Corrective Action Plans

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View ofResponsible Officials and Planned CorrectiveActions:Managementacknowledges anisolated payrollprocessingerrorduringfiscalyear2023in which overtime hours werenotproperlyenteredforoneemployee.Thiserrordidnotresultinquestionedcosts,asreimbursedpayrollexpenseswere less thanactualpayrollcosts incur...
View ofResponsible Officials and Planned CorrectiveActions:Managementacknowledges anisolated payrollprocessingerrorduringfiscalyear2023in which overtime hours werenotproperlyenteredforoneemployee.Thiserrordidnotresultinquestionedcosts,asreimbursedpayrollexpenseswere less thanactualpayrollcosts incurred. We retrained staffonpayrollprocessingwithemphasis onovertimeentry andverification.Weupdatedpayrollprocesses toensurepayrollstaffarenotifiedwhen overtime isapproved.Weimplementedpre-processingpayrollreconciliation andsupervisoryreviewpriortofinalsubmission.Payrollentries are subjectto supervisory reviewand periodic spotchecks.Correctiveactions havebeenimplementedand are operating onanongoingbasis.
View ofResponsible Officials and Planned CorrectiveActions:Managementacknowledges this findingrelatedtoinconsistentretentionoflease extensionsorrenewals forrentalassistanceprovided beyond originallease terms duringfiscalyear2023.Originalleases were retained forallparticipants;however,extensionsweren...
View ofResponsible Officials and Planned CorrectiveActions:Managementacknowledges this findingrelatedtoinconsistentretentionoflease extensionsorrenewals forrentalassistanceprovided beyond originallease terms duringfiscalyear2023.Originalleases were retained forallparticipants;however,extensionswerenotconsistently obtained. We implementedalease trackingprocess to monitorlease expirationdates.Weupdatedproceduresto requirelease renewalsorextensions priorto issuingassistancebeyondtheoriginallease term.Weimplementedstandardizedfile checklists.Supervisorystaffconductperiodic filereviewsto confirmleasedocumentation coverage.Corrective actionshavebeenimplementedand are operatingonanongoingbasis.
VITEMA concurs with this finding. VITEMA uses the sub-recipient agreement as the source of documentation for enrollment into FFATA. This agreement is signed by the Director of VITEMA and Sub Recipient. VITEMA's Grant Management staff will upload this information into the FRS/SAMS.GOV system. VITEMA'...
VITEMA concurs with this finding. VITEMA uses the sub-recipient agreement as the source of documentation for enrollment into FFATA. This agreement is signed by the Director of VITEMA and Sub Recipient. VITEMA's Grant Management staff will upload this information into the FRS/SAMS.GOV system. VITEMA's Deputy Director of Grants Management will review the FFTA information and validate that the information is true and correct based on the amount approved by DHS and sub-recipient agreement. This FFTA document will be signed and dated by the Deputy Director of Grants Management within the 30 days of required enrollment.
VITEMA concurs with this finding. This information is documented in BSIR as part of the submittal process and does not allow for the submittal of reporting if not verified to meet this requirement. VITEMA will also document this information when preparing the SF 425 report by including this informat...
VITEMA concurs with this finding. This information is documented in BSIR as part of the submittal process and does not allow for the submittal of reporting if not verified to meet this requirement. VITEMA will also document this information when preparing the SF 425 report by including this information in the notes section of this report. This will be conducted on a quarterly basis.
In accordance with 2CFR #200.303 federal recipients VITEMA/ODR must create internal controls that provide reasonable assurance that FFATA reporting requirements are met. Currently, internal controls have been established to ensure compliance with the Federal Funding Accountability and Transparency A...
In accordance with 2CFR #200.303 federal recipients VITEMA/ODR must create internal controls that provide reasonable assurance that FFATA reporting requirements are met. Currently, internal controls have been established to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA). On a monthly basis, the Disaster Program Administrative Assistant in responsible for obtaining the P5 report from the Grants Manager and entering all project with obligated funds exceeding $30,000 into the SAM.gov database, formerly FSRS.gov. The report must be submitted by the end of the following month. Once the data is entered, the Territorial Public Assistance Officer reviews the submission and, upon the verification, certifies that the information has been accurately reported in the federal database. The reports and associated certifications will be placed in a centralized database.
Currently, reports are submitted for review via email. The CMS-64 as well as the CMS-37 is prepared by a consulting firm who submits the copy of the reports for review and approval. Once the Medicaid Director is satisfied, an email is sent approving the report, for further entering into the MBES (CM...
Currently, reports are submitted for review via email. The CMS-64 as well as the CMS-37 is prepared by a consulting firm who submits the copy of the reports for review and approval. Once the Medicaid Director is satisfied, an email is sent approving the report, for further entering into the MBES (CMS system of record) and certification. To ensure access for audit purposes, the Department has implemented a shared folder where copies of approval emails and any time extension requests are stored, since the submission portal does not allow for attachments. Additionally, a Director of Federal Grants has been on-boarded who will assume the role of preparing the reports.
Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibil...
Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibility of reviewing completed case files.
DHS is committed to strengthening internal controls and addressing the auditors’ concern related to the reconciliation process and the importance of clear, auditable reconciliation processes that fully support the preparation of the Schedule of Expenditures of Federal Awards (SEFA) and demonstrate c...
DHS is committed to strengthening internal controls and addressing the auditors’ concern related to the reconciliation process and the importance of clear, auditable reconciliation processes that fully support the preparation of the Schedule of Expenditures of Federal Awards (SEFA) and demonstrate compliance with internal control requirements. DHS will continue to collaborate closely with the auditors and other stakeholders in the reconciliation process and SEFA preparation to ensure all affected parties confirm receipt of required documentation so determination of compliance can be readily identified, confirming DHS’s commitment to federal funds stewardship. To achieve this, DHS will streamline communication between all parties through a designated point of contact, the Director of Audit & Compliance who onboarded in August 2025, to make certain that necessary documentation is distributed to all stakeholders involved.
DHS remains in collaboration with Federal Partners relative to the required change to reflect a consolidated report in the Payment Management System financial reporting module. All parties are in agreement that one report is required representing the financial expenditure reporting mirroring the cor...
DHS remains in collaboration with Federal Partners relative to the required change to reflect a consolidated report in the Payment Management System financial reporting module. All parties are in agreement that one report is required representing the financial expenditure reporting mirroring the core concept of the consolidation of the various grants. Relative to the pre and post expenditures, reports are submitted through the portal, represented by a submission log. There are no provisions for approval or acceptance by the Federal partners apparent in said portal. While email notices are received acknowledging receipt, a formal acceptance is not received. Conversations are ongoing with the Federal partners relative to receiving a formal notification.
DHS remains in compliance with this finding from previous audit years, the untimely submission led to the issue in current year. To address this, a shared file will be established to ensure that the necessary information for each year is readily available for audit purposes.
DHS remains in compliance with this finding from previous audit years, the untimely submission led to the issue in current year. To address this, a shared file will be established to ensure that the necessary information for each year is readily available for audit purposes.
A Federal Grants Financial Analyst for CCDF program has been hired and is tasked with ensuring the accuracy and submission of financial reports. Internal controls have been established, requiring final review and approval by a supervisor.
A Federal Grants Financial Analyst for CCDF program has been hired and is tasked with ensuring the accuracy and submission of financial reports. Internal controls have been established, requiring final review and approval by a supervisor.
The Governing Board transitioned to virtual meetings due to the pandemic, which pre-empted the FY22 training, and has incorporated electronic voting into its procedures. Regular training is now conducted to enable the governing body to effectively perform its legal, fiscal, and oversight responsibil...
The Governing Board transitioned to virtual meetings due to the pandemic, which pre-empted the FY22 training, and has incorporated electronic voting into its procedures. Regular training is now conducted to enable the governing body to effectively perform its legal, fiscal, and oversight responsibilities. Technical Assistance from the Region II TA team assists the Head Start program in meeting this requirement.
Training was provided directly by the Federal Partner to ensure the completion of said reports. Additionally, the completion and submission of this report is being repositioned to the Fiscal Office. A review of these reports will be incorporated in the Quarterly standing meetings with the Office of ...
Training was provided directly by the Federal Partner to ensure the completion of said reports. Additionally, the completion and submission of this report is being repositioned to the Fiscal Office. A review of these reports will be incorporated in the Quarterly standing meetings with the Office of Head Start and the Office of Fiscal Management.
The Government concurs with the auditor’s findings and recommendations. VIDE is addressing deficiencies in the reporting processes for the COVID-19 Education Stabilization Fund (ESF-SEA) by committing to enhance reporting practices for compliance with federal requirements. This includes implementing...
The Government concurs with the auditor’s findings and recommendations. VIDE is addressing deficiencies in the reporting processes for the COVID-19 Education Stabilization Fund (ESF-SEA) by committing to enhance reporting practices for compliance with federal requirements. This includes implementing a structured review and approval process for all performance and special reports, ensuring they are vetted by appropriate officials. Additionally, training will be provided to all staff involved in report preparation and submission.
The Government concurs with the auditor’s findings and recommendations. VIDE plans to address the audit finding on FFATA reporting by developing detailed reporting policies and procedures. These will include guidelines for identifying and tracking subawards, collecting required data, and setting sub...
The Government concurs with the auditor’s findings and recommendations. VIDE plans to address the audit finding on FFATA reporting by developing detailed reporting policies and procedures. These will include guidelines for identifying and tracking subawards, collecting required data, and setting submission timelines. Roles and responsibilities of personnel involved will be clearly defined. VIDE will enhance existing system or implement a new system for tracking subawards and provide comprehensive training to staff. Data verification and validation procedures will be strengthened, with formal processes for reviewing data accuracy before submission and regular reconciliations to ensure consistency. Mandatory training sessions will ensure all personnel understand FFATA requirements and new reporting procedures.
The Government concurs with the auditor’s findings and recommendations. Starting in 2024, OMB has implemented a reporting approval memo, signed by the OMB Director, to confirm the review and approval of Treasury reports. OMB has enhanced the collection and storage of supporting financial information...
The Government concurs with the auditor’s findings and recommendations. Starting in 2024, OMB has implemented a reporting approval memo, signed by the OMB Director, to confirm the review and approval of Treasury reports. OMB has enhanced the collection and storage of supporting financial information for all projects in quarterly reports, ensuring necessary support is available upon request as of FY23.
VIDOL concurs with the auditor’s findings and recommendations. VIDOL has reviewed its policies and procedures and is working to provide staff training to ensure supporting documentation is secure and readily accessible. VIDOL will update its policies and procedures to ensure that all supporting docu...
VIDOL concurs with the auditor’s findings and recommendations. VIDOL has reviewed its policies and procedures and is working to provide staff training to ensure supporting documentation is secure and readily accessible. VIDOL will update its policies and procedures to ensure that all supporting documentation is certified by the UI Director or designee before a report is submitted to the grantor. VIDOL will provide a copy of the report along with supporting documentation to the Business Administration Unit for recordkeeping. VIDOL is implementing a RESEA case management system for reporting and program services, currently in the testing and configuration phase. This case management system will serve as the official system for documenting all services provided to RESEA claimants participating in the program.
VIDOL concurs with the auditor’s findings and recommendations. VIDOL has reviewed its policies and procedures and is working to provide staff training to ensure supporting documentation is secure and readily accessible. VIDOL will update its policies and procedures to ensure that all supporting docu...
VIDOL concurs with the auditor’s findings and recommendations. VIDOL has reviewed its policies and procedures and is working to provide staff training to ensure supporting documentation is secure and readily accessible. VIDOL will update its policies and procedures to ensure that all supporting documentation is certified by the UI Director or designee before a report is submitted to the grantor. The UI Division will provide a copy of the report along with supporting documentation to the Business Administration Unit for recordkeeping. VIDOL is seeking alternative funding to procure a Trust Fund accounting system due to the loss of previously identified ARPA funding.
The Government concurs with the auditor’s findings and recommendations. The Government plans a high-level review of internal control policies and closely monitoring reports for completeness, accuracy, timeliness, and consistency with Cognizant Agency guidelines. An analyst will be assigned to track ...
The Government concurs with the auditor’s findings and recommendations. The Government plans a high-level review of internal control policies and closely monitoring reports for completeness, accuracy, timeliness, and consistency with Cognizant Agency guidelines. An analyst will be assigned to track reporting schedules, oversee grant activity, and manage document storage, ensuring timely submission of all required reports for each grant award.
The Department of Health will create an internal control procedure to indicate proper review and approval of the SF-425 excel print out from the electronic USDA FPRS System.
The Department of Health will create an internal control procedure to indicate proper review and approval of the SF-425 excel print out from the electronic USDA FPRS System.
The AAIHB missed the filing deadline for the FY 2023 Federal Financial Reports for seven different reports due during the 2023 FY. The AAIHB has filed the FY 2023 Federal Financial Reports as of the date this report is dated. The AAIHB will review and revise its internal review processes to ensure f...
The AAIHB missed the filing deadline for the FY 2023 Federal Financial Reports for seven different reports due during the 2023 FY. The AAIHB has filed the FY 2023 Federal Financial Reports as of the date this report is dated. The AAIHB will review and revise its internal review processes to ensure future Federal Financial Reports are completed and filed in a timely manner. Corrective action plan timeline is to submit FY 2024 and FY 2025 Federal Financial Reports within the required timeline. Designation of Employee Position Responsible for Meeting Deadline Executive Director and Finance Officer
The AAIHB has missed the filing deadline for the FY 2023 Data Collection Form. The AAIHB will file the FY 2023 Data Collection Form within 30 days. The AAIHB will review and revise its internal review processes to ensure future Data Collection Forms are completed and filed in a timely manner. Correc...
The AAIHB has missed the filing deadline for the FY 2023 Data Collection Form. The AAIHB will file the FY 2023 Data Collection Form within 30 days. The AAIHB will review and revise its internal review processes to ensure future Data Collection Forms are completed and filed in a timely manner. Corrective action plan timeline is to submit FY 2024 audit and data collection forms within 30 days. Executive Director and Finance Officer
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did...
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did not agree to the underlying profit and loss detail from the Organization’s General Ledger(s) for the related grants. In addition, the certified authorized official was not an employee of the Organization and there was a lack of documentation for how the certifying official was deemed appropriate. In the sample quarterly reports, the Organization had contradicting responses related to whether reimbursement requests reflect actual spending of designated Supportive Services for Veteran Families (SSVF) funding. Corrective Action Plan: • Internal Controls are being evaluated and addressed with the Board of Directors on clarity of Financial Policy and Procedures • Implement a formal reconciliation process to ensure all grant financial reports agree to the underlying general ledger and profit and loss statements. • Establish a documented policy identifying employees authorized to certify grant reports, ensuring these individuals are employees of the Organization and appropriately trained. • Conduct regular training and internal reviews to confirm consistent understanding of grant-specific reporting requirements, particularly those related to reimbursement-based funding such as SSVF. • Develop a standard operating procedure (SOP) for reviewing and approving financial reports before submission to funders. Prior to sending to funder/portal. Must have reconciliation to numbers prior to next period reporting. • Site Review of reporting will have oversight of Financial Dept and reconciliation communication. Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: We cannot alleviate within 12 months
Personnel Responsible for Corrective Action: Jim Keeney, CFO, Eljana Kaziaj, Controller, Ro White, Grant Manager Anticipated Completion Date: Completed. Corrective Action Plan: Management acknowledges the recommendation and will implement the policy and procedure for timely federal grant reports. Th...
Personnel Responsible for Corrective Action: Jim Keeney, CFO, Eljana Kaziaj, Controller, Ro White, Grant Manager Anticipated Completion Date: Completed. Corrective Action Plan: Management acknowledges the recommendation and will implement the policy and procedure for timely federal grant reports. The additional accounting resources will now ensure proper oversight of the process. Reports will be timely and reviewed/approved by the CFO.
Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 2...
Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 27, 2025. The Medical Center has implemented a tracking procedure for all grants that includes due dates for required reporting. The Controller maintains a list of compliance requirements for each grant which is reviewed by the Chief Financial Officer. Additionally, the primary contact information for grants is updated upon any changes in personnel to ensure communications are routed to the appropriate individual for follow-up.
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