Corrective Action Plans

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Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit report to the federal clearing house in May 2026, eight months after it was due. Statement of Concurrence or Nonconcurrence: The Organization concurs with this finding. In 2025, the Organization hired...
Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit report to the federal clearing house in May 2026, eight months after it was due. Statement of Concurrence or Nonconcurrence: The Organization concurs with this finding. In 2025, the Organization hired a new accounting firm with a firm commitment to system integration to improve efficiency in month-end and year-end close, as well as upgrades to its time keeping and payroll system that allows for real time posting of allocated time directly to the accounting software. In prior years, this was a manual process. This automation will eliminate the lag time in posting payroll allocations to the general ledger and greatly reduce the end of year closing process timeline. David Heitstuman, Chief Executive Officer, Phone 916 442-0185, email David.heitsuman@sacccenter.org
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 1213950 (2024-009)
Material Weakness 2024
It has been brought to our attention that we need an additional policy that covers conflict of interests and govern the performance of its employees engaged in the selection, award, and administration of contracts. We have taken this recommendation and are implementing the proper language, for all e...
It has been brought to our attention that we need an additional policy that covers conflict of interests and govern the performance of its employees engaged in the selection, award, and administration of contracts. We have taken this recommendation and are implementing the proper language, for all employees to acknowledge in our County Handbook. We will strengthen this control and add this be updated yearly, so that all conflict can be disclosed. Creek County prides itself in moving toward complete transparency and holding each employee accountable to disclose all information needed to make a proper selection of purchases. Creek County Clerk’s Office will work with the District Attorney’s Office for proper language.
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.
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.
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.
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
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
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
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.
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.
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.: 2024-049 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.
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.: 2024-046 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.: 2024-041 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.
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.
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.
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.
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.
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.
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