Corrective Action Plans

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Effective January 2025, RYASAP has transferred all accounting and finance responsibilities to an in-house finance/accounting department. The process of transitioning to this model commenced in October 2023 with the hiring of a Vice President of Finance (a CFO equivalent) who reviewed the current acc...
Effective January 2025, RYASAP has transferred all accounting and finance responsibilities to an in-house finance/accounting department. The process of transitioning to this model commenced in October 2023 with the hiring of a Vice President of Finance (a CFO equivalent) who reviewed the current accounting/finance reporting model. Shortly thereafter, based on the VP of Finance’s recommendation, a Controller was hired (March 2024). Later in the year, an additional Staff Accountant was hired (December 2024). Transitioning of financial report preparation began in very early 2024 with almost all reporting being transitioned for the March 31, 2024 reporting period. As a result of this transition, reporting is handled by a central group with consistent reporting processes and procedures as well as improved internal notification tools, including a Grant Cover Sheet in which the program directors, the Director of Development, and the finance/accounting team review at or prior to contract receipt a7nd a Grant Cover Sheet Budgets Report which helps the Finance/Accounting team track and manage financial reporting.
Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls and did not comply with allowable activities and allowable costs requirements. Name, address, and telephone of District contact person: Mitch Thompson 1620 S. Pioneer Way Moses Lake, WA 98837 (...
Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls and did not comply with allowable activities and allowable costs requirements. Name, address, and telephone of District contact person: Mitch Thompson 1620 S. Pioneer Way Moses Lake, WA 98837 (509) 766-2650 Corrective action the auditee plans to take in response to the finding: While the district concurs with the finding that it didn’t have adequate internal controls during the 2022-23 school year, the district disagrees that the monies were not spend on allowable costs under the grants. The district has changed leadership as well as accounting staff. Following the change, the new Executive Director of Finance & Operations instituted measures to ensure that the district complies with grant claims and journal entry procedures. One of the changes was that the person who inputs the journal entries has those entries reviewed by another person. This means that if the Accounting Supervisor inputs the journal entry, the Executive Director of Finance & Operations reviews the entry for accuracy as well as if the expenditures are allowable under the new account code(s). One of the other changes put into place was the implementation of uploading the supporting documentation into the accounting system the district uses so that the documentation doesn’t get lost or misplaced. The district realizes the importance of verifying expenditures and internal reviews to ensure accuracy and these two actions by the district will ensure compliance and proper internal controls. Anticipated date to complete the corrective action: 12/31/2024
View Audit 345047 Questioned Costs: $1
Federal Agency: U.S. Department of Transportation Program/Cluster: Highway Planning and Construction Federal Assistance Listing Number: 20.205 Pass‐through: California Department of Transportation Award No. and Year: 5923, 2022/2023 Compliance Requirement: Subrecipient Monitoring Type of Finding: Ma...
Federal Agency: U.S. Department of Transportation Program/Cluster: Highway Planning and Construction Federal Assistance Listing Number: 20.205 Pass‐through: California Department of Transportation Award No. and Year: 5923, 2022/2023 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. All Public Works contracts receiving federal funding will be evaluated to determine if the vendor is a contractor or subrecipient going forward. This practice is already followed for the other divisions within the Department, and Public Works will now be included. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: June 30, 2024
Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Epidemiology and Laboratory Capacity for Infectious Diseases Federal Assistance Listing Number: 93.323 Pass‐through: California Department of Public Health Award No. and Year: COVID-19ELC48, COVID-19ELC106, 2021/2022 Compl...
Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Epidemiology and Laboratory Capacity for Infectious Diseases Federal Assistance Listing Number: 93.323 Pass‐through: California Department of Public Health Award No. and Year: COVID-19ELC48, COVID-19ELC106, 2021/2022 Compliance Requirement: Procurement, Suspension and Debarment Type of Finding: Material Weakness in Internal Control over Compliance, Instances of Noncompliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. The purchasing division of General Services is in the process of updating the County’s purchasing and contracting policy. Input from stakeholders is being sought and an outside vendor engaged to assist with revisions. Responsible Individual(s): Lorraine Tang, Support Services Manager Anticipated Completion Date: June 2025
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2022/2023 Compliance Requirement: Reporting Type of Finding: Material Weakness in In...
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2022/2023 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: The County spent many months contacting multiple agencies trying to report through the FSRS system on the multiple Housing Voucher awards, with no success. The County’s assigned Housing and Urban Development (HUD) office is the San Francisco regional office. Per their director, “These are systems that we don’t work with in HUD PIH so I won’t be able to be of assistance relative to this.” The County is unable to complete FFATA reporting for reasons outside of the County’s control. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: Because the corrective action is outside of the County’s control, we cannot determine an anticipated completion date.
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2022/2023 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material ...
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2022/2023 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: The subrecipient agreement was updated to include required federal award identification elements and was approved by the Board of Supervisors and executed on July 25, 2023. Discussion between the County and the City of Vacaville, including several meetings about the new contract took place throughout the audit period of July 1, 2022 and June 30, 2023. The risk assessment was completed in November 2022. The risk assessment will be updated on an annual basis going forward. A site visit was conducted in December 2022. Monitoring activities were occurring for this contract but were not formally documented. Documentation will be retained as support monitoring activities are occurring for this contract going forward. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: June 30, 2024
Views of Responsible Officials and Planned Corrective Actions: We acknowledge the finding related to the delayed submission of the Single Audit report and appreciate the recommendation provided. Management is committed to ensuring timely completion and submission of future Single Audit reports in ac...
Views of Responsible Officials and Planned Corrective Actions: We acknowledge the finding related to the delayed submission of the Single Audit report and appreciate the recommendation provided. Management is committed to ensuring timely completion and submission of future Single Audit reports in accordance with the required deadlines. To address this, we will implement the following corrective actions: 1. Enhanced Internal Timeline: We will establish an internal deadline for audit-related documentation and review, allowing sufficient time for finalization before the official reporting deadline. 2. Increased Coordination: Management will work closely with auditors and key stakeholders throughout the audit process to ensure timely responses and resolution of outstanding items. 3. Resource Allocation: Additional internal resources will be dedicated to supporting the audit process, ensuring that necessary documentation and financial records are prepared in advance. 4. Regular Progress Monitoring: We will implement periodic check-ins during the audit period to track progress and address any potential delays proactively. We are confident that these measures will improve our ability to meet future reporting deadlines and enhance overall efficiency in the audit process.
Finding 2023-004 Noncompliance-Reporting Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: The report for the year ende...
Finding 2023-004 Noncompliance-Reporting Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: The report for the year ended December 31, 2022, was not filed within the required report submission period. Actions Planned in Response to the Finding: Prior to 2022, the Organization barely had the infrastructure to fully run a non-profit organization. The state legislature has been kind to provide funding to build the infrastructure within the organization. The learning curve has been steep but senior management staff and Board members in understanding the federal requirements. With adequate resources, the Organization is on track to accelerate the submission of future audit reports henceforth. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: July 15, 2025
Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Emplo...
Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Employee time sheets do not identify the hours charged to each federal grant, and do not identify hours worked by employees on non-federal grants. Actions Planned in Response to the Finding: The timeline for hiring an in-house accountant is very compressed. The in-house accountant will undergo various training on Uniform Guidance and federal grant management. These training programs will help the organization to create a system of time and effort reporting that will meet the Standards for Documentation of Personnel Expenses included in OMB Uniform Guidance. Specifically, time sheets will be redesigned to ensure that employees record hours charged to each federal grant, any other projects, and administrative time. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: June 30, 2025
View Audit 344524 Questioned Costs: $1
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minn...
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minneapolis, MN 55415 African American Child Wellness Institute submits the following corrective action plan for the year ended December 31, 2023. Please contact Akinyele Akinsanya at 763-522-0100. Finding 2023-001 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Expenses charged to the federal grant cannot be traced into the Organization’s general ledger. Invoices submitted to the pass-through agency for reimbursement also cannot be traced into the general ledger. Actions Planned in Response to the Finding: It is clear to management that the Organization needs to boost its accounting team to fulfil effective reporting that could easily be traced into the organization’s general ledger. As a result, the organization will recruit and hire a full-time accountant to work with the current team. Further steps may be required including replacing the organization’s current accounting software that will identify and record expenditure specific to each cost centers for each federal grant. The in-house accountant will also be required to obtain additional training in Uniform Guidance and federal grant management and create a system of financial reporting to record expenditure directly to each federal grant award. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: March 15, 2025
View Audit 344524 Questioned Costs: $1
Finding 2023-004 - Accounting for Grants, Schedule of Expenditures of Federal Awards, and Fiscal Management (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education Criteria: CFR Part 200.508, CFR Part 200.510, Auditee R...
Finding 2023-004 - Accounting for Grants, Schedule of Expenditures of Federal Awards, and Fiscal Management (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Errors in recording and reporting of revenues and expenditures of federal awards may not be detected and/or corrected. Because the Auditee’s SEFA that was presented for audit was completed incorrectly, and not reconciled to the general ledger, the SEFA was materially misstated, prior to auditors’ correction recommendations. Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • Inadequate reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: No Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. District’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: November 1, 2024 Responsible Person: District Business Manager
Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a...
Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a checklist to ensure that these reports are filed timely once the agreements with the subrecipients have been approved.
Construction projects for A+ Arts were facilitated by the management company with approval from the Board of Directors. Although the likelihood of additional construction projects being done in the future using Federal dollars since ESSER funds are no longer available is very remote, the management ...
Construction projects for A+ Arts were facilitated by the management company with approval from the Board of Directors. Although the likelihood of additional construction projects being done in the future using Federal dollars since ESSER funds are no longer available is very remote, the management company is aware of the prevailing wage and certified payroll requirement and will make sure any future projects adhere to these requirements.
Finding 524581 (2023-001)
Significant Deficiency 2023
Management’s Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 3...
Management’s Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 30, 2023.
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to as...
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025
View Audit 343640 Questioned Costs: $1
Name of Federal Agency: U.S. Department of the Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Identification number unavailable. Program year 2023. Name of Pass-through Entity (if applic...
Name of Federal Agency: U.S. Department of the Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Identification number unavailable. Program year 2023. Name of Pass-through Entity (if applicable): The Community Economic Development Assistance Corporation. Recommendation: It is recommended that the Agency establish written procurement policies and procedures to ensure that the Agency is in compliance with the Uniform Guidance and that all staff are trained on this policy to ensure compliance and related internal controls over compliance are operating effectively. Action Taken: Management is in the process of revising internal controls to address procurement, suspension, and debarment requirements. Additionally, management has retroactively performed this requirement to the applicable transactions during the audit period, noting no vendors were suspended or debarred. As the agency has experienced significant growth and increasingly complex reporting requirements, the investment was made early in FY24 to have a department dedicated to agency compliance. FBMS is committed to ensuring compliance with all funder requirements. Anticipated Completion Date: Management estimates that additional processes will be in place by June 30, 2025.
All future federal expenditures will be reconciled to the disbursement ledger.
All future federal expenditures will be reconciled to the disbursement ledger.
To resolve this issue and prevent recurrence, we are taking the following corrective actions: To ensure that all reports are submitted within the required time frame, we will implement a tracking system using calendar reminders that will provide alerts for upcoming deadlines, ensuring no reports are...
To resolve this issue and prevent recurrence, we are taking the following corrective actions: To ensure that all reports are submitted within the required time frame, we will implement a tracking system using calendar reminders that will provide alerts for upcoming deadlines, ensuring no reports are late. We will streamline our internal processes to ensure there is a clear and defined workflow for report preparation and submission. This will include setting internal submission deadlines well in advance of the official due dates to allow for any necessary review or corrections.
Finding 524097 (2023-004)
Material Weakness 2023
Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be moni...
Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be monitored closely when entered into the system to ensure it is entered into the system in the correct period in which the expense is incurred. Documentation will be reviewed by the Controller before posting to the general ledger to ensure expenses are charged to the correct grant period. During the grant invoice preparation there will be an additional review of the expenses in the general ledger to ensure the cut-off for grant expenditures are included in the correct period for the monthly grant vouchers. Trilogy will also implement a quarterly review of expenses charged to grants in preparation of the quarterly reports to ensure proper allocation to grants and cut off grant expenditures during the first and last month of the grant budget period. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster, Han Qi Planned completion date for corrective action plan: October 31, 2024, and ongoing as needed.
View Audit 343276 Questioned Costs: $1
We understand the importance of proper monitoring of providers and are taking steps to improve our system.
We understand the importance of proper monitoring of providers and are taking steps to improve our system.
Finding 523656 (2023-231)
Significant Deficiency 2023
Finding 23-1: The School’s net cash resources exceeded 3 months average expenditures at the end of the year. Recommendation: To keep monitoring the net cash resources throughout the year to ensure it doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue,...
Finding 23-1: The School’s net cash resources exceeded 3 months average expenditures at the end of the year. Recommendation: To keep monitoring the net cash resources throughout the year to ensure it doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue, the School’s administrator has begun to routinely monitor the net cash resources to ensure it does not exceed three months of average expenditures. As such, the required correction actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of March 13, 2024. Person Responsible for Implementation: Yonoson Sanders, the Administrator, is the responsible party for implementation of the CAP. Telephone Number: (732)901-3913.
We created a file for new vendors and/or transactions greater than $25K done outside of the consortium with saved W9s and subsequent business search for debarment.
We created a file for new vendors and/or transactions greater than $25K done outside of the consortium with saved W9s and subsequent business search for debarment.
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
View Audit 342736 Questioned Costs: $1
Finding 523384 (2023-034)
Significant Deficiency 2023
Finding No.: 2023-034 Refunding of Overpayments Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and has developed a corrective action plan that includes a new Stan...
Finding No.: 2023-034 Refunding of Overpayments Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and has developed a corrective action plan that includes a new Standard Operating Procedure (SOP), 2024-005, for the Intake and Processing of Overpayment Checks. This new SOP addresses a gap in our process for tracking overpayment checks and refunding the Federal Share of Medicaid Overpayments to Providers. Furthermore, we are also in the process of updating SOP 2023-03, which focuses on Public Health Professional (PHPro) Entry for Provider Overpayment Checks and Recoupments, to improve our tracking and monitoring of overpayment checks and recoupment reconciliations. Currently, we are still addressing updates to this SOP and require additional time to work with BHCFA staff(s) to gather more information in finalizing the SOP. We intend to complete this SOP no later than February 28, 2025.
View Audit 342645 Questioned Costs: $1
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.
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