Corrective Action Plans

Finding 523391 (2023-005)

Material Weakness 2023

OK

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principle...

Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024

View Audit 342657 Questioned Costs: $1

Finding 523387 (2023-027)

Material Weakness 2023

Government of Guam

GU

Questioned Costs Procurement, Suspension & Debarment

Finding No.: 2023-027 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) For condition 1 the procurement processed was followed based off GAC Title 5 Chapter 5 §5213. For condition 2, the ...

Finding No.: 2023-027 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) For condition 1 the procurement processed was followed based off GAC Title 5 Chapter 5 §5213. For condition 2, the lease was procured by DOA. For condition 3, auditor to provide clarification regarding insufficiency of documentation.

View Audit 342645 Questioned Costs: $1

Finding 523384 (2023-034)

Significant Deficiency 2023

Government of Guam

GU

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

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

Government of Guam

GU

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

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 523377 (2023-031)

Material Weakness 2023

Government of Guam

GU

Questioned Costs Subrecipient Monitoring Reporting

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

Government of Guam

GU

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

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

Government of Guam

GU

Questioned Costs Matching / Level of Effort / Earmarking

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 523364 (2023-022)

Material Weakness 2023

Government of Guam

GU

Questioned Costs Program Income Reporting

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 523359 (2023-017)

Material Weakness 2023

Government of Guam

GU

Questioned Costs Procurement, Suspension & Debarment

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

Government of Guam

GU

Questioned Costs Subrecipient Monitoring Eligibility

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 523354 (2023-012)

Material Weakness 2023

Government of Guam

GU

Questioned Costs Procurement, Suspension & Debarment

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 523349 (2023-009)

Material Weakness 2023

Government of Guam

GU

Questioned Costs Special Tests & Provisions Eligibility

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 523311 (2023-003)

Significant Deficiency 2023

Quest Community Development Organization, Inc.

GA

Questioned Costs Eligibility Special Tests & Provisions

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

Finding 522901 (2023-004)

Significant Deficiency 2023

Clarkson University

NY

Questioned Costs Cash Management Internal Control / Segregation of Duties § 200.303

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 522816 (2023-001)

None 2023

Congregation Masores Hachinuch INC

NY

Questioned Costs

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

Finding 522654 (2023-002)

Significant Deficiency 2023

Fort Fairfield Utilities District

ME

Questioned Costs Allowable Costs / Cost Principles

Management’s response/corrective action plan - We agree the $49,807 was reimbursed twice. We communicated the error to our contact at the USDA and our next grant draw shall be reduced by $49,807.

View Audit 341902 Questioned Costs: $1

Finding 522506 (2023-006)

Material Weakness 2023

Barbour County Board of Education

AL

Questioned Costs Matching / Level of Effort / Earmarking Special Tests & Provisions

The Board will comply with Title 29, U. S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the "Davis-Bacon Act") when using COVID- 19 Education Stabilization Funds for construction.

View Audit 341776 Questioned Costs: $1

Finding 522505 (2023-005)

Material Weakness 2023

Barbour County Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.403

No payments will be made for purchases until the proper documentation is received and attached to the purchase order

View Audit 341776 Questioned Costs: $1

Finding 522501 (2023-006)

Significant Deficiency 2023

Akron Community Service Center & Urban League, Inc.

OH

Questioned Costs Allowable Costs / Cost Principles

For the coding of expenditures for Federal Awards, State Awards, or Pass-through funding, the appropriate Finance, Program Manager, and Program personnel should review the award packet especially the compliance expenditure section where the agency defines the allowable expenses that can be paid, or ...

For the coding of expenditures for Federal Awards, State Awards, or Pass-through funding, the appropriate Finance, Program Manager, and Program personnel should review the award packet especially the compliance expenditure section where the agency defines the allowable expenses that can be paid, or unallowable expenses cannot be included in the program reporting. There are free webinars provided by the Federal Government that will help personnel understand the criteria under “2 CFR Part 200, Subpart E – Cost Principles “for federal awards. Before expenses are incurred, they should be approved through the Purchase Authorization Process with all appropriate signatures being acquired depending on the amount of the expense planned. We meet on a monthly basis to review allowable expenses and the tracking of funds with departments heads.

View Audit 341763 Questioned Costs: $1

Finding 522500 (2023-005)

Significant Deficiency 2023

Akron Community Service Center & Urban League, Inc.

OH

Questioned Costs Allowable Costs / Cost Principles

With the changes in the Leadership Team, the staff is currently reviewing and re-allocating personnel costs into direct program costs and indirect allocatable costs to be distributes through an acceptable allocation or De Minimus calculation. These changes are planned for the current contract year ...

With the changes in the Leadership Team, the staff is currently reviewing and re-allocating personnel costs into direct program costs and indirect allocatable costs to be distributes through an acceptable allocation or De Minimus calculation. These changes are planned for the current contract year with the original program budget submissions being amended to reflect these changes and approved by the funding agency. Currently, AUL utilizes two allocation methods when applicable. Those methods are the Federal De Minimus calculation, or the Direct Administrative Cost Recovery Allocation developed in conjunction with Maximus. All direct labor personnel should be recording their time spent on a program in the Paychek’s Payroll System using the appropriate dropdown listing if the program is a Summit County program the personnel should complete a PAR report monthly for the program time and it should be signed and approved by the Program Director or their designee. These forms should be forwarded to the Finance Department to that they are included in any Program Billing that is necessary for reimbursement. We have established a signature coversheet before we send the invoice to the entity for payment. PAR's are part of this reviewing process.

View Audit 341763 Questioned Costs: $1

Finding 522444 (2023-009)

Material Weakness 2023

Arkansas Baptist College

AR

Questioned Costs Student Financial Aid Eligibility

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Fin...

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to calculating and awarding Pell. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing

View Audit 341725 Questioned Costs: $1

Finding 522442 (2023-008)

Material Weakness 2023

Arkansas Baptist College

AR

Questioned Costs Student Financial Aid Eligibility

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial ...

Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing

View Audit 341725 Questioned Costs: $1

Finding 522440 (2023-007)

Material Weakness 2023

Arkansas Baptist College

AR

Questioned Costs Student Financial Aid Procurement, Suspension & Debarment

Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's...

Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's policy. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing

View Audit 341725 Questioned Costs: $1

Finding 522439 (2023-006)

Material Weakness 2023

Arkansas Baptist College

AR

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Direct...

Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid, Chief Financial Officer & V.P. of Academic Affairs Effective: Immediately and ongoing

View Audit 341725 Questioned Costs: $1

Finding 522432 (2023-002)

Material Weakness 2023

Arkansas Baptist College

AR

Questioned Costs Student Financial Aid Eligibility

Management concurs with this finding. The College will keep accurate attendance and participation records. The College will calculate R2T4s accurately and will return the funds in a timely manner. The College will review and adhere to its practices, policies, and procedures along with federal gui...

Management concurs with this finding. The College will keep accurate attendance and participation records. The College will calculate R2T4s accurately and will return the funds in a timely manner. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to R2T4 regulations. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing

View Audit 341725 Questioned Costs: $1

Corrective Action Plans

Filters