurance Team, Procurement, Program Managers, Finance Managers, Grants, and other internal partners to update the FFATA process. The process moving forward will include a communication plan, updates to the current standard work, the creation of a new standard work if necessary for the subaward communication process, and additional training.
Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS...
Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Anticipated completion date: December 31, 2027 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiatives to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for comprehensive, system-wide strategies. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Actions Taken: ● Increased scrutiny of claims based on claims volume. ● Issued a moratorium on new provider registrations for impacted provider types. ● Prevented Reimbursement of Claims for Impossibly Rendered Services. ● Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment. ● Set thresholds for services to initiate a prepayment review. ● Required claims to be billed for specific dates of service rather than ranges. ● Flagged claims for services of the same style/overlapping codes. ● Created a prepayment review process for providers utilizing suspicious billing practices. ● Eliminated retroactive billing. ● Credible Allegation of Fraud suspensions include both provider entities and owners/ behavioral health (BH) practitioners. ● Implemented ID.Me identity verification for AHCCCS Online. ● Required providers to disclose any third-party billing relationships. ● BH Providers are now considered high-risk provider types for provider enrollment. ● Per Diem codes have been set to only be able to be billed once per day. ● Practitioners, including BH Technicians, can no longer be patients at the same provider. ● Worked with the Arizona Corporation Commission to flag suspicious registrations. ● Ensured AHCCCS coding adhered to National Correct Coding Initiative standards and confirmed no edits had been turned off. ● Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. ● Creation and publication of the Covered Behavioral Health Services Guide to connect all relevant AHCCCS policies and explain how they interact in the Behavioral Health System of Care. ● Robust changes to our AHCCCS Provider Enrollment System to address fraud, waste and abuse (FWA) issues. ● Update to the Behavioral Health Residential Facilities policy (to be published shortly) to provide greater detail and clarity for providers and members about what should and should not be included in services rendered by this provider type. ● Creation of the prepayment review process for fee for service claims and inclusion of data measurement to allow for agile modification going forward to respond to over utilization or abuse of codes. ● Creation of the Community Partner Assistor Organization Reviews to prevent abuse of access to the Health-e-Arizona Plus system. ● Designated pathways of partnering on large scale quality of care investigations between the Division of Fee for Service and managed care organizations to prevent unnecessary member impact. ● Social media campaign to encourage the public to report FWA/abuse & neglect. ● Requirement of all providers to transition to Electronic Funds Transfer. ● Removed the phone attestation option for American Indian Health Program (AIHP) enrollment, and are in the process of implementing the AIHP verification process with tribal partners and Indian Health Services based on utilization. ● Memorandums of Understanding with AZ Board of BH Examiners and Board of Nursing to promote interagency information sharing and referrals, as well as the close referral relationship with the Arizona Department of Health Services. ● Regular Public BH System Cross-Agency Collaboration meetings including all agencies, boards, commissions and the GO in the public health space ● Updates to the provider enrollment policy in AMPM 610, explicitly requiring many more disclosures of providers, and making it clear without full and transparent registration information, providers will be terminated or denied enrollment with AHCCCS. ● Implemented policies which required BH Professionals, required to oversee the clinical services provided at Behavioral Health Residential Facilities and Outpatient Behavioral Health Clinics, to be reported upon registration and be listed on claims submissions ● Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements ● Linking BHP to BH companies and facilities they work for Actions Remaining (but not limited to): Implementing eligibility integrity requirements for AIHP enrollment. ● Implementation of Alivia – a new AI powered data analytics platform for pre-pay and post-pay claims analysis, currently in the development and planning stage ● Conduct onsite quality of care reviews for patients in treatment longer than 90 days. ● Require medical records to define specialized services. ● Implement a new pre/post pay claims system. AHCCCS continuously monitors our systems and investigates instances of fraud, waste or abuse. Any areas of concern which are identified are then addressed and system improvements are made. Furthermore, AHCCCS utilizes data analysis to confirm that these system improvements are having the intended impacts and that provider networks remain robust.
Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 - Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 - Child Care Mandatory and Matching Funds of the ...
Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 - Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 - Child Care Mandatory and Matching Funds of the Child Care and Development Fund Agency: Department of Economic Security (DES) Name of contact person and titles Lacie Butler, Administrative Services Officer Anticipated completion date: May 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department is revising its procedures to ensure that it receives and retains documentation to support its provider’s expenditures, including Payment Disbursed Quickly (PDQ) submitted billings. Specifically, due to PDQ system limitations the Department is implementing additional validation procedures for these payments, and restricting the use of this system to limited providers to ensure future compliance. The Department is conducting an internal audit to validate that all required PDQ submissions are on file for Fiscal Year 2025; instances of non-compliance will be resolved in the same manner as an overpayment. The Department will continue to retain all records related to a federal award for a period of 3 years from the final expenditure report submission date.
Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 Child Care Mandatory and Matching Funds of the Chil...
Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 Child Care Mandatory and Matching Funds of the Child Care and Development Fund Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will review, correct, and /or complete any incomplete or inaccurate information for its subawards on the Federal Funding Accountability and Transparency Act Subaward Reporting System. The Department will follow the State’s accounting manual for reporting subaward actions equaling or exceeding $30,000 no later than month-end of the month following the subaward action. The Department has implemented procedures that ensure that the contracts team communicates all new contracts and contract amendments in the APP.
Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 – Education Stabilization Fund –Elementary and Secondary School Emergency R...
Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 – Education Stabilization Fund –Elementary and Secondary School Emergency Relief (ESSER) 84.425U COVID-19 – Education Stabilization Fund – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP-ESSER) Agency: Arizona Department of Education (ADE) Name of contact person and title: Matthew McClary, Grants Management Compliance Officer Nicole von Prisk, Deputy Associate Superintendent Anticipated completion date: October 2027 Agency’s Response: Concur The Arizona Department of Education has worked in cooperation with our vendor to correct outdated SQL queries that were identified and return only approved grant award amounts rather than all awarded amounts, regardless of approval status. This issue was causing several subaward amounts to incorrectly update. Moving forward, we are ensuring that the original award amounts are being queried and, in return, reported within SAM.gov (System for Award Management). Additionally, through the reconciliation process each month, correct award amounts will align with the corresponding Federal Award Identification Number (FAIN). Reports being submitted late: We have implemented an automated monthly reporting workflow/schedule which will help ensure required FFATA reporting is submitted timely. This process automation helps prompt monthly FFATA reporting uploads by leveraging office tools that are readily available and ensures monthly upload deadlines are met by automatically scheduling the task and requiring follow-up by the assignee. In January of 2024, the staff assigned to FFATA uploads changed again (for the fourth time in a year) and at that point a new staff member assumed responsibility for FFATA uploads. As numerous corrections needed were discovered through the reconciliation process, new reports were uploaded. Some of these were original uploads for entities that were missing SAM.gov (formerly FSRS) information altogether, and some were corrections to previously uploaded yet incorrect information. With each monthly upload, a new date was being captured and while some of the information was new entity award information, not all the information being updated was untimely. This has been a long and arduous process, and we look forward to not having continued FFATA findings, as we are making progress to correct award information for all federal grants moving forward from this point. Inaccurate and/or Incomplete Data: Our Compliance Officer conducts a monthly reconciliation of current SAM.gov award information in coordination with either the Lead Grants Coordinator or the Deputy Associate Superintendent. During this review, any missing, inconsistent, or duplicate data is identified and corrected prior to the upload into SAM.gov. Once the subawards have been uploaded, the reconciliation process is repeated to verify the accuracy of the information recorded within SAM.gov. Note: On October 30, 2025, we became aware that USASpending.gov was no longer updating subawards to correspond with the data we have submitted in SAM.gov. We raised a service desk ticket to USA Spending (Case 00089604), but the issue is ongoing. USA Spending has stated that they “are aware of an issue with the outbound API in SAM to USA Spending, but due to the lapse in funding, the SAM team working on this specific issue has been furloughed until funding is restored.” The reconciliation process where subawards uploaded to SAM.gov are compared to the data in USASpending.gov continues to be heavily impacted until this service is restored. To ensure accurate documentation and timely resolution of system related challenges encountered when submitting subawards in SAM.gov, the Compliance Officer has implemented a formal Incident Tracking process. All technical issues are logged at the time they occur, and each incident is subsequently submitted to the Federal Service Desk (FSD.gov). Upon submission, the incident is assigned an official Incident Request ID along with a corresponding date and time stamp, enabling effective monitoring and follow‑up. Grants Management will establish, implement, and enforce internal and external controls to ensure that risk is minimized and can be appropriately evaluated during any monitoring conducted by the agency. The internal and external controls that will be implemented will establish guidelines addressing conflicts of interest, related-party transactions, and insufficient segregation of duties. Implementation will be based on reference materials provided by the U.S. Department of Education Office of Inspector General, as well as technical assistance from organizations with legal and governmental expertise. ADE’s software will be updated appropriately.
Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Anticipat...
Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Anticipated completion date: December 31, 2026 Agency’s Response: Concur The Office agrees with this finding and will continue to take corrective action to bring the program fully into compliance with Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Federal grant reporting requirements. The Office recognizes the importance of transparency in the use of Federal grants and has taken significant corrective action to resolve any inaccuracies in Federal grant reporting. The Office has implemented specific actions to ensure reporting inaccuracies and program expenditure understatements/overstatements do not occur. During fiscal year 2025 and 2026, the Office has taken corrective action to improve SLFRF reporting processes, including conducting weekly reviews and monthly reconciliations as outlined: ● Award Reconciliation — The Office has conducted a comprehensive review and extensive reconciliation of all awards to identify reporting inaccuracies. This reconciliation will continue as an ongoing process through the SLFRF closeout. ● Expenditure Reconciliation — The Office staff responsible for preparing the SLFRF quarterly reports is completing the reconciliation of all expenditures to the State’s accounting records, which are the official expenditures for the program. This will continue as an ongoing process through the SLFRF closeout. ● Enhanced Reporting Mechanisms—The Office will review, correct, and/or resubmit any inaccurately reported information. The staff responsible for preparing the SLFRF quarterly reports is no longer reconciling to the Office’s internal grants-management system. Reports will be compiled from the State’s accounting records, which are the official record of expenditures made for the program. The Office will investigate and resolve any differences prior to submitting the report to the federal agency. This will continue as an ongoing process through the SLFRF closeout. ● Update Procedures—Based on the comprehensive review noted in the response above, the Office is continuing to implement improved reporting procedures to ensure the accurate submission of grant expenditure data. This includes revised standardized templates, improved guidelines, and enhanced communication channels to improve reporting accuracy. ● Ongoing Training — Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of reporting errors. During fiscal years 2025 and 2026, staff engaged in 18 professional development opportunities, including monthly federal reporting calls, grants management webinars and trainings, internal training sessions, state accounting system training, and participation in a Microsoft data conference. These ongoing efforts reflect our commitment to staying current with compliance requirements and best practices. The Office will continue to strengthen internal controls to prevent similar issues in the future. This involves strengthening oversight, providing additional training to staff members in reporting processes, and implementing regular quality assurance checks. As of this date, the Office has allocated sufficient resources to comply with the award terms and program reporting requirements by establishing the Grants Technology and Data team dedicated to overseeing the necessary SLFRF program reporting procedures. The Office is committed to eliminating any risk through a full reconciliation of expenditures by the end of the program, which occurs during fiscal year 2027.
Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: C...
Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will prepare and retain detailed documentation, including system reports, queries, screenshots, and other evidence, to support the program information reported to the federal agency for each Emergency Rental Assistance Program (ERAP) award. DES will also abide by its ERAP policies and procedures to retain all records related to the award for a period of 5 years after all federal funds are expended. The Department sunset the ERAP program on October 13th, 2023, due to an exhaustion of ERA 1 and ERA 2 funding.
Assistance listing number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Department of Economic Security (DES) Office of Economic Opportunity (OEO) Name of contact persons and titles: David Almaraz, DES DERS Business Admi...
Assistance listing number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Department of Economic Security (DES) Office of Economic Opportunity (OEO) Name of contact persons and titles: David Almaraz, DES DERS Business Administrator Stephen Sifuentes, OEO Finance Administrator Senior Anticipated completion date: See below Agency’s Response: Concur DES Anticipated completion date: December 31, 2026 The Department will address the audit recommendations by amending its ISA subaward with the Arizona Office of Economic Opportunity. The Department will also adjust its subrecipient monitoring schedule, procedures and offer training and assistance on conference-related requirements to the Arizona Office of Economic Opportunity. OEO Anticipated completion date: June 30, 2027 The Office of Economic Opportunity (OEO) acknowledges the finding regarding the use of WIOA Dislocated Worker Formula Grant funds for conference meals and promotional items. To address these concerns, OEO has undertaken proactive measures to strengthen internal controls, enhance oversight, and improve compliance with federal cost principles. As such, OEO will utilize these findings to strengthen its existing system, address any identified deficiencies, and continue to enhance fiscal management. Through these corrective actions, the OEO is committed to full compliance and the effective stewardship of federal funds. 1. Ensure Summit costs charged to the WIOA federal program are appropriate, necessary, and managed to minimize charges to the federal award. The OEO acknowledges the auditors’ findings regarding the management of Summit costs charged to the Workforce Innovation and Opportunity Act (WIOA) federal program. OEO is committed to ensuring that all expenditures are appropriate, necessary, and managed with the highest level of fiscal responsibility to ensure charges are necessary and allowable to the federal award. To address this finding, OEO will collaborate closely with the Arizona Department of Economic Security (ADES) to develop and implement comprehensive formal policies and procedures governing the State Workforce Development Board and WIOA funded events including Summit expenditures. Our joint efforts will focus on implementing a documented review and approval process to ensure costs charged to the federal award are supported by documentation and evaluated in accordance with 2 CFR §§ 200.403. As part of this corrective action, the process will integrate cost-containment measures into the planning and approval of the events budget planning phase. This will include requiring staff to assess whether proposed costs are necessary, reasonable, allocable and limited to helping the workforce development system achieve the purpose of the Workforce Innovation and Opportunity Act (WIOA). OEO and ADES will conduct working sessions to develop, implement, and monitor these protocols, with the goal of finalizing a standardized procedure for all WIOA-funded event expenditures. This approach ensures consistency across agencies and establishes clear oversight to prevent recurrence. 2. Develop and implement written procedures, including a standardized review process, to ensure that costs charged to the WIOA federal program are allowable prior to requesting reimbursement from DES. The OEO recognizes the importance of verifying the allowability of expenditures prior to the reimbursement phase. We concur that a standardized documented review process is necessary to maintain fiscal integrity and compliance of WIOA federal program funding and federal regulations. OEO, in partnership with the ADES, will develop and formalize written internal control procedures designed to vet all costs before they are submitted to ADES for reimbursement. The proposed standardized review process will align with existing practices for monitoring and expending federal funds as described under WIOA for the State Workforce Development Board and will include: ● Pre-submission verification: Implementation of an internal review checklist based on 2 CFR 200 Subpart E Cost Principles and applicable State policy. This will ensure that every line item is: ○ Allowable under both WIOA statutory requirements and federal cost principles. ○ Allocable to the specific federal award in proportion to the benefits received. ○ Compliant with the State of Arizona Accounting Manual ○ Documented with sufficient supporting evidence (pictures, invoices, receipts, and justifications) to withstand audit scrutiny. ● Standardized approval workflow: Establishment of a clear designated approval framework. ● Policy Integration: These procedures will be codified into an OEO Fiscal Manual, providing staff with a clear roadmap for processing WIOA-related expenditures. OEO will coordinate with ADES technical assistance teams to ensure our internal review templates align with ADES’s appropriate reimbursement systems. This collaborative design phase will ensure that once a request reaches ADES, it has already undergone a vetting process, thereby reducing errors. 3. Work with federal grantor and/or DES to resolve the $90,015 of questioned costs associated with the 2024 Summit and any subsequently held Summits. OEO will collaborate with the ADES, the primary grant recipient, to establish the most appropriate course of action for resolving any unallowable expenditures. Initially, OEO will work with ADES to precisely define the actual allowable amount based on programmatic cost allowability, which may require consultation with the original federal grantor, for final clarification on disputed cost. Subsequent steps for resolution will be guided by ADES’s direction and the requirements of the federal grantor.
2024-003 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economi...
2024-003 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000073444, C000075689, C000082264, C000086078, and PEMA-2022-007 Condition/Context: The County’s December 31, 2023 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Views of Responsible Officials and Planned Corrective Actions: Management understands and is working to better anticipate the needs and timing and availability of staff/information to complete the audit. The County has a third party that compiles the information to give to the auditors for auditing. The County is hoping with this that the information being audited will be timelier to get the audit completed.
Finding Reference: 2024-008 Finding Title: Noncompliance and Significant Deficiency, Data Collection Form CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Joseph Psioda, Controller, Financial Affairs, (312) 322-6346 Planned Corrective Actions: 1. Submi...
Finding Reference: 2024-008 Finding Title: Noncompliance and Significant Deficiency, Data Collection Form CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Joseph Psioda, Controller, Financial Affairs, (312) 322-6346 Planned Corrective Actions: 1. Submission of Federal Reporting Package: Management will implement procedures to ensure the timely completion and submission of the annual audit, reporting package, and data collection form. This will include establishing a detailed audit timeline with interim milestones, strengthening coordination among departments responsible for required data and information, and proactively monitoring federal reporting deadlines. Management will also develop contingency plans to address delays in complex audit areas to minimize the risk of future reporting delays. These procedures will be implemented for the 2025 audit cycle to ensure timely submission to the Federal Audit Clearinghouse. Anticipated Completion Date: 06/30/2026
Finding Reference: 2024-007 Finding Title: Timecard Approval Controls – Payroll Charge to Federal Grant, Significant Deficiency CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Scott Dolude, Director of Payroll, Financial Affairs, (312) 322-6526 Planne...
Finding Reference: 2024-007 Finding Title: Timecard Approval Controls – Payroll Charge to Federal Grant, Significant Deficiency CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Scott Dolude, Director of Payroll, Financial Affairs, (312) 322-6526 Planned Corrective Actions: 1. Timecard Approval Requirements for Federal Grants: Management will reinforce payroll control procedures to require that all employee timecards charged to Federal grants are reviewed and approved by designated supervisors in a timely manner and in accordance with established payroll deadlines. Specifically, that all required approvals must be completed prior to payroll processing and fiscal period close to ensure the allowability, accuracy, and proper allocation of costs charged to Federal awards. By June 30, 2026, management will send an email to all impact supervisory and management personnel responsible for time review and approval processes. 2. Documentation Standards and Audit Trail: Management will establish formal documentation standards to ensure that evidence of supervisory review and approval, including approval dates, is consistently retained in a secure, centralized system. These standards will support a clear and retrievable audit trail demonstrating compliance with the payroll documentation and allowability requirements of 2 CFR §200.430(i). 3. Monitoring and Compliance Oversight: Management will implement periodic monitoring procedures to assess compliance with timecard review and approval requirements. These procedures will include exception reporting, timely follow-up on identified deficiencies, and management review of monitoring results. Corrective actions will be implemented, as necessary, to address recurring or systemic issues related to untimely, incomplete, or undocumented approvals. Based on the results of monitoring processes, Director of Payroll and Timekeeping will conduct organizational, departmental, or team-based follow-up to address non-compliance or other issues. Anticipated Completion Date: 06/30/2026
Effective July 1, 2025, the San Diego Workforce Partnership (SDWP) will strengthen its internal controls to ensure compliance with the WIOA Youth Out‑of‑School Youth (OSY) expenditure requirement. SDWP recognizes that the 75 percent minimum Out of School Youth (OSY) expenditure requirement was not m...
Effective July 1, 2025, the San Diego Workforce Partnership (SDWP) will strengthen its internal controls to ensure compliance with the WIOA Youth Out‑of‑School Youth (OSY) expenditure requirement. SDWP recognizes that the 75 percent minimum Out of School Youth (OSY) expenditure requirement was not met during the audit period. This resulted from insufficient monitoring controls, the absence of a systematic process to track spending progress, and the failure to pursue and obtain an approved waiver to reduce the requirement to the allowable 50 percent minimum. To address this finding, SDWP is implementing an enhanced expenditure tracking and monitoring system that will include: • A monthly OSY expenditure report that reconciles budget‑to‑actual spending and highlights progress toward the requirement. • A review process requiring the Programs Manager to validate monthly OSY compliance reports. • Quarterly financial compliance reviews conducted by the CFO to ensure timely corrective action if spending trends indicate potential noncompliance. • An annual review process will be established to determine whether submission of a waiver is applicable, including the preparation and formal review of any required waiver documentation. The WIOA Out of School Youth Waiver Application for FY25–26 has been completed and will be incorporated into this annual review process moving forward. The Accounting Manager will be responsible for maintaining the tracking system, performing monthly reviews, and coordinating with program staff to ensure expenditures align with federal requirements. The Chief Financial Officer (CFO) will provide oversight, verify compliance during quarterly reviews, and ensure that policies and procedures are adhered to.
Significant Deficiency 2024-001 – Internal Control Over Financial Reporting Name of Contact Person: Helen McFalls, Town Clerk Corrective Action: The Town is committed to taking steps to improve its financial management and accounting capacity and the Council will remain involved in the financial aff...
Significant Deficiency 2024-001 – Internal Control Over Financial Reporting Name of Contact Person: Helen McFalls, Town Clerk Corrective Action: The Town is committed to taking steps to improve its financial management and accounting capacity and the Council will remain involved in the financial affairs of the Town to provide oversight. Proposed Completion Date: Management has implemented the above action.
Fund Account - Deposit funds to reimburse account - October 16, 2025 Segregation & Monitoring - Transfer all new deposits immediately; perform monthly reconciliations - Effective immediately. Policies & Training - Update policies; train staff on deposit handling and monitoring - May/June 2026 Oversi...
Fund Account - Deposit funds to reimburse account - October 16, 2025 Segregation & Monitoring - Transfer all new deposits immediately; perform monthly reconciliations - Effective immediately. Policies & Training - Update policies; train staff on deposit handling and monitoring - May/June 2026 Oversight & Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to Finance Committee - Ongoing
Fund Account - Deposit additional funds to cover shortfall. - March 3, 2026 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - May/June ...
Fund Account - Deposit additional funds to cover shortfall. - March 3, 2026 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - May/June 2026 Oversight and reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to Finance Committee - ongoing
Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards,...
Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards, and updated procedures Ongoing Monitoring - Quarterly internal audits; COO and Board Finance Committee review of compliance - ongoing Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to finance committee - ongoing
Compliance Calendar - Implement a calendar for all federal reporting deadlines with advance reminders - May 2026 Month-End and Year-End Close - Standardize closing procedures; set internal deadlines ahead of REAC requirement - May 2026 Oversight and Monitoring - CFO review of compliance; periodic up...
Compliance Calendar - Implement a calendar for all federal reporting deadlines with advance reminders - May 2026 Month-End and Year-End Close - Standardize closing procedures; set internal deadlines ahead of REAC requirement - May 2026 Oversight and Monitoring - CFO review of compliance; periodic updates to CEO and Board Finance Committee Contingency Procedure - Submit owner-certified report if audited statements not finalized within 90 days - as needed
Fund Account - Deposited back to the replacement reserve account - October 16, 2025 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - M...
Fund Account - Deposited back to the replacement reserve account - October 16, 2025 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - May/June 2026 Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to Finance Committee. - Ongoing
Fund Account - Deposit additional funds to cover shortfall - March 25, 2026 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - May/June ...
Fund Account - Deposit additional funds to cover shortfall - March 25, 2026 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - May/June 2026 Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to Finance Committee - Ongoing
Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards,...
Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards, and updated procedures Ongoing Monitoring - Quarterly internal audits; COO and Board Finance Committee review of compliance - ongoing Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to finance committee - ongoing
Compliance Calendar - Implement a calendar for all federal reporting deadlines with advance reminders - May 2026 Month-End and Year-End Close - Standardize closing procedures; set internal deadlines ahead of REAC requirement - May 2026 Oversight and Monitoring - CFO review of compliance; periodic up...
Compliance Calendar - Implement a calendar for all federal reporting deadlines with advance reminders - May 2026 Month-End and Year-End Close - Standardize closing procedures; set internal deadlines ahead of REAC requirement - May 2026 Oversight and Monitoring - CFO review of compliance; periodic updates to CEO and Board Finance Committee Contingency Procedure - Submit owner-certified report if audited statements not finalized within 90 days - as needed
Action taken: CRMHS management concurs with the finding. During the fiscal year ended June 30, 2024, CRMHS did not consistently operate internal controls over federal cash management as designed. Specifically, a federal draw was processed in excess of immediate cash needs and was not fully reconcile...
Action taken: CRMHS management concurs with the finding. During the fiscal year ended June 30, 2024, CRMHS did not consistently operate internal controls over federal cash management as designed. Specifically, a federal draw was processed in excess of immediate cash needs and was not fully reconciled to supporting allowable expenditures prior to submission. This resulted in federal funds being drawn in advance of program disbursement requirements. Management acknowledges that this practice does not comply with 2 CFR §200.305, which requires non-federal entities to minimize the time between drawdown of federal funds and their disbursement for program purposes. While the funds were ultimately expended on allowable program costs, the timing of the draw created a compliance exception and reflects a material weakness in internal control over compliance. Management takes this matter seriously and has implemented corrective measures to strengthen cash management oversight and reconciliation procedures. Such actions include: • CRMHS has completed a full reconciliation of all drawdowns under Assistance Listing 93.696 to supporting allowable expenditures through June 30, 2024. • Any excess cash balances identified were evaluated and adjusted to ensure compliance with federal cash management requirements. • Pre-Draw Reconciliation Requirement—No draw request may be submitted without documented reconciliation to recorded allowable expenditures. • Segregation of Duties and Review—the draw request and documented reconciliation will be reviewed and signed off on by a second qualified member of the accounting team. • Monthly Grant Cash Monitoring—CRMHS will compare cumulative drawdowns to cumulative allowable expenditures to identify and resolve any excess cash position.
Person Responsible for Corrective Action: Edward S. Churchill Jr., Chief Operating Officer Corrective Action Plan: College for Social Innovation’s corrective action plan to ensure timely preparedness for auditing is twofold. First, we are developing a new “Financial Command Center” tool to allow gre...
Person Responsible for Corrective Action: Edward S. Churchill Jr., Chief Operating Officer Corrective Action Plan: College for Social Innovation’s corrective action plan to ensure timely preparedness for auditing is twofold. First, we are developing a new “Financial Command Center” tool to allow greater speed, accuracy, and regularity in tracking account balances and transactions. This new tool better consolidates our tracking processes and allows for regular reconciliations across tracking platforms including Expensify, QuickBooks, Excel, and BambooHR. Second, College for Social Innovation is currently seeking the support services of a Certified Public Accountant. As of February 2, 2026, we have identified a list of potential candidates, are developing a formal request for proposals, and expect to enter a contracted agreement in early March of 2026. This new supporting role will assist in ensuring that our accounting practices fully align with accounting principles generally accepted in the United States. Anticipated Completion Date: 3/30/2026
CORRECTIVE ACTION PLAN The Town of Billerica, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of the independent public accounting firm: CBIZ CPAs P.C. 53 State Street, 17th Floor Boston, MA 02109 Audit Period: July 1, 2023 t...
CORRECTIVE ACTION PLAN The Town of Billerica, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of the independent public accounting firm: CBIZ CPAs P.C. 53 State Street, 17th Floor Boston, MA 02109 Audit Period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding 2024-003: Missing Federally Required Procurement Clauses in Vendor Contracts Views of Responsible Officials: The Town is committed to strengthening its procurement practices and ensuring compliance with Uniform Guidance requirements. To address this issue, the Town will develop and implement standardized contract templates, and a comprehensive checklist of required federal clauses applicable to federally funded procurements for any future federal dollars. The Town will formalize procedures to ensure that a secondary review is consistently performed and documented for all required federal reports prior to submission and will designate a member of management or another qualified official to perform and document this review. Official Responsible for Implementing Corrective Action: Amit Chhayani Town Accountant
CORRECTIVE ACTION PLAN Name of auditee: Friends of the Mission Finding: 2024-002 Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: January 1, 2024 through December 31, 2024 CAP prepared by: Scott Thurmond, Executive Director Telephone: (916) 416-0901 Comments: Managemen...
CORRECTIVE ACTION PLAN Name of auditee: Friends of the Mission Finding: 2024-002 Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: January 1, 2024 through December 31, 2024 CAP prepared by: Scott Thurmond, Executive Director Telephone: (916) 416-0901 Comments: Management agrees with the finding. Actions: Management will ensure that audited financial statements are submitted to the Federal Audit Clearinghouse within the required time frame.
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