Corrective Action Plans

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Finding 523384 (2023-034)
Significant Deficiency 2023
Finding No.: 2023-034 Refunding of Overpayments Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and has developed a corrective action plan that includes a new Stan...
Finding No.: 2023-034 Refunding of Overpayments Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and has developed a corrective action plan that includes a new Standard Operating Procedure (SOP), 2024-005, for the Intake and Processing of Overpayment Checks. This new SOP addresses a gap in our process for tracking overpayment checks and refunding the Federal Share of Medicaid Overpayments to Providers. Furthermore, we are also in the process of updating SOP 2023-03, which focuses on Public Health Professional (PHPro) Entry for Provider Overpayment Checks and Recoupments, to improve our tracking and monitoring of overpayment checks and recoupment reconciliations. Currently, we are still addressing updates to this SOP and require additional time to work with BHCFA staff(s) to gather more information in finalizing the SOP. We intend to complete this SOP no later than February 28, 2025.
View Audit 342645 Questioned Costs: $1
Finding 523380 (2023-032)
Significant Deficiency 2023
Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau wil...
Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau will hold providers accountable by issuing a Letter of Warning (LOW) and a Correction Action Plan (CAP) from the Social Service Licensing Officer or Child Care Compliance Officer to ensure compliance with the standards. The Agency disagrees with Condition 1. License-exempt childcare providers will not have an annual DEH inspection since they are not required to obtain a sanitary permit.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds...
Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds under the Qualified and Eligible Child Care Providers, Provider Reporting and Monitoring, the ARP Act does not include specific reporting requirements for childcare providers receiving subgrants and any subgrant reporting requirements are at the discretion of the lead agency, page 21. Additionally, Lead Agencies that use other governmental or non-governmental subrecipients to administer the program must have written agreements in place outlining roles and responsibilities for meeting CCDF requirements. The contents of the written agreement may vary based on the role the subrecipient is asked to assume or the type of product undertaken, but must include, at a minimum, tasks to be performed, a schedule for completing tasks, a budget which itemizes categorical expenditures, and indicators or measures to assess performance. The Lead Agency has fulfilled this requirement in accordance with 45 CFR section 98.1.
View Audit 342645 Questioned Costs: $1
Finding 523371 (2023-029)
Significant Deficiency 2023
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
View Audit 342645 Questioned Costs: $1
Finding 523368 (2023-028)
Significant Deficiency 2023
Finding No.: 2023-028 Matching, Level of Effort, Earmarking Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward. Howev...
Finding No.: 2023-028 Matching, Level of Effort, Earmarking Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward. However, the Matching Level of Effort (MOE) earmarking is not a requirement in accordance with the Supplemental Terms and Conditions for the Child Care Mandatory and Matching Funds of the Child Care & Development Fund's Cost Sharing or Matching (Non-Federal Share) of Program Funding, page 2. Item 6 identifies that a state match is not required while Item 8 identifies that the MOE threshold applies to states only.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-022 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza (GEPA) Agency disagrees with the findings. The program income is not tied to assist or supplement the federal awards. The program income is us...
Finding No.: 2023-022 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza (GEPA) Agency disagrees with the findings. The program income is not tied to assist or supplement the federal awards. The program income is used to supplement the special revenue funds handle by the department.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-017 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Procurement personnel will continue to enforce compliance with applicable procurement. A requirement of no less tha...
Finding No.: 2023-017 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Procurement personnel will continue to enforce compliance with applicable procurement. A requirement of no less than three (3) price quotations to be on file, with evidence of solicitation from other potential suppliers to participate. In addition, a requirement for a “no quote” submission and to solicit from other potential suppliers should a “no quote” be received. It is our belief that we have followed the procurement process based on GAC Title 5 Chapter 5 §5213 for conditions 1 and 2. Condition 3, $3.35 mil are not a cost in our books, as these costs are captured in GMHA’s audit expenditures.
View Audit 342645 Questioned Costs: $1
Finding 523357 (2023-015)
Significant Deficiency 2023
Finding No.: 2023-015 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) All documents were provided to HAF for client’s eligibility for the program. However, due to a move, file was misplaced. Records Management SO...
Finding No.: 2023-015 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) All documents were provided to HAF for client’s eligibility for the program. However, due to a move, file was misplaced. Records Management SOPs will be updated to have all documentation stored electronically.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-012 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Legal requirement was followed. In circumstances where less than 3 quotes are obtained, that is a market indication...
Finding No.: 2023-012 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Legal requirement was followed. In circumstances where less than 3 quotes are obtained, that is a market indication that further efforts to secure quotation will be unsuccessful.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-009 ADP System for SNAP Responding Agency: Department of Public Health and Social Services (DPHSS) Agency disagrees with the finding. [Case Numbers 600020362, 300075627 and 300073890] Documentation was provided to auditor electronically on 09/03/2024. Additional documentati...
Finding No.: 2023-009 ADP System for SNAP Responding Agency: Department of Public Health and Social Services (DPHSS) Agency disagrees with the finding. [Case Numbers 600020362, 300075627 and 300073890] Documentation was provided to auditor electronically on 09/03/2024. Additional documentation was provided in person on 11/15/2024 because the files were too large to send via email. [Case Number 201301439] The additional documentation related to the "processing of the household size of the applicant, resulting in an overpayment" was included in the files provided on 11/15/2024 to dispute this finding. Additional information was provided to explain. 201301439 -benefit amount is for a household size of 8 based on the renewal and change reports submitted during the certification period 3/1/2024-02/29/2024. Benefit amount indicated on the audit report says $312, which was not what was issued. Screenshots of this process was provided. 600020362 – The notice of action was provided and all other documents for this case. Details of corrective actions and target dates are set forth in GovGuam’s Corrective Action Plan.
View Audit 342645 Questioned Costs: $1
Finding 523340 (2023-002)
Significant Deficiency 2023
This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the ...
This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the 2024 audit. Responsible contact person is Caitlin Cole, Human Resources manager.
Criteria: Regulations require that HOME-assisted units in a rental housing project must be occupied only be households that are eligible as low-income families and must meet certain limits on rents that can be charged. Condition: The Organization was unable to provide evidence of income verificati...
Criteria: Regulations require that HOME-assisted units in a rental housing project must be occupied only be households that are eligible as low-income families and must meet certain limits on rents that can be charged. Condition: The Organization was unable to provide evidence of income verification, to be completed upon signing an annual rental agreement, for seven of the tenants selected for testing. Effect: The Organization did not comply with 24 CFR § 92.252 (h). Per 24 CFR § 92.252 (h), this results in material noncompliance with the provisions of Federal statues, regulations, and terms and conditions of Federal awards related to major programs. Questioned Costs: The Organization’s lack of compliance resulted in $77,295 of questioned costs. Questioned costs were calculated by comparing the subsidies received for the exceptions noted and applying the prorated percentages to the remaining affected population. Cause: The Organization did not maintain evidence of annual income verification for seven of the tenants selected for testing. Recommendations: We recommend management review the tenant roles annually to ensure required income verifications are documented in compliance with program requirements. Views of Responsible Officials: The Organization agrees with the finding and will work to implement the recommendations.
View Audit 342579 Questioned Costs: $1
Criteria: Regulations require that the Organization must submit the single audit data collection form and reporting package within the earlier of 30 calendar days after receipt of the auditor’s report or 9 months after the end of the audit period, to comply with 2 CFR § 200.512(a)(1). Condition: T...
Criteria: Regulations require that the Organization must submit the single audit data collection form and reporting package within the earlier of 30 calendar days after receipt of the auditor’s report or 9 months after the end of the audit period, to comply with 2 CFR § 200.512(a)(1). Condition: The Organization submitted their 2022 Single Audit Data Collection form on September 5, 2024, which was 20 months after the end of the audit period. Effect: The Organization did not comply with 2 CFR § 200.512(a)(1). Per 2 CFR § 200.516(a)(2), this results in material noncompliance with the provisions of Federal statues, regulations, and terms and conditions of Federal awards related to major programs. Questioned Costs: No questioned costs were identified as a result of our procedures. Cause: The Organization failed to submit their 2022 Single Audit Data Collection form before the end of September 2023 – the 9 month post-audit period ending deadline.   Recommendations: We recommend management finalize and submit their single audit data collection forms within the 9 month window moving forward. Views of Responsible Officials: The Organization agrees with the finding and will work to implement the recommendations.
We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 30 days after the end of ...
We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 30 days after the end of the calendar year, in order to complete the audit within the first 120 days after the end of the calendar year. This plan was implemented in December 2024. However, because the report for the single audit for December 2023 was already past due by the time of implementation, the positive effects of this plan will be reflected in future reporting periods.
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the allocation of individual employees' time. This policy should ensure that all r...
MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the allocation of individual employees' time. This policy should ensure that all relevant documentation, such as timesheets and work allocation records, is retained for the required period and is easily accessible for audit purposes. Additionally, staff responsible for timekeeping and financial recordkeeping should receive training on the importance of documentation retention and the specific requirements under the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To establish a standardized cost allocation methodology for staff time, CMJTS implemented in-person monthly allocation meetings with the executive team and program managers responsible for programming, staffing, and budget oversight. These meetings provide a thorough review of program expenditures and staff time, ensuring accurate alignment with funding requirements. Conducting payroll allocation reviews in a group setting allows the executive team to validate cost assignments, address changes in percentage allocations across cost categories, and maintain compliance with administrative regulations and funding guidelines. Name(s) of the contact person(s) responsible for corrective action: Jake Humphrey Planned completion date for corrective action plan: Implemented
Head Start - ALN #93.600 Recommendation: We recommend that the Organization should review and approve the indirect costs that are allocated by the preparer and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...
Head Start - ALN #93.600 Recommendation: We recommend that the Organization should review and approve the indirect costs that are allocated by the preparer and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCCA will implement a policy to ensure a documented review and approval of indirect cost allocations. Name(s) of the contact person(s) responsible for corrective action: Carrie Tripp, Executive Director Planned completion date for corrective action plan: September 30, 2025
Head Start - ALN #93.600 Recommendation: We recommend that the assigned individual to review, formally documents their review and approval of the SF-425 and SF-429/A reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of...
Head Start - ALN #93.600 Recommendation: We recommend that the assigned individual to review, formally documents their review and approval of the SF-425 and SF-429/A reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of all reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCCA will implement a control policy for a documented review and approval of reports prior to submission as well as ensuring reports are filed timely. Name(s) of the contact person(s) responsible for corrective action: Carrie Tripp, Executive Director Planned completion date for corrective action plan: September 30, 2025
Finding 522963 (2023-005)
Significant Deficiency 2023
Management accepts this finding. Sponsored Research Service and the Controller’s Office work in tandem on the closing process. The Controller’s office has a schedule of projects ready to close and has assigned this pool of projects among the research accounting staff. In February 2024, the Controlle...
Management accepts this finding. Sponsored Research Service and the Controller’s Office work in tandem on the closing process. The Controller’s office has a schedule of projects ready to close and has assigned this pool of projects among the research accounting staff. In February 2024, the Controller’s Office hired a second Research Accountant. With the additions of these two positions the University will work towards closing out projects within 90-120 days. In March 2024, the Controller’s Office developed a Close out excel form to aid in capturing each of the necessary steps required on the accounting side of the process.
Finding 522901 (2023-004)
Significant Deficiency 2023
Management accepts this finding and notes that the University’s policy regarding drawdowns was updated in August 2023 to clarify our procedures to include a secondary review by someone other than the preparer of the drawdown request. “Awards from federal agencies are not paid in full or in advance a...
Management accepts this finding and notes that the University’s policy regarding drawdowns was updated in August 2023 to clarify our procedures to include a secondary review by someone other than the preparer of the drawdown request. “Awards from federal agencies are not paid in full or in advance at the time they are awarded to the University. Instead, the University is required to draw funds down from the federal agencies payment systems periodically to reimburse the University for its expenses on all of our federal grants. The Research Accountant accesses the federal payment systems periodically to prepare cash drawdowns for reimbursement of expenditures on federal grants at the University. The Research Accountant receives a report on all sponsored projects. That list of grants can be used to run an expense detail report for the period of time that the reimbursement request is covering on a monthly schedule throughout the year. That list of grants can also be used to check that our records are up to date and accurate as far as award amounts and budgets are concerned. The payment request amount is calculated as the difference between the Cumulative Expenses as of the end date of the month you are doing the drawdown for and the Cumulative Expenses as of the last day of the period the last drawdown was requested. This calculation is done on each active award and the sum of all of the calculated payment requests is the total amount of the drawdown to be requested. The payment calculations are reviewed and approved by either the Sr. Research Accountant, Associate Controller or Controller. In the event the Sr. Research Accountant prepares the drawdown, the Associate Controller or the Controller must review and approve prior to submission. After receiving approval, whoever initiated the drawdown will submit and certify the drawdown. In no circumstance, shall the preparer submit and certify without first obtaining approval from the Associate Controller or Controller.” It has also been the practice in the Controller’s Office that drawdowns are posted to the General Ledger by the AR Specialist/Cashier as they appear in the M&T bank account which the bank reconciliation process is then separate from and performed by someone other than the person preparing the drawdown. The Controller’s Office also documented Drawdown Procedures in order to clarify the process. In July 2023, the Controller’s Office added an additional Research Accountant bringing the staff from one to two employees to better share and segregate job duties.
View Audit 342222 Questioned Costs: $1
Finding 522900 (2023-003)
Significant Deficiency 2023
Management accepts this finding and notes that payrolls effected were at the very end of the current audit period and that the error was identified and corrected independently in the subsequent fiscal year. To further address this repeat issue, payroll will run monthly payroll queries and conduct an...
Management accepts this finding and notes that payrolls effected were at the very end of the current audit period and that the error was identified and corrected independently in the subsequent fiscal year. To further address this repeat issue, payroll will run monthly payroll queries and conduct an internal audit of payroll. Additionally, the Sponsored Research Office will work with PI’s to encourage them to plan their summer research efforts such that a research project is not included on more than one summer salary request forms. Although management feels this was an isolated incidence, the University will implement a set of controls that require a secondary review of all manuals calculation for payroll authorizations.
Finding 522899 (2023-002)
Significant Deficiency 2023
Management accepts this finding and notes that loan disbursement notifications are automatically sent to students (we mail notifications to parents and have copies of those saved). There was a glitch in the system that was discovered while going through the audit that occurred on 2 dates in 2023 (Ma...
Management accepts this finding and notes that loan disbursement notifications are automatically sent to students (we mail notifications to parents and have copies of those saved). There was a glitch in the system that was discovered while going through the audit that occurred on 2 dates in 2023 (May 31, 2023 and September 3, 2023) which has since been fixed. Financial Aid worked with the Office of Information Technology to develop a daily report that will notify the Director of Financial Aid of anyone that did not receive a notification.
Recommendation: The Organization will use the correct modified total direct cost base to calculate indirect costs. Congregation Masores Hachinuch, Inc. DBA Bas Mikroh will restore the excess funds to its nonprofit food service account. Action Taken: As per an approved payment plan, Congregation Maso...
Recommendation: The Organization will use the correct modified total direct cost base to calculate indirect costs. Congregation Masores Hachinuch, Inc. DBA Bas Mikroh will restore the excess funds to its nonprofit food service account. Action Taken: As per an approved payment plan, Congregation Masores Hachinuch, Inc. DBA Bas Mikroh is restoring the full amount specified above to its nonprofit food service account. We have implemented the above-mentioned recommendation regarding calculation of indirect costs to ensure that only proper indirect costs are included in the base calculation of indirect costs. We have designated Rabbi Shaul Rosengarten, administrator, to implement and monitor the plan of corrective action for this finding. Anticipated Completion Date: 06/30/2033
View Audit 342215 Questioned Costs: $1
TOFMHS concurs with the finding. The excess drawdowns were the result of accounting entries to record refunds, or other adjustments which reduced previously allowable expenses. Subsequent drawdowns should have been reduced to offset these adjustments. TOFMHS will implement ACF-IM-HS-23-01 (Treatment...
TOFMHS concurs with the finding. The excess drawdowns were the result of accounting entries to record refunds, or other adjustments which reduced previously allowable expenses. Subsequent drawdowns should have been reduced to offset these adjustments. TOFMHS will implement ACF-IM-HS-23-01 (Treatment of Rebates, Refunds, Discounts), and prevent an recurrence of this issue in the future. Corrective Active Taken: TOFMHS returned the $51,664 to the Payment Management System on January 16, 2025 in accordance with the referenced Information Memorandum. Drawdowns will be based upon actual expenses and disbursed within 3 business days. Responsible Person: Finance Director with oversight by the Program Director.
Finding 522781 (2023-010)
Significant Deficiency 2023
2023-010– Special Reporting for Federal Funding Accountability and Transparency Act Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Programs. Choice Neighborhoods Implementation Grant; U.S. Department of Housing and Urban Development; ...
2023-010– Special Reporting for Federal Funding Accountability and Transparency Act Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Programs. Choice Neighborhoods Implementation Grant; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.889' Award Number MI5F519CNG117. Substance Abuse and Mental Health Services - Projects of Regional and National Significance; U.S. Department of Health and Human Services; Assistance Listing Number 93.243; Award Number 1H79SM084918-01. Auditor Description of Condition and Effect: Despite passing through qualifying amounts, the City could produce no evidence that the subawards had been reported through the FSRS. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that reporting of subawards greater than $30,000 is submitted to the FSRS for all direct grants. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
2023-011– Report Filing - 2022 and 2023 CAPER Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Contol Over Compliance (Reporting). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All Aw...
2023-011– Report Filing - 2022 and 2023 CAPER Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Contol Over Compliance (Reporting). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All Award Numbers. Auditor Description of Condition and Effect: As of the completion of audit fieldwork, the 2022 and 2023 CAPERs have not been filed. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all required reports are submitted in a timely manner. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Officer Anticipated Completion Date: January 21, 2025
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