Corrective Action Plans

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CONTACT PERSON: Mandy Hess, Finance Director, mhess@pickenscity.com CORRECTIVE ACTION: The City has implemented procedures to ensure that amounts reported for grant reporting amounts are accurate and are consistent with the City’s general ledger. PROPOSED COMPLETION DATE: December 31, 2026
CONTACT PERSON: Mandy Hess, Finance Director, mhess@pickenscity.com CORRECTIVE ACTION: The City has implemented procedures to ensure that amounts reported for grant reporting amounts are accurate and are consistent with the City’s general ledger. PROPOSED COMPLETION DATE: December 31, 2026
2024-005 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Education Stabilization Fund - U.S. Department of Education passed through the Pennsylvania Department of Education COVID-19 - Elementary and Secondary School Emergency Relief Fund (ARP ESSER) ALN 84.425U; Contract #223-21-0141; Grant Perio...
2024-005 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Education Stabilization Fund - U.S. Department of Education passed through the Pennsylvania Department of Education COVID-19 - Elementary and Secondary School Emergency Relief Fund (ARP ESSER) ALN 84.425U; Contract #223-21-0141; Grant Period 03/13/20 - 09/30/24 COVID-19 - ARP ESSER Learning Loss Set Aside ALN 84.425U; Contract #225-21-0141; Grant Period 03/13/20 - 09/30/24 Criteria The District is required to submit an annual performance report to the Commonwealth of Pennsylvania (the “State”) with data on expenditures, planned expenditures, subrecipients, and uses of funds, including for mandatory reservations. Condition During the year ended June 30, 2024, the District submitted a report for the funds used during the year ended June 30, 2023. The report submitted by the District contained expenditure amounts that did not agree to the amounts reported on the schedule of expenditures of federal awards for the year ended June 30, 2023 as well as other key reporting line items. Recommendation We recommend the District keep a reconciliation of grant awards available to expenditure incurred. The accurate use of funding source codes will assist in that process. We also recommend the District continue working toward more timely financial and compliance audits. Management Response When the district received the audit, the 2023 federal reports were already submitted. The District made the adjustments for non-allowable expenses in the 2023 SEFA and took out the non-allowable in the 2024 State reports. The District has begun using and reconciling funding source codes related to grants more timely.
Management will file the audited financial statements for the year ended June 30, 2024, as soon as possible. The underlying causes included prolonged resource constraints within the Finance Department, turnover in key accounting positions, challenges associated with the ERP system implementation, an...
Management will file the audited financial statements for the year ended June 30, 2024, as soon as possible. The underlying causes included prolonged resource constraints within the Finance Department, turnover in key accounting positions, challenges associated with the ERP system implementation, and delays in reconciling certain major balance sheet accounts. To address these issues, the City engaged an external financial consultant to assist in completing outstanding bank reconciliations and restoring timely financial reporting. Management is also implementing additional corrective measures, including reprioritizing workloads, enhancing oversight of monthly close activities, and establishing standardized reconciliation checklists for all major balance sheet accounts. Management anticipates that this finding will extend through the Fiscal Year 2025, and possibly Fiscal Year 2026 financial statement reporting cycles, with full resolution expected in Fiscal Year 2027.
Finding 1213951 (2024-010)
Material Weakness 2024
The Creek County Clerk’s Office will work with the SEFA preparer to ensure that the correct paid dates are being used when reporting. This should eliminate the actual expenditures differences. We will work to educate all offices involved in the reporting process on financial statement and SEFA.
The Creek County Clerk’s Office will work with the SEFA preparer to ensure that the correct paid dates are being used when reporting. This should eliminate the actual expenditures differences. We will work to educate all offices involved in the reporting process on financial statement and SEFA.
2024-001 – Data Collection Forms Finding: Our audit procedures noted Alliance for Rights and Recovery, Inc. did not certify or submit the required Data Collection Form for the fiscal year ended December 31, 2023 related to the 2023 Single Audit. As of the date of our 2024 audit, the Data Collection ...
2024-001 – Data Collection Forms Finding: Our audit procedures noted Alliance for Rights and Recovery, Inc. did not certify or submit the required Data Collection Form for the fiscal year ended December 31, 2023 related to the 2023 Single Audit. As of the date of our 2024 audit, the Data Collection Form and accompanying reporting package remain unsubmitted. Recommendation: We recommend that the organization implement procedures to ensure the timely preparation, certification, and submission of the annual Data Collection Form and reporting package. This should include assigning responsibility for tracking deadlines, establishing a completion checklist, and documenting management review prior to submission. Action Taken: The Agency will assign the CFO the responsibility of reviewing all 9melines and documents needed for the annual audit.
Name of Contact Person: Willow Hetrick-Price Corrective Action Planned: Due to turnover of the Commission's accounting staff, the Commission was unable to have the annual audit completed within the required timeframe, and subsequently was also late in submission of the FAC report. The Commission has...
Name of Contact Person: Willow Hetrick-Price Corrective Action Planned: Due to turnover of the Commission's accounting staff, the Commission was unable to have the annual audit completed within the required timeframe, and subsequently was also late in submission of the FAC report. The Commission has hired internal staff to help with the audit preparation and contracted with an accounting firm that has provided the Commission a CPA to conduct audit preparation and other financial services as requested. The Commission will work on getting financial information in a timely fashion and submit the reporting package in accordance with the guidelines. Anticipated completion date: September 30, 2026.
While the Authority continues to be delinquent on the current year audit completion, a consulting firm was hired to assist with bringing records up to date. The Authority also had hired an assistant fiscal officer in the fall of 2021 and another assistant fiscal officer in the fall of 2022. As a res...
While the Authority continues to be delinquent on the current year audit completion, a consulting firm was hired to assist with bringing records up to date. The Authority also had hired an assistant fiscal officer in the fall of 2021 and another assistant fiscal officer in the fall of 2022. As a result of the hiring, job responsibilities have been re-assigned and data gathering for future audits will occur in a timely manner. Accounts have been reconciled through December 31, 2025 prior to the 2024 audit commencing. The Authority will continue to execute their plan to have the audits completed on a timely basis and expects to submit the audited financial statements and single audit reporting package for the year ended December 31, 2025 to the Federal Audit Clearinghouse timely.
The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which in...
The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. This finding has since been resolved in 2025, with a new policy developed and implemented on April 1, 2025.
In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annu...
In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Report (CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. This finding has since been resolved in 2025, with a new policy developed and implemented on December 12, 2025.
Finding 2024-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Cindy Sharp, Deputy Finance Director Corrective Action Plan: Management has hired a new finance director with governmental accounting experience, as well as an accountant (a licensed CPA in Colorado...
Finding 2024-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Cindy Sharp, Deputy Finance Director Corrective Action Plan: Management has hired a new finance director with governmental accounting experience, as well as an accountant (a licensed CPA in Colorado) with a long history of governmental auditing and accounting experience. Management, together with experienced accounting staff, will review reporting deadlines and work diligently toward timely report submissions in the future. Management and accounting staff will also carefully review reporting requirements and ensure that requirements are adhered to. This includes the following program(s): Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) / ARPA Non-Profit Recovery Funds (NPRF) (ALN 21.027). Proposed Completion Date: Fiscal year 2025.
Response: Management agrees with the finding and will work to assure that the 2025 audit is submitted to the Federal Audit Clearinghouse by the due date of September 30, 2026. Responsible Party: Ann Rogers, Chief Executive Officer Estimated Completion Date: September 30, 2026
Response: Management agrees with the finding and will work to assure that the 2025 audit is submitted to the Federal Audit Clearinghouse by the due date of September 30, 2026. Responsible Party: Ann Rogers, Chief Executive Officer Estimated Completion Date: September 30, 2026
Auditor’s recommendation: The Organization’s internal control over financial reporting should be modified to present financial statements in accordance with US GAAP through reduction in audit adjusting journal entries and improve the timing of the six-month period end closing process. Auditee’s resp...
Auditor’s recommendation: The Organization’s internal control over financial reporting should be modified to present financial statements in accordance with US GAAP through reduction in audit adjusting journal entries and improve the timing of the six-month period end closing process. Auditee’s response: The Organization is continuing to develop effective internal controls over financial reporting to ensure that financial statements are prepared in accordance with US GAAP on a timely basis.
Auditor’s recommendation: The Organization’s internal control over financial reporting should be modified to present financial statements in accordance with US GAAP through reduction in audit adjusting journal entries and improve the timing of the year end closing process. Auditee’s response: The Or...
Auditor’s recommendation: The Organization’s internal control over financial reporting should be modified to present financial statements in accordance with US GAAP through reduction in audit adjusting journal entries and improve the timing of the year end closing process. Auditee’s response: The Organization is continuing to develop effective internal controls over financial reporting to ensure that financial statements are prepared in accordance with US GAAP on a timely basis.
VIDCOE will establish and document capitalization thresholds and procedures for identifying, recording, and depreciating capital assets, including maintaining a fixed asset register with periodic reconciliations. Procedures will also be implemented to ensure prepaid expenses are recorded appropriate...
VIDCOE will establish and document capitalization thresholds and procedures for identifying, recording, and depreciating capital assets, including maintaining a fixed asset register with periodic reconciliations. Procedures will also be implemented to ensure prepaid expenses are recorded appropriately and amortized over the periods benefited. In addition, grant accounting policies will be strengthened to ensure that funds received in advance are recorded as refundable advances and recognized as revenue only as allowable expenditures are incurred, in compliance with grant agreements and federal requirements. To further strengthen internal controls, VIDCOE will implement formal supervisory review and reconciliation procedures, including routine account reconciliations and financial statement reviews, to ensure transactions are properly classified, supported, and recorded. VIDCOEs’ Management expects to fully implement all corrective actions by July 30, 2026.
Finding No.: 2024-052 Reporting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will work with DOA to make sure reports are submitted on time. GHS will also retain documentation of submitted reports.
Finding No.: 2024-052 Reporting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will work with DOA to make sure reports are submitted on time. GHS will also retain documentation of submitted reports.
Finding No.: 2024-051 Period of Performance Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures over compliance with applicable period of Performance require...
Finding No.: 2024-051 Period of Performance Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures over compliance with applicable period of Performance requirements, as well as retention of all grant agreements. GHS will also identify department personnel responsible.
Finding No.: 2024-048 Eligibility Special Test and Provisions- Utilization Control Provider Eligibility (Screening and Enrolment) Provider Health and Safety Standards Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agr...
Finding No.: 2024-048 Eligibility Special Test and Provisions- Utilization Control Provider Eligibility (Screening and Enrolment) Provider Health and Safety Standards Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. To address the recommendation for a reconciliation process, DPHSS is in the process of forming a multi-agency technology initiative which will include: • Establishment of an Inter-Agency Data Hub: DPHSS, in collaboration with the Office of Technology (OTECH) and the Department of Administration (DOA), aims to establish a centralized Data Hub. This hub will facilitate real-time or scheduled data synchronization between the DPHSS medical management systems and DOA’s financial accounting records, which are managed in the Guam Financial Management Information System (GFMIS). The data hub is intended to ensure all claims paid are automatically after proper approvals and are then reconciled with the general ledger. • Inter-Agency Agreement and Coordination: DPHSS acknowledges that successful implementation of this Data Hub requires a unified commitment. DPHSS leadership is coordinating with the Director of DOA to discuss the technical requirements and administrative protocols. A formal Memorandum of Agreement (MOA) or a joint standard procedure will be sought, subject to the concurrence and approval by both Agency Directors. • Manual Interim Reconciliation: Until the Data Hub is fully operational, DPHSS will work with DOA to implement a monthly manual reconciliation process. This will involve a "crosswalk" review of claim batch totals against financial system postings to identify and resolve variances (such as voided checks or manual adjustments) in a timely manner. • Engagement with OTECH: Once the two directors agree on the framework, DPHSS will engage OTECH to design the data architecture necessary to ensure data integrity, security, and compliance with federal reporting standards. Estimated implementation timeframe: March 31, 2027
Finding No.: 2024-047 Special Test and Provisions Provider Eligibility (Screening and Enrolment) Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. DPHSS is aware that deficiencies exist with the...
Finding No.: 2024-047 Special Test and Provisions Provider Eligibility (Screening and Enrolment) Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. DPHSS is aware that deficiencies exist with the Medicaid provider enrolment process. DPHSS’s response to this deficiency is addressed in its modernization plan, which will automate certain provider enrolment functions. In March 2024, DPHSS performed site visits for 21 providers, and since then has continued to perform site visits year-round. Memorandums regarding provider compliance topics have also been communicated to providers and published on the provider portal, including information regarding criminal background checks. DPHSS is currently contracted with a consultant that is assisting in the implementation of compliant provider enrolment operations, which includes policy revisions, updates to provider applications and disclosure forms, development of standard operating procedures, and training for both staff and providers. In addition, DPHSS is currently in the process of establishing a Medicaid Program Integrity Unit (PI Unit) with a mission to conduct independent and objective Medicaid program integrity functions adherent to federal and local laws. The PI Unit will also assist DPHSS in addressing and managing Medicaid related Corrective Action Plans.
Finding No.: 2024-046 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS disagrees with this finding and provided documentation of grantor approval to use the FY 2024 award to pay prior year obligati...
Finding No.: 2024-046 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS disagrees with this finding and provided documentation of grantor approval to use the FY 2024 award to pay prior year obligations. The enclosed communication from Linda Gee, CMS, dated July 1, 2021, provides more information. 45 CFR 95.7 (https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.95&rgn=div5#se45.1.95_17) provides that a state Medicaid agency (i.e. Guam Medicaid Agency) has up to two years to file for a claim that it made. DPHSS welcomes the opportunity to discuss and collaboratively identify the relevant information and guidance during an entrance conference for each year’s audit.
Finding No.: 2024-045 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. The Bureau of Economic Security (BES) recognized the finding as an issue and in response, held a bureau-wide t...
Finding No.: 2024-045 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. The Bureau of Economic Security (BES) recognized the finding as an issue and in response, held a bureau-wide training for both front desk personnel and eligibility specialists on December 22 - 23, 2025. This training focused on application handling including the timeliness of eligibility determinations and proper documentation maintenance procedures. The training reinforced use of a standardized application checklist that was developed to support application completeness. Staff were also trained in the correct method for uploading documents into the OnBase system, the bureau’s digital record archive, for secure storage and efficient retrieval. In January 2026, BES conducted a Customer Email Standard Operating Procedure (SOP) training to reinforce staff compliance with documentation requirements, including the use of document imaging process (DIP) to ensure customer documentation received via email is uploaded into the OnBase system within two business days. In addition, DPHSS is preparing additional training sessions, which are currently being developed, on topics such as Medicaid Basics 101, Customer Service, and Medicaid Eligibility. To assess compliance with the training, Eligibility Specialist Supervisors were tasked with periodically reviewing random samples of applications across all three centers to verify application completeness, including required documents. BES will further reinforce timeliness compliance by incorporating 45-day timeliness checks and targeted reviews of higher-risk cases into supervisory case reviews. Findings from these reviews will be used to inform corrective action and retraining as needed. DPHSS is also revising the document verification list in the Public Application form to help clients clearly identify required documentation needed to support eligibility determination and reduce the risk of missing or incomplete case files.
Finding No.: 2024-044 Special Test and Provisions Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. All applicable providers ...
Finding No.: 2024-044 Special Test and Provisions Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. All applicable providers were monitored and met necessary health and safety requirements. All supporting inspection reports and certifications exist and were provided to the auditors via a OneDrive link on February 9, 2026, following a subsequent request for information. Additionally, in accordance with the Rules and Regulations Governing Child Care Facilities Section 1.5.00 (a), Relative Care facilities are exempt from Sanitary Permits. BCCS requests a detailed breakdown of the $3,726,391 valuation to clarify if the audit team applied a total disallowance of payments or a weighted penalty for perceived documentation gaps. We maintain that this dollar amount is fundamentally inaccurate if the assessment did not properly factor in the specific regulatory exemptions applicable to these providers. Furthermore, BCCS questions the rationale used to assign such a substantial fiscal impact to an administrative-heavy finding, especially where the core program requirements and services were successfully fulfilled.
Finding No.: 2024-043 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Bureau of Child Care Services (BCCS) disagrees with this finding. BCCS maintains that it enforces strict monitoring controls over co...
Finding No.: 2024-043 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Bureau of Child Care Services (BCCS) disagrees with this finding. BCCS maintains that it enforces strict monitoring controls over compliance with reporting requirements and that the variances noted are not a result of inaccurate data entry but that is due to the cumulative reporting until the end of the grant period. BCCS’ ACF-696 quarterly reports are reported cumulatively through the grant's liquidation end date, and any quarterly reported variances are reconciled by the end of the grant period. During a Reporting Walkthrough meeting with Ernst & Young Senior Auditor, on November 17, 2025, BCCS discussed detailed reporting requirements, processes, and procedures. During this meeting, the agency communicated how responsible personnel review accounting records and perform the reconciliation of required reports.
Finding No.: 2024-042 Matching, Level of Effort, Earmarking Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding and maintains that it has enhanced monitoring c...
Finding No.: 2024-042 Matching, Level of Effort, Earmarking Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding and maintains that it has enhanced monitoring controls to ensure compliance with all applicable earmarking requirements. BCCS reports expenditures on a cumulative basis until the grant’s liquidation end date. This reporting structure provides the necessary flexibility to reconsolidate cost categories, ensuring that final totals align with mandated spending thresholds by the end of the grant period. Furthermore, BCCS maintains that Quality Rating and Improvement System (QRIS) initiatives and other quality-enhancing activities were actively conducted throughout the performance period. To ensure a thorough reconciliation of these expenditures, BCCS formally requests the supporting documentation and specific sample set used by the auditors to conclude that these activities were not sufficiently documented or performed. We are prepared to provide evidence of these programmatic activities to demonstrate compliance with earmarking requirements.
Finding No.: 2024-041 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. Eligibility determinations were conducted in accordance with federal and...
Finding No.: 2024-041 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. Eligibility determinations were conducted in accordance with federal and local requirements. The exceptions noted are due to a subsequent request received by BCCS on January 20, 2026, and consequently responded to on January 29, 2026. Additional supporting documents were provided on February 9, 2026. Certain payment variances reflect allowable program exceptions.
Finding No.: 2024-038 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS ELC Program disagrees with the findings. Condition 1: The questioned labor costs of $16,668 align with payment of Core funded ...
Finding No.: 2024-038 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS ELC Program disagrees with the findings. Condition 1: The questioned labor costs of $16,668 align with payment of Core funded staff during that approved budget period for BP01. The PPE coincides with two draws for the ending and beginning of those fiscal years. Supporting documents were submitted twice, once on February 9, 2026, and February 20, 2026, including the Notice of Award (NOA) for this grant with issue date of July 9, 2024. Condition 2: The question of compliance with period of performance was justified through supporting documentations as reflected in the NOAs and extensions of NOAs which were provided twice February 9, 20206 and February 23, 2026. Program also noted that core funds have expanded authority to be utilized in subsequent budget periods throughout the 5-year cycle of the Cooperative Agreement. Upon auditor’s review, a correspondence email noted that the documents were received and findings were removed for all but on expense. Although all supporting NOAs were submitted for every expenditure amount, a follow up email with the last NOA for 6NU50CK000561-05-00 was provided again as an attachment.
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