Corrective Action Plans

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Federal Agency Review *Significant Deficiency in Internal Controls over Compliance; Noncompliance Federal Program - CFDA 10.555 – National School Lunch Program ASDOE School Lunch Program (SLP) continues to work with the representative who oversees civil rights for the USDA Western region. SLP co...
Federal Agency Review *Significant Deficiency in Internal Controls over Compliance; Noncompliance Federal Program - CFDA 10.555 – National School Lunch Program ASDOE School Lunch Program (SLP) continues to work with the representative who oversees civil rights for the USDA Western region. SLP continues to have training to correct the issues in their USDA FNS report. POC  SLP Assistant Director Christina Fualaau
Special Tests and Provisions * Significant Deficiencies in Internal Controls over Compliance; Non-Compliance Federal Program - CFDA 20.205 - Highway Planning & Construction The Department of Public Works (DPW) awaits approval of its Implementation and Stewardship agreement from Federal Highway. ...
Special Tests and Provisions * Significant Deficiencies in Internal Controls over Compliance; Non-Compliance Federal Program - CFDA 20.205 - Highway Planning & Construction The Department of Public Works (DPW) awaits approval of its Implementation and Stewardship agreement from Federal Highway. The finding will remain open until the agreement is approved. POC  DPW Deputy Director Laupule Tilei  Civil Engineer Uaealesi Doris Faumuina-Sipelii
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Organization concurs that the reserve for replacement account is underfunded as of September 30, 2023. S3800-130 Response Indicator Agree. S3800-140 Completion Date September 30, 2024 S3800-150 Response The ...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Organization concurs that the reserve for replacement account is underfunded as of September 30, 2023. S3800-130 Response Indicator Agree. S3800-140 Completion Date September 30, 2024 S3800-150 Response The Organization will fund the reserve for replacement. S3800-160 Contact Person First Name Carl S3800-180 Contact Person Last Name Marquette, Jr.
View Audit 310523 Questioned Costs: $1
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report...
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Management will improve accounting and financial reporting policies and procedures to include timely issuance of the financial statement and the uniform guidance report. IMPLEMENTATION DATE March 31, 2025 RESPONSIBLE PERSON Jamille Muriente, CFO, Marjuli, David Mateo, Contract Coordinator Officer
Newmarket Housing Authority Audit Finding Response: Finding reviewed with program specialist and manager with following action plan in place to ensure key EIV reports are run on a scheduled basis and appropriate actions are taken; • Policies and procedures surrounding EIV reviewed. • Program special...
Newmarket Housing Authority Audit Finding Response: Finding reviewed with program specialist and manager with following action plan in place to ensure key EIV reports are run on a scheduled basis and appropriate actions are taken; • Policies and procedures surrounding EIV reviewed. • Program specialist implemented the use of "tickler" reminders on outlook calendar to prompt EIV reports within 90 days for new move-ins. • The Manager will monitor monthly and quarterly to ensure EIV report is run for all move-ins and recertifications.
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP assisted in the Preparation of Schedule of Expenditures of Federal Awards Responsible ...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP assisted in the Preparation of Schedule of Expenditures of Federal Awards Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: Mile Bluff Medical Center has not had a lot of experience with a single audit prior to COVID grant funds. This year we experienced turnover in our CFO role, leaving the process to be re-created. We pulled together most of the information that was required but needed assistance/guidance from our auditors on how to pull the information together and report them on the required forms. We will continue to learn the layout and review the Schedule of Expenditures of Federal Awards prior to sending or addressing this with the Auditors. Anticipated Completion Date: Ongoing
The Department of Behavioral Health (DBH) agrees with the findings. DBH will work to ensure that the time management/payroll system accurately shows where an employee’s cost is being charged. An employee was not charged to the grant even though they were noted as key personnel (100% to be charged t...
The Department of Behavioral Health (DBH) agrees with the findings. DBH will work to ensure that the time management/payroll system accurately shows where an employee’s cost is being charged. An employee was not charged to the grant even though they were noted as key personnel (100% to be charged to the grant). DBH will work with the OCFO to make sure Peoplesoft can assign attributes that can be reported to show that they were charged to the grant. In addition, DBH will review with program staff the process to have a “Letter of Temporary Detail” noting when an employee is assigned to work on the grant so that their time can be charged to the grant. DBH will have the grants management system configured so that the PDF of the Letter of Temporary Detail can be attached to the grant file. Contact - PeopleSoft Set-up: Adran Reid, DBH Agency Fiscal Officer and Michael Neff, DBH Chief Operating Officer, Letter of Temporary Detail: Sharon Hunt, State Opioid Treatment Authority , Grants Management System Configuration: Michael Neff, DBH Chief Operating Officer Estimated Completion Date - Grants Management System, Uploading Documents to Grant File: January 1, 2025 See Corrective Action Plan for chart/table
The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of requests for reimbursement for all federal grants prior to submitting the request in the federal system. The accountant will be required to su...
The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of requests for reimbursement for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit supporting documentation reflecting the summary and detailed personal and non-personal service expenditures. Contact - Adran Reid, DBH Agency Fiscal Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table
View Audit 310468 Questioned Costs: $1
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior D...
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table
The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invo...
The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invoice, the vendor will add the interest that should have been billed. Currently, the drug rebate vendor calculates interest every Tuesday. The system is also calibrated to calculate interest on invoices that were paid in full that had outstanding balances based on the postmark date applied in the system. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - November 30, 2024 See Corrective Action Plan for chart/table
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact- Melisa Byrd, Senior De...
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact- Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table
The Child and Family Services Agency (CFSA) concurs with the findings. The Business Services Administration will install correspondence protocols whereby the invoicing/cost reporting team will acknowledge the review and acceptance of quarterly cost reports from the provider community. Contact - Ja...
The Child and Family Services Agency (CFSA) concurs with the findings. The Business Services Administration will install correspondence protocols whereby the invoicing/cost reporting team will acknowledge the review and acceptance of quarterly cost reports from the provider community. Contact - James J. Murphy, Director, Business Services Administration Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
The Child and Family Services Agency (CFSA) concurs with the findings. Corrective action for the licensing issue will be addressed in the development of the permanent CCWIS system, Standing Together Against Abuse and Neglect in the District (STAAND), wherein official foster care provider license ce...
The Child and Family Services Agency (CFSA) concurs with the findings. Corrective action for the licensing issue will be addressed in the development of the permanent CCWIS system, Standing Together Against Abuse and Neglect in the District (STAAND), wherein official foster care provider license certificates will be available for download on demand. STAAND is currently in development with expected completion in late 2025. Corrective action for the household composition issue will also occur in the development of the STAAND system, wherein foster parents will interact with the system directly and provide household composition information during each licensure cycle. In the meantime, starting immediately, CFSA licensing workers will sign and date checklists during each licensure cycle until STAAND has been fully implemented. CFSA will submit adjusting claims for questioned costs following HHS review of this finding. Contact - James J. Murphy, Director, Business Services Administration Estimated Completion Date - September 30, 2025 (with interim corrective action beginning immediately). See Corrective Action Plan for chart/table
View Audit 310468 Questioned Costs: $1
The Department of Energy and Environment (DOEE) agrees with the conditions and recommendations of this finding. DOEE personnel perform initial reviews of individual applications before, during, and after certification. Supervisory level reviews of 5 applications are performed per processor per mont...
The Department of Energy and Environment (DOEE) agrees with the conditions and recommendations of this finding. DOEE personnel perform initial reviews of individual applications before, during, and after certification. Supervisory level reviews of 5 applications are performed per processor per month, which is documented in the Operations Manual. On a semi-annual basis, program personnel will conduct an inventory of applications to ensure a 25% threshold of secondary reviews is being met. Additionally, DOEE will conduct and require staff participation in system demonstration and refresher trainings in order to strengthen existing policies and procedures. Contact - Danielle Wright, Deputy Director Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
The Department of Human Services (DHS) agrees with the finding noting that appropriate actions were taken to approve the case, however, the reviewing supervisor failed to sign the document after conducting the supervisory audit. The corrective action plan developed for the Child Care Services Divis...
The Department of Human Services (DHS) agrees with the finding noting that appropriate actions were taken to approve the case, however, the reviewing supervisor failed to sign the document after conducting the supervisory audit. The corrective action plan developed for the Child Care Services Division (CCSD) is to conduct refresher training with the CCSD supervisory team on the requirement for the Supervisor reviewing the case file to double-check the Internal Audit Form to ensure that it is completed in its entirety and includes the supervisor’s signature and date of review. The internal control will now require the supervisor to forward the Internal Audit Form to the CCSD Section Chief who will conduct a second-level review to ensure the form is completed and can be filed. Contact - Ann Pierre, Deputy Administrator, Division of Customer Workforce Employment & Training (DCWET) Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
The Department of Human Services (DHS) agrees with the finding in this report. These case numbers will have tickets entered and a root cause investigation will be conducted. A solution will be developed based on the results of the investigation and the solution will be implemented. Contact - Steph...
The Department of Human Services (DHS) agrees with the finding in this report. These case numbers will have tickets entered and a root cause investigation will be conducted. A solution will be developed based on the results of the investigation and the solution will be implemented. Contact - Stephanie Bloch-Newman, Deputy Administrator for Innovation & Change Management Estimated Completion Date - September 30, 2025 See Corrective Action Plan for chart/table
The Department of Human Services (DHS) agrees with the findings. Economic Security Administration (ESA) agrees with the documentation issue, which is compounded by the lack of interface between the reporting data systems. This requires collaboration efforts between multiple units within ESA that in...
The Department of Human Services (DHS) agrees with the findings. Economic Security Administration (ESA) agrees with the documentation issue, which is compounded by the lack of interface between the reporting data systems. This requires collaboration efforts between multiple units within ESA that includes the Division of Customer Workforce Employment & Training (DCWET), the Department of Program Operations (DPO), and the Division of Innovation and Change Management (DICM). ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The Office of Performance Monitoring (OPM) has a process in place to monitor and confirm the hours reported from CATCH; however, the process to monitor and verify the hours received from DCAS needs to be strengthened to capture and resolve discrepancies in work hours. During the monthly Q5I reviews, we found multiple discrepancies from the data received from DCAS showing that the customer was not employed during the sample month or fiscal year; but hours were reported in Q5i. When OPM conducts their review of DCAS hours, and identifies income and hour differences, the DPO is informed and/or the Office of Work Opportunity (OWO) requests their assistance with resolving the discrepancy. While this was a temporary fix for the problem, however, a permanent solution would require a multi-faceted approach: (1) Training (re-training) all DPO SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to provide adequate training to SSRs involved in updating customers’ employment information in DCAS. While this would be a short-term solution it will go a long way to resolving some of the discrepancies in reported work hours that are being transmitted to Q5i. (2) Requiring DICM to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. Her suggestion is to have Brian initiate the meetings between DCWET, DPO, and DICM. This would be automating the process by connecting the 2- step process into one task. This would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. (3) Continuing to randomly select and review a sample of 40 cases from Q5i each month. OPM monitors will randomly generate 40 sample cases from Q5i, review them and if they find any discrepancies would refer them to either OWO, DPO, or TEP Providers for resolution. (4) Continuing to cross-reference all customers assigned to a vendor to verify that each customer’s DCAS hours are confirmed by OPM during its participation audit process. OPM will continue to ensure that all customers’ participation documents are uploaded in Fileshare during each bi-weekly audit cycle. Contact - Christian Okonkwo, Program Manager, Office of Performance Monitoring, DHS/ESA Estimated Completion Date - DICM will create a Jira ticket to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This process will take four (4) months, September 30, 2024, to complete. DPO will train (retrain) all DPO SSR on the DCAS screens which require action to confirm employment. The training will last up to six (6) months, March 30, 2025. See Corrective Action Plan for chart/table
Department of Human Services (DHS)/Economic Security Administration (ESA) concur with the findings. DHS will re-issue a memorandum related to the Fleeing Felons Policy to all staff. To include verbiage related to the 10-year period that began on the date the individual was convicted in Federal or S...
Department of Human Services (DHS)/Economic Security Administration (ESA) concur with the findings. DHS will re-issue a memorandum related to the Fleeing Felons Policy to all staff. To include verbiage related to the 10-year period that began on the date the individual was convicted in Federal or State court of having made a fraudulent statement or representation with respect to place of residence in order to simultaneously receive assistance from two or more States and any individual who was fleeing to avoid prosecution, or custody or confinement after conviction, for a felony or attempt to commit a felony, or who is violating a condition of probation or parole imposed under Federal or State law. Contact - Francine Miller, Deputy Administrator, DHS/ESA Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
View Audit 310468 Questioned Costs: $1
The Office of State Superintendent of Education (OSSE) concurs with the auditor’s finding and recommendations. OSSE will further strengthen its internal controls for its FFATA reporting process to enhance operational efficiency and accuracy by increasing the frequency and rigor of agency review an...
The Office of State Superintendent of Education (OSSE) concurs with the auditor’s finding and recommendations. OSSE will further strengthen its internal controls for its FFATA reporting process to enhance operational efficiency and accuracy by increasing the frequency and rigor of agency review and checks on the collection and submission. Contact - Carol D’Avilar-Etkins, Program Officer Estimated Completion Date - October 2024 See Corrective Action Plan for chart/table
The Office of the State Superintendent (OSSE) agrees with the conditions and recommendations of this finding. The OSSE corrective action plan includes the following: • The OCFO budget team will ensure that every budgeted federal award has a corresponding equivalent Federal Notice of Grant Award (...
The Office of the State Superintendent (OSSE) agrees with the conditions and recommendations of this finding. The OSSE corrective action plan includes the following: • The OCFO budget team will ensure that every budgeted federal award has a corresponding equivalent Federal Notice of Grant Award (NOGA). • Grant reconciliations done to determine carryover balances and subsequent budget modifications will incorporate cash as well as accrued expenditures. • Quarterly financial reviews will be conducted to properly review and support expenditures. • During the year-end close process, the accounting team will compare total awarded amount and total expenditures. Contact - Keith Fletcher, Agency Fiscal Officer, OSSE, Crosby Boyd, Controller, Education Cluster Estimated Completion Date - February 1, 2025 See Corrective Action Plan for chart/table
The Department of Housing and Community Development (DHCD) concurs with the conditions and recommendations of this finding. DHCD will create a compliance plan to validate the review of applicant’s eligibility. In January 2024, DHCD updated the Document Checklist to strengthen the program’s eligibi...
The Department of Housing and Community Development (DHCD) concurs with the conditions and recommendations of this finding. DHCD will create a compliance plan to validate the review of applicant’s eligibility. In January 2024, DHCD updated the Document Checklist to strengthen the program’s eligibility determination and review. Beginning in April 2024, DHCD reviewed the eligibility of applicants before payments were disbursed. Contact - Lesley Edmond, DHCD Housing Compliance Officer Estimated Completion Date - This will be incorporated into the revised monitoring plan on July 28, 2024. See Corrective Action Plan for chart/table
The Department of Human Services (DHS) OCFO concurs with the finding. Expenditures were inadvertently categorized to the incorrect fund. Moving forward, a meeting will be scheduled with the HSSC Comptroller, the Accounting Officer, the AFO and the Budget Staff for a detailed review and walk through...
The Department of Human Services (DHS) OCFO concurs with the finding. Expenditures were inadvertently categorized to the incorrect fund. Moving forward, a meeting will be scheduled with the HSSC Comptroller, the Accounting Officer, the AFO and the Budget Staff for a detailed review and walk through of the SEFA to confirm the expenditures are correctly categorized by fund and grant, and expenditures reconcile to reports from the financial system. Contact - Barbara Roberson, Accounting Officer Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
The Department of Human Services (DHS) agrees with the findings. To address any documentation gaps, DHS introduced new Standard Operating Procedures (SOPs) for Family Rehousing and Stabilization Program (FRSP) in fiscal year 2023. The new SOP implements stricter internal control procedures, regular...
The Department of Human Services (DHS) agrees with the findings. To address any documentation gaps, DHS introduced new Standard Operating Procedures (SOPs) for Family Rehousing and Stabilization Program (FRSP) in fiscal year 2023. The new SOP implements stricter internal control procedures, regular audits, and streamlining the eligibility determination process. The majority of findings were for participants enrolled into FRSP before the new SOPs took effect. DHS will continue execution of the stricter internal controls and audits, to ensure there are no documentation gaps moving forward. Contact - Noah Abraham, Interim FSA Administrator, DC Department of Human Services Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table
View Audit 310468 Questioned Costs: $1
The Department of Housing and Community Development (DHCD) concurs with the conditions and recommendations of this finding. DHCD will input data into Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for all Community Development Block Grants Section 108 Loan Guar...
The Department of Housing and Community Development (DHCD) concurs with the conditions and recommendations of this finding. DHCD will input data into Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for all Community Development Block Grants Section 108 Loan Guarantees program subawards. Contact - Lesley Edmond, DHCD Housing Compliance Officer Estimated Completion Date - June 28, 2024 See Corrective Action Plan for chart/table
The District Department of Health (DC Health) concurs with the finding. Management Evaluations to Determine Use of COVID Self Declared by Local Agency Staff: The DC WIC State agency will conduct a statewide management assessment exercise to evaluate at least 8 WIC clinics in DC across all 4 local a...
The District Department of Health (DC Health) concurs with the finding. Management Evaluations to Determine Use of COVID Self Declared by Local Agency Staff: The DC WIC State agency will conduct a statewide management assessment exercise to evaluate at least 8 WIC clinics in DC across all 4 local agencies in June 2024 to evaluate adherence to WIC Program regulations, policies and procedure. The areas to be evaluated will include certification and eligibility determination practices by clinic staff in determining income eligibility. Training for all DC WIC Staff by September 30, 2024: As part of staff development and quality assurance, the DC State Agency will conduct a statewide training for all WIC clinic staff to reinforce the steps in determining and documenting the household income of WIC program applicants. Development to Remove the Option to Use COVID Self Declared in HANDS Management Information System: The DC WIC Program is part of a consortium of seven (7) states using the same software. All system changes that require software development will require the consent of all consortium members. DC Will make a request for the option to remove “COVID Self Declared” from the system. The agency hopes this can be done by the end of December 2024, however, there are other developmental changes ongoing that may push the timeline further. Contact - Akua Odi Boateng, WIC State Director Estimated Completion Date - December 30, 2024 See Corrective Action Plan for chart/table
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