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Corrective Action Plans

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Finding 1213903 (2024-004)
Material Weakness 2024
Redevelopment Authority of the County of Berks
PA
Procurement, Suspension & Debarment Questioned Costs Subrecipient Monitoring
The Authority has revised its policy for Section 3 and will include the policy and requirements in all applicable agreements, pre-bid documents, and resulting contracts. Section 3 requirements will also be reviewed during pre-construction meetings for any applicable projects.
The Authority has revised its policy for Section 3 and will include the policy and requirements in all applicable agreements, pre-bid documents, and resulting contracts. Section 3 requirements will also be reviewed during pre-construction meetings for any applicable projects.
View Audit 400734
Finding 1213895 (2024-001)
Material Weakness 2024
Redevelopment Authority of the County of Berks
PA
Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303
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.
View Audit 400734
Finding 1213844 (2024-005)
Material Weakness 2024
The Salvation Army Golden State Division
CA
Period of Performance Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403
Planned Corrective Action: The Division will implement their control of ensuring that they only charge allowable costs incurred during the approved budget period of a federal award’s period of performance or will obtain authorization from the grantor for any costs incurred before the grant's approve...
Planned Corrective Action: The Division will implement their control of ensuring that they only charge allowable costs incurred during the approved budget period of a federal award’s period of performance or will obtain authorization from the grantor for any costs incurred before the grant's approved budget period. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Controller
View Audit 400681
Finding 1213811 (2024-003)
Material Weakness 2024
The Salvation Army Golden State Division
CA
Eligibility Questioned Costs Subrecipient Monitoring
Planned Corrective Action: The Division will design and implement a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and maintain such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Divisi...
Planned Corrective Action: The Division will design and implement a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and maintain such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Controller
View Audit 400681
Finding 1213788 (2024-002)
Material Weakness 2024
The Salvation Army Golden State Division
CA
Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.502
Planned Corrective Action: The Division will design and implement a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Co...
Planned Corrective Action: The Division will design and implement a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Controller
View Audit 400681
Finding 1213651 (2024-001)
Material Weakness 2024
City of Anacortes
WA
Procurement, Suspension & Debarment Subrecipient Monitoring
Corrective action the auditee plans to take in response to the finding: The violation of Suspension and Debarment came from the hiring of a contract service provider in relation to a grant funded project, but was not specifically a Public Works contract. The City of Anacortes' past practice has been...
Corrective action the auditee plans to take in response to the finding: The violation of Suspension and Debarment came from the hiring of a contract service provider in relation to a grant funded project, but was not specifically a Public Works contract. The City of Anacortes' past practice has been to verify Suspension and Debarment for all public works projects, regardless of funding source. The City of Anacortes is committed to ensuring compliance with all applicable statutes and regulations, and therefore has made the organizational change to centralize grant management with contract management, to heighten awareness of those grant requirements relative to let contracts. Additionally, the City has made the commitment to expand the Suspension and Debarment check to all contracts, not just public works, to ensure future compliance can be illustrated.
View Audit 400573
Finding 1213575 (2024-053)
Material Weakness 2024
Government of Guam
GU
Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.305
Finding No.: 2024-053 Special Test and Provisions – Project Accounting 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 in compliance with applicable spec...
Finding No.: 2024-053 Special Test and Provisions – Project Accounting 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 in compliance with applicable special tests and provision requirements. GHS will also identify department personnel responsible.
View Audit 400461
Finding 1213574 (2024-052)
Material Weakness 2024
Government of Guam
GU
Subrecipient Monitoring Reporting § 200.302 § 200.328 § 200.329
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.
View Audit 400461
Finding 1213571 (2024-049)
Material Weakness 2024
Government of Guam
GU
Allowable Costs / Cost Principles Subrecipient Monitoring § 200.403 § 200.431 § 200.447
Finding No.: 2024-049 Activities Allowed or Unallowed: Allowable Costs/Cost Principles Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director Guam Homeland Security (GHS) will make sure that proper supporting documentation is available. GHS will also identify...
Finding No.: 2024-049 Activities Allowed or Unallowed: Allowable Costs/Cost Principles Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director Guam Homeland Security (GHS) will make sure that proper supporting documentation is available. GHS will also identify department personnel responsible.
View Audit 400461
Finding 1213565 (2024-048)
Material Weakness 2024
Government of Guam
GU
Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.302
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
View Audit 400461
Finding 1213562 (2024-046)
Material Weakness 2024
Government of Guam
GU
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles
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.
View Audit 400461
Finding 1213561 (2024-045)
Material Weakness 2024
Government of Guam
GU
Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring
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.
View Audit 400461
Finding 1213560 (2024-044)
Material Weakness 2024
Government of Guam
GU
Questioned Costs Special Tests & Provisions Subrecipient Monitoring
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.
View Audit 400461
Finding 1213557 (2024-041)
Material Weakness 2024
Government of Guam
GU
Questioned Costs Subrecipient Monitoring Eligibility
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.
View Audit 400461
Finding 1213544 (2024-038)
Material Weakness 2024
Government of Guam
GU
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles
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.
View Audit 400461
Finding 1213543 (2024-037)
Material Weakness 2024
Government of Guam
GU
Equipment & Real Property Management Subrecipient Monitoring Reporting § 200.303 § 200.313
Finding No.: 2024-037 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Implementation of a Fixed Assets Module as part of the new FMIS system that will help automate the tracking and reporting of Capital asse...
Finding No.: 2024-037 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Implementation of a Fixed Assets Module as part of the new FMIS system that will help automate the tracking and reporting of Capital assets, is near completion with final testing in progress. DOA will update the SOP for the Fixed Assets for capital asset reporting accordingly. Review of Assets acquired in FY2024 was completed, with FY2025 in progress. As noted previously, the process is hampered by difficulties in recruiting personnel.
View Audit 400461
Finding 1213537 (2024-035)
Material Weakness 2024
Government of Guam
GU
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.307
Finding No.: 2024-035 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Guam EPA has implemented processes relevant to the monitoring and reconciliation of program income. As part of our Correction Action for the FY2023 ...
Finding No.: 2024-035 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Guam EPA has implemented processes relevant to the monitoring and reconciliation of program income. As part of our Correction Action for the FY2023 audit, which is a repeat finding in FY2024, Guam EPA is attaching a sample report of all program income collected through the Transaction Processing System (TPS) to include external payments received by DOA. Also, variances not captured by this report, consisting of payments/transactions submitted directly to DOA via electronic method of payments, are being reconciled by our staff and DOA.
View Audit 400461
Finding 1213536 (2024-034)
Material Weakness 2024
Government of Guam
GU
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles
Finding No.: 2024-034 Period of Performance Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Request to DOA will require immediate collaboration between Guam EPA and DOA to gather, reconcile, and provide all supporting documentation t...
Finding No.: 2024-034 Period of Performance Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Request to DOA will require immediate collaboration between Guam EPA and DOA to gather, reconcile, and provide all supporting documentation to support compliance with the period of performance in question.
View Audit 400461
Finding 1213533 (2024-031)
Material Weakness 2024
Government of Guam
GU
Subrecipient Monitoring § 200.332
Finding No.: 2024-031 Subrecipient Monitoring Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will create Standard Operating Procedures as well as a checklist, to assist in the monitoring of subrecipient compliance.
Finding No.: 2024-031 Subrecipient Monitoring Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will create Standard Operating Procedures as well as a checklist, to assist in the monitoring of subrecipient compliance.
View Audit 400461
Finding 1213532 (2024-030)
Material Weakness 2024
Government of Guam
GU
Reporting Subrecipient Monitoring Cash Management
Finding No.: 2024-030 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to make sure reports are submitted on time. BBMR will also retain documentation of submitted reports.
Finding No.: 2024-030 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to make sure reports are submitted on time. BBMR will also retain documentation of submitted reports.
View Audit 400461
Finding 1213530 (2024-028)
Material Weakness 2024
Government of Guam
GU
Subrecipient Monitoring § 200.332
Finding No.: 2024-028 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency disagrees with this finding. Please refer to a letter dated March 31, 2026, regarding Reports on Compliance September 30, 2024.
Finding No.: 2024-028 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency disagrees with this finding. Please refer to a letter dated March 31, 2026, regarding Reports on Compliance September 30, 2024.
View Audit 400461
Finding 1213526 (2024-024)
Material Weakness 2024
Government of Guam
GU
Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.302 § 200.328 § 200.329
Finding No.: 2024-024 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.
Finding No.: 2024-024 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.
View Audit 400461
Finding 1213524 (2024-022)
Material Weakness 2024
Government of Guam
GU
Reporting Questioned Costs Subrecipient Monitoring
Finding No.: 2024-022 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.
Finding No.: 2024-022 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.
View Audit 400461
Finding 1213522 (2024-020)
Material Weakness 2024
Government of Guam
GU
Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.329
Finding No.: 2024-020 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency disagrees with this finding. Please refer to a letter dated March 31, 2026, regarding Reports on Compliance September 30, 2024
Finding No.: 2024-020 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency disagrees with this finding. Please refer to a letter dated March 31, 2026, regarding Reports on Compliance September 30, 2024
View Audit 400461
Finding 1213520 (2024-018)
Material Weakness 2024
Government of Guam
GU
Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.403
Finding No.: 2024-018 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing the management of Federal Grants to ensure robust handover and succession plans are in place for future programs. The sudden passing of the ...
Finding No.: 2024-018 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing the management of Federal Grants to ensure robust handover and succession plans are in place for future programs. The sudden passing of the ERA Program Coordinator directly impacted overall management of the program.
View Audit 400461
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