Corrective Action Plans

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The Organization experienced substantial growth of programmatic activities which required the department to focus on ongoing maintenance and tracking. The Organization completed a significant components of year end close in the fall of 2023 and final review and adjustments to the SEFA were conducted...
The Organization experienced substantial growth of programmatic activities which required the department to focus on ongoing maintenance and tracking. The Organization completed a significant components of year end close in the fall of 2023 and final review and adjustments to the SEFA were conducted in January 2025. The department is finalizing the year end close for the next year end close and will focus on the completeness and accuracy of the SEFA.
Finding 523479 (2023-001)
Significant Deficiency 2023
We are in agreement with the auditors' finding. In the future, we will be prepared for the reporting requirements and the data collection form will be submitted within 30 days after the receipt of the auditor’s report or nine months after the end of the audit period. Moving forward, the SEFA will be...
We are in agreement with the auditors' finding. In the future, we will be prepared for the reporting requirements and the data collection form will be submitted within 30 days after the receipt of the auditor’s report or nine months after the end of the audit period. Moving forward, the SEFA will be prepared alongside other necessary documents to facilitate the audit process efficiently, and the audit submission will be completed on time. The organization has implemented new measures to monitor the progress of audit activities, including the preparation of the audit by their independent auditing firm, and ensure adequate time is allotted for submission and correspondences within the required deadlines.
Finding #2023-002 – Significant Deficiency. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93...
Finding #2023-002 – Significant Deficiency. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93.788, Opioid STR, Passed through the Texas Health and Human Services Commission, Contract #HHS000357900001, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the University of Texas Health Science Center, San Antonio, Contract #HHS000561800001, Contract year: 09/01/21 – 08/31/22. Other federal programs: U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/21 – 09/29/22, Contract #5H79TI080624-04, Contract year: 09/30/22 – 09/29/23, Passed through the City of Houston Health Department, Assistance Listing #93.243, Contract #H79SP080300, Contract years: 11/01/21 – 10/31/22, 11/01/22 – 10/31/23 and 06/08/21 – 06/30/23, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Passed through the Texas Health and Human Services Commission, Contract #HHS000130500019. Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23. Condition and context: Houston Recovery Center is required to submit monthly reimbursement requests for five of its federal programs; one program requires reimbursement requests based on achievement of certain milestones rather than time. Out of a sample of 17 requests for the five reimbursement programs, we found six did not have evidence of review and approval as required by Houston Recovery Center’s policies and procedures. Recommendation: Training should be provided to ensure that policies and procedures regarding independent review and approval are followed. Planned corrective action: Houston Recovery Center will strengthen its internal control policies and procedures over independent review and approval of grant payment requests by shifting the primary review and approval process from the Chief Executive Officer (CEO) to the Chief Operating Officer (COO). The COO has full knowledge of allowable costs and has more availability than the CEO, which will make it easier to ensure that our policies and procedures are followed on a consistent basis. The CEO will continue in this role as backup to the COO to ensure immediate access for needed approval. We believe we have a strong system in place used by our accounting department to ensure all expenses underlying the grant payment requests are reviewed, checked for accuracy, and properly approved which further supports the reimbursement policies and procedures. Responsible officer: Leonard Kincaid, Executive Director. Estimated completion date: November 1, 2023.
Finding No.: 2023-026 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Implementation of a Fixed Assets Module as part of the new FMIS system is near completion which will help automate ...
Finding No.: 2023-026 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Implementation of a Fixed Assets Module as part of the new FMIS system is near completion which will help automate the tracking and reporting of capital assets. DOA will update the SOP for the Fixed Assets for capital asset reporting accordingly. In addition, the Agency will require all line agencies to designate a property manager to periodically track tagged assets on a revolving basis. Review of Assets acquired in FY2023 was completed, with FY2024 in progress. As noted previously, the process is hampered by difficulties in recruiting personnel.
Finding 523383 (2023-033)
Significant Deficiency 2023
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with t...
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with the Department of Administration (DOA) financial system. One of the primary challenges arises from transactions that are not processed within the designated reporting period, which impacts on our initial submissions to CMS. Any adjustments or transactions made after the quarter's close, which were not captured in our previous reports, contribute to this issue. We understand that addressing this finding is a critical part of our corrective action measures. We are currently working on updating the existing Standard Operating Procedure (SOP) 2023-01, which governs interactions between the Department of Public Health and Social Services (DPHSS) and DOA/Division of Accounts. Since November 2024, we have been collaborating with DOA to revise this SOP with the goal of reconciling Medicaid and CHIP expenditures, as well as aligning reports from CMS-64 with the new Guam Financial Management Information System (GFMIS). Currently, PMS staff is in the process in finalizing the DRAFT SOP. We intend to have the DRAFT SOP completed and forwarded to DOA by Friday, January 31, 2025. If there are no changes to the SOP, we will work to have the SOP signed by all parties no later than February 14, 2025.
Finding 523380 (2023-032)
Significant Deficiency 2023
Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau wil...
Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau will hold providers accountable by issuing a Letter of Warning (LOW) and a Correction Action Plan (CAP) from the Social Service Licensing Officer or Child Care Compliance Officer to ensure compliance with the standards. The Agency disagrees with Condition 1. License-exempt childcare providers will not have an annual DEH inspection since they are not required to obtain a sanitary permit.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds...
Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds under the Qualified and Eligible Child Care Providers, Provider Reporting and Monitoring, the ARP Act does not include specific reporting requirements for childcare providers receiving subgrants and any subgrant reporting requirements are at the discretion of the lead agency, page 21. Additionally, Lead Agencies that use other governmental or non-governmental subrecipients to administer the program must have written agreements in place outlining roles and responsibilities for meeting CCDF requirements. The contents of the written agreement may vary based on the role the subrecipient is asked to assume or the type of product undertaken, but must include, at a minimum, tasks to be performed, a schedule for completing tasks, a budget which itemizes categorical expenditures, and indicators or measures to assess performance. The Lead Agency has fulfilled this requirement in accordance with 45 CFR section 98.1.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-030 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due ...
Finding No.: 2023-030 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process. For condition 2, the Agency will report first-tier subawards to the FSRS system. However, it is noteworthy to mention that the system will be expiring as of March 2025.
Finding 523371 (2023-029)
Significant Deficiency 2023
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-025 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any ...
Finding No.: 2023-025 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any subrecipient account a copy of the FATA report be attached, as well as, creating a check list of subrecipient monitoring requirements prior to any payments being made.
Finding No.: 2023-023 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Du...
Finding No.: 2023-023 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process.
Finding No.: 2023-022 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza (GEPA) Agency disagrees with the findings. The program income is not tied to assist or supplement the federal awards. The program income is us...
Finding No.: 2023-022 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza (GEPA) Agency disagrees with the findings. The program income is not tied to assist or supplement the federal awards. The program income is used to supplement the special revenue funds handle by the department.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-019 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) An awardee could not report the required information in FSRS unless the federal awarding agency has registered the award. The US Treasury has no...
Finding No.: 2023-019 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) An awardee could not report the required information in FSRS unless the federal awarding agency has registered the award. The US Treasury has not advised the Government that they have registered the Capital Projects Fund award.
Finding 523358 (2023-016)
Significant Deficiency 2023
Finding No.: 2023-016 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Du...
Finding No.: 2023-016 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process.
Finding 523357 (2023-015)
Significant Deficiency 2023
Finding No.: 2023-015 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) All documents were provided to HAF for client’s eligibility for the program. However, due to a move, file was misplaced. Records Management SO...
Finding No.: 2023-015 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) All documents were provided to HAF for client’s eligibility for the program. However, due to a move, file was misplaced. Records Management SOPs will be updated to have all documentation stored electronically.
View Audit 342645 Questioned Costs: $1
Finding 523356 (2023-014)
Significant Deficiency 2023
Finding No.: 2023-014 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Du...
Finding No.: 2023-014 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process.
Finding 523355 (2023-013)
Significant Deficiency 2023
Finding No.: 2023-013 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Du...
Finding No.: 2023-013 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process.
Finding No.: 2023-011 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Implementation of a Fixed Assets Module as part of the new FMIS system is near completion which will help automate ...
Finding No.: 2023-011 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Implementation of a Fixed Assets Module as part of the new FMIS system is near completion which will help automate the tracking and reporting of capital assets. DOA will update the SOP for the Fixed Assets for capital asset reporting accordingly. In addition, the Agency will require all line agencies to designate a property manager to periodically track tagged assets on a revolving basis. Review of Assets acquired in FY2023 was completed, with FY2024 in progress. As noted previously, the process is hampered by difficulties in recruiting personnel.
Finding No.: 2023-010 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The subrecipients were not listed in the FFATA Subaward Reporting System (FSRS). This was an oversight on our part and have corrected this actio...
Finding No.: 2023-010 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The subrecipients were not listed in the FFATA Subaward Reporting System (FSRS). This was an oversight on our part and have corrected this action. The FSRS was updated to include the subrecipients to the Guam Department of Administration Guam Broadband Infrastructure Program (Federal Award ID Number 66-08-I2208). Moving forward, we will ensure to report first-tier subawards of $30,000 or more to the Federal funding Accountability and Transparency Act Subaward Reporting System. This has been remedied as the Agency did the reporting in FSRS in FY24.
Finding No.: 2023-009 ADP System for SNAP Responding Agency: Department of Public Health and Social Services (DPHSS) Agency disagrees with the finding. [Case Numbers 600020362, 300075627 and 300073890] Documentation was provided to auditor electronically on 09/03/2024. Additional documentati...
Finding No.: 2023-009 ADP System for SNAP Responding Agency: Department of Public Health and Social Services (DPHSS) Agency disagrees with the finding. [Case Numbers 600020362, 300075627 and 300073890] Documentation was provided to auditor electronically on 09/03/2024. Additional documentation was provided in person on 11/15/2024 because the files were too large to send via email. [Case Number 201301439] The additional documentation related to the "processing of the household size of the applicant, resulting in an overpayment" was included in the files provided on 11/15/2024 to dispute this finding. Additional information was provided to explain. 201301439 -benefit amount is for a household size of 8 based on the renewal and change reports submitted during the certification period 3/1/2024-02/29/2024. Benefit amount indicated on the audit report says $312, which was not what was issued. Screenshots of this process was provided. 600020362 – The notice of action was provided and all other documents for this case. Details of corrective actions and target dates are set forth in GovGuam’s Corrective Action Plan.
View Audit 342645 Questioned Costs: $1
Finding 523340 (2023-002)
Significant Deficiency 2023
This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the ...
This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the 2024 audit. Responsible contact person is Caitlin Cole, Human Resources manager.
The Utility System agrees with the recommendation and has implemented new procedures to ensure better accuracy of data on the compliance reporting.
The Utility System agrees with the recommendation and has implemented new procedures to ensure better accuracy of data on the compliance reporting.
Corrective action planned – The Organization will reinforce and expand its policy of reviewing contracts for federal awards to include development properties and other forms of non-standard expenditures including non-cash assistance and loans. These policies and procedures will be added to the year-...
Corrective action planned – The Organization will reinforce and expand its policy of reviewing contracts for federal awards to include development properties and other forms of non-standard expenditures including non-cash assistance and loans. These policies and procedures will be added to the year-end financial statement reporting checklist which is reviewed and monitored by the Controller. During this process, the staff member assigned to completing the schedule of federal expenditures (currently the senior fiscal program analyst), will communicate with risk management to review incoming contracts during the year, as well as at year end to ensure that federal monies are accounted for, and that significant unusual transactions will be accounted for. The staff member assigned to completing this report will also communicate it to the Controller for review. Name(s) of contact person(s) responsible for corrective action – Richard Sroka, Senior Fiscal Program Analyst in charge of grant reporting Anticipated completion date – Implemented.
Criteria: Regulations require that the Organization must submit the single audit data collection form and reporting package within the earlier of 30 calendar days after receipt of the auditor’s report or 9 months after the end of the audit period, to comply with 2 CFR § 200.512(a)(1). Condition: T...
Criteria: Regulations require that the Organization must submit the single audit data collection form and reporting package within the earlier of 30 calendar days after receipt of the auditor’s report or 9 months after the end of the audit period, to comply with 2 CFR § 200.512(a)(1). Condition: The Organization submitted their 2022 Single Audit Data Collection form on September 5, 2024, which was 20 months after the end of the audit period. Effect: The Organization did not comply with 2 CFR § 200.512(a)(1). Per 2 CFR § 200.516(a)(2), this results in material noncompliance with the provisions of Federal statues, regulations, and terms and conditions of Federal awards related to major programs. Questioned Costs: No questioned costs were identified as a result of our procedures. Cause: The Organization failed to submit their 2022 Single Audit Data Collection form before the end of September 2023 – the 9 month post-audit period ending deadline.   Recommendations: We recommend management finalize and submit their single audit data collection forms within the 9 month window moving forward. Views of Responsible Officials: The Organization agrees with the finding and will work to implement the recommendations.
Finding 2023-001 Central Valley Improvement Act, Title XXXIV. We recommend that the District provide accurate federal expenditure information prior to the beginning of audit fieldwork. Management's Response: The District concurs with the finding. Responsible Individuals: General Accountant Maria Gar...
Finding 2023-001 Central Valley Improvement Act, Title XXXIV. We recommend that the District provide accurate federal expenditure information prior to the beginning of audit fieldwork. Management's Response: The District concurs with the finding. Responsible Individuals: General Accountant Maria Garcia, and Assistant Controller Alondra Morales. Corrrective Action Plan: SEFA will be prepared and then reviewed by a second person for accuracy. Anticipated Completion Date: April 2025.
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