Corrective Action Plans

Finding 572324 (2023-057)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Reporting Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

VIEWS OF RESPONSIBLE OFFICIALS According to the audit recommendation, it is requested that a written process for reconciling EBT Reconciliation Reports be implemented and developed. Additionally, it is recommended that staff be trained in this matter. The Finance Division will be preparing a task fo...

VIEWS OF RESPONSIBLE OFFICIALS According to the audit recommendation, it is requested that a written process for reconciling EBT Reconciliation Reports be implemented and developed. Additionally, it is recommended that staff be trained in this matter. The Finance Division will be preparing a task force to assign roles, provide training, and develop a protocol to improve processes and ensure that EBT Reports are reconciled. Manuals will be amended to establish a clearer written procedure. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572322 (2023-056)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305 § 200.328 § 200.329

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572321 (2023-055)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Reporting Procurement, Suspension & Debarment Subrecipient Monitoring § 200.302

VIEWS OF RESPONSIBLE OFFICIALS The Department of the Family has initiated several corrective actions. Since the first months of Fiscal Year 2024, the Accounting Department has started a review of unliquidated obligations on a monthly basis, canceling any invalid obligations and reporting them in the...

VIEWS OF RESPONSIBLE OFFICIALS The Department of the Family has initiated several corrective actions. Since the first months of Fiscal Year 2024, the Accounting Department has started a review of unliquidated obligations on a monthly basis, canceling any invalid obligations and reporting them in the FY 2024 SSA-4513 report. In fact, Budget and Finance staff had multiple working sessions with PR-DDS personnel to identify and write-off unliquidated obligations that were no longer current. Also, we conducted training for finance and budget staff on accounting controls and administrative cost reporting to ensure compliance with federal regulations. Includes a review of 2 CFR Part 225 on allowable costs (direct allowable and indirect allocable, the difference between direct and indirect costs), reasonable and allocable costs. In addition, we addressed issues of unliquidated obligations (Consultative Examinations (CE) and Medical Evidence of Record (MER), among others). Nevertheless, beginning the first quarter of FY2026, following recent staffing changes in the Finance Department, we are in the process of re-training our team to ensure that unliquidated obligations are reviewed every month and invalid commitments are promptly canceled. To reinforce these practices, the Department of the Family will also deliver a series of new workshops to relevant staff outlining the procedures and best practices for SSA-4513 preparation and POMS compliance. IMPLEMENTATION DATE September 2025 RESPONSIBLE PERSON Office of the Secretariat

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Finding 572319 (2023-054)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302 § 200.303 § 200.305 § 200.328 § 200.334

VIEWS OF RESPONSIBLE OFFICIALS Review the accounting system to ensure consistency with SF– 425 reporting. Establish a protocol for the review and approval of financial reports. Designate a financial compliance officer to validate reports prior to submission. IMPLEMENTATION DATE During Fiscal Year 20...

VIEWS OF RESPONSIBLE OFFICIALS Review the accounting system to ensure consistency with SF– 425 reporting. Establish a protocol for the review and approval of financial reports. Designate a financial compliance officer to validate reports prior to submission. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)

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Finding 572318 (2023-053)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

VIEWS OF RESPONSIBLE OFFICIALS Draft and approve eligibility criteria in accordance with federal reporting requirements. Implement monthly reconciliations between TANF and internal records. Establish a report review committee with designated personnel. It’s important to note that administrative expe...

VIEWS OF RESPONSIBLE OFFICIALS Draft and approve eligibility criteria in accordance with federal reporting requirements. Implement monthly reconciliations between TANF and internal records. Establish a report review committee with designated personnel. It’s important to note that administrative expenses are listed under Letter F of the Family Preservation program. Other expenses that could be considered administrative under different letters—such as materials, payroll, etc.—are related to direct services, since the employees being paid under these accounts are social workers and the materials are used for activities that are part of the direct service. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)

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Finding 572317 (2023-052)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.305 § 200.334 § 200.335 § 200.336

VIEWS OF RESPONSIBLE OFFICIALS ADSEF has controls and procedural manuals related to data collection. As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. Annexes IMPLEMENTATION DATE Up to Dat...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF has controls and procedural manuals related to data collection. As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. Annexes IMPLEMENTATION DATE Up to Date RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym) AUDITORS’ COMMENT ADSEF did not provide us with a manual describing the data collection process as requested during the auditing procedures. An unsigned and undated Manual was attached to the Corrective Action Plan. Also, ADSEF was required to provide us with the corresponding participant worksheet appendix and the physical file to corroborate the information included in the report. ADSEF provided us with evidence of the hand-completed forms; however, we were not provided with the physical files to validate the information included in each document. This represents a scope limitation.

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Finding 572316 (2023-051)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305 § 200.328 § 200.329

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572312 (2023-050)

Significant Deficiency 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Reporting Significant Deficiency

VIEWS OF RESPONSIBLE OFFICIALS 1. Assess the need to hire additional staff or reallocate existing resources to ensure the necessary capacity for continued FFATA/FSRS compliance. 2. Create a detailed and comprehensive Procedures Manual for FFATA/FSRS management and reporting, including steps for effe...

VIEWS OF RESPONSIBLE OFFICIALS 1. Assess the need to hire additional staff or reallocate existing resources to ensure the necessary capacity for continued FFATA/FSRS compliance. 2. Create a detailed and comprehensive Procedures Manual for FFATA/FSRS management and reporting, including steps for effective implementation of the process. 3. Develop and deliver a mandatory training program for all Office of Legal Affairs staff, and any other staff involved in the administration or monitoring of sub-awards. 4. Establish regular monitoring to ensure that FSRS reporting is conducted in a timely and accurate manner. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Office of Legal Affairs Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)

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Finding 572311 (2023-049)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302 § 200.303 § 200.305 § 200.334 § 200.335

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572279 (2023-047)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Reporting § 200.510

VIEWS OF RESPONSIBLE OFFICIALS Regarding this finding as it relates to SEFA preparation, we similarly note that grant-level accounting and internal control procedures are supported by PRIFAS. Moreover, the grant-level accounting and internal control are being strengthened through initiatives set for...

VIEWS OF RESPONSIBLE OFFICIALS Regarding this finding as it relates to SEFA preparation, we similarly note that grant-level accounting and internal control procedures are supported by PRIFAS. Moreover, the grant-level accounting and internal control are being strengthened through initiatives set forth in the 2024 Certified Fiscal Plan, certified by FOMB. Section 3.1.2.4 (“Improve federal funds management”) calls for the consolidation of grant management under a centralized financial framework. This will improve transparency and visibility of federal and non-federal funds, enable accurate budgeting aligned with strategic priorities, and ensure compliance requirements are clearly understood by both individual agencies and the Puerto Rico Treasury Department. In conjunction with the ERP rollout, the Plan calls for establishing a central Grants Management Office tasked with enhancing oversight and compliance, supporting corrective-action follow-up on single audit findings, building local capacity to maximize federal funding, and codifying best practices. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Office of the Secretariat and Administrations

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Finding 572263 (2023-046)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.305 § 200.328 § 200.329

VIEWS OF RESPONSIBLE OFFICIALS We wish to clarify that the Puerto Rico Department of the Family does not maintain a standalone accounting system but rather records all financial transactions directly in the Puerto Rico Integrated Financial Accounting System (PRIFAS), the centralized accounting platf...

VIEWS OF RESPONSIBLE OFFICIALS We wish to clarify that the Puerto Rico Department of the Family does not maintain a standalone accounting system but rather records all financial transactions directly in the Puerto Rico Integrated Financial Accounting System (PRIFAS), the centralized accounting platform hosted by the Puerto Rico Treasury Department. Consequently, it is not necessary for PRDF to “update its accounting practices” or “implement” a new financial management system, since PRIFAS already provides a comprehensive and reporting framework that meets state and local agreement requirements. However, it is important to mention that the Certified Fiscal Plan for 2024, certified by the Financial Oversight and Management Board (FOMB), in Section 3.1.7.5, explicitly prioritizes the implementation of an enterprise resource planning (ERP) system to further centralize and streamline financial management across Commonwealth agencies. Once deployed, this ERP will enhance financial transparency, unify budgeting and procurement processes, support real-time transaction recording, and deliver centralized reporting consistent with public sector accounting standards, thereby addressing the core objectives of this finding. IMPLEMENTATION DATE Awaiting system implementation. RESPONSIBLE PERSON Office of the Secretariat and Administrations

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Finding 572256 (2023-040)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Eligibility Material Weakness § 200.334 § 200.337

VIEWS OF RESPONSIBLE OFFICIALS As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. For this Digitalization project we have available matching funds of approximately 7 million dollars. IMPLEM...

VIEWS OF RESPONSIBLE OFFICIALS As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. For this Digitalization project we have available matching funds of approximately 7 million dollars. IMPLEMENTATION DATE Awaiting System Implementation RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572255 (2023-039)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Eligibility Material Weakness § 200.303

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym) continue

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Finding 572253 (2023-038)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Eligibility Material Weakness § 200.303

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. Anexes: • Comunicación Límite de tiempo de Beneficios Categoría C • Comunicación sobre periodo de certificación Categoría C, próximos a cumplir los 60 meses. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572248 (2023-036)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Eligibility Material Weakness § 200.303

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572246 (2023-035)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Cash Management Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305

VIEWS OF RESPONSIBLE OFFICIALS Based on the audit report submitted, it is recommended that the Cash Management Section Procedures Manual be amended, and that the segregation of employee duties be identified. To this end, work has begun on reading and amending the Manual. It will be updated consideri...

VIEWS OF RESPONSIBLE OFFICIALS Based on the audit report submitted, it is recommended that the Cash Management Section Procedures Manual be amended, and that the segregation of employee duties be identified. To this end, work has begun on reading and amending the Manual. It will be updated considering both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572243 (2023-034)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.302 § 200.305 § 200.334 § 200.335 § 200.336

VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026....

VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)

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Finding 572241 (2023-033)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.302 § 200.305 § 200.328 § 200.329 § 200.334

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572237 (2023-032)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.302 § 200.303 § 200.305 § 200.328 § 200.329

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572236 (2023-031)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.300 § 200.306 § 200.309 § 200.403

VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Estab...

VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Establish an indirect cost policy to standardize the evaluation and approval for subrecipient. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572233 (2023-030)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302 § 200.405

VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPL...

VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Doris Jiménez, Finance Director Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)

View Audit 363366 Questioned Costs: $1

Finding 572232 (2023-029)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.302 § 200.305 § 200.328 § 200.329 § 200.334

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

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Finding 572057 (2023-003)

Significant Deficiency 2023

Waikiki Health

HI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directl...

Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directly with the Director of Clinical Operations, Kei Wee, to conduct a comprehensive review of the Center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and definition of family size. The Clinical Operations Director, Kei Wee, will develop and implement a step-by-step standard operating procedure (SOP) for staff to consistently assess and apply sliding fee discounts. The SOP will include clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director, Kei Wee's management team, will conduct monthly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to management for corrective follow-up and provide training for registration/front-desk staff and billing personnel on the updated policy and procedures as needed.

View Audit 363175

Finding 571810 (2023-001)

Significant Deficiency 2023

Town of Plainville

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Correction Action Plan – Finding 2023-001 “Document Policies and Procedures Over Federal Awards” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Expected Completion Date: We anticipate t...

Correction Action Plan – Finding 2023-001 “Document Policies and Procedures Over Federal Awards” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Expected Completion Date: We anticipate that the policies and procedures will be completed and approved by June 30, 2026. Contact Person: Julie Hebert, Finance Director

View Audit 362825

Finding 571680 (2023-002)

Significant Deficiency 2023

City of Bloomington

IN

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

FINDING 2023-002 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Sign...

FINDING 2023-002 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficiency Condition: City of Bloomington completed quarterly reporting in a timely manner substantiated by the City’s expenditure detail. However, management could not differentiate between subrecipients and standard vendor purchases. Context: During our testing procedures over CSLFRF reporting, we noted that segregation of duties is not present in the Federal reporting process. The Deputy Controller prepared and submitted the reports without a secondary review taking place. As a result, the City did not report expenditures for the grant that were consistent with the expenditures reported on the SEFA and could not properly identify subrecipient expenditures. Views of Responsible Officials and Planned Corrective Actions: Management will develop an internal controls process to ensure that there’s segregation of duties within the reporting process for federal programs. Responsible party and timeline for completion: The City’s Controller will oversee the implementation of the corrective action plan, which will be implemented starting during calendar year 2025.

View Audit 362617

Corrective Action Plans

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