Corrective Action Plans

Finding 523670 (2023-002)

Significant Deficiency 2023

Fair & Balanced Pf Pa, Inc.

PA

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

We understand the importance of proper monitoring of providers and are taking steps to improve our system.

View Audit 343096

Finding 523656 (2023-231)

Significant Deficiency 2023

Bais Tova, Inc.

NJ

Subrecipient Monitoring

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.

View Audit 343045

Finding 523473 (2023-003)

Material Weakness 2023

East Liverpool City School District

OH

Procurement, Suspension & Debarment Subrecipient Monitoring

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.

View Audit 342736

Finding 523471 (2023-002)

Material Weakness 2023

East Liverpool City School District

OH

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.421 § 200.439 § 200.516

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

Government of Guam

GU

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

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

Government of Guam

GU

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

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.

View Audit 342645

Finding 523380 (2023-032)

Significant Deficiency 2023

Government of Guam

GU

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau wil...

Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau will hold providers accountable by issuing a Letter of Warning (LOW) and a Correction Action Plan (CAP) from the Social Service Licensing Officer or Child Care Compliance Officer to ensure compliance with the standards. The Agency disagrees with Condition 1. License-exempt childcare providers will not have an annual DEH inspection since they are not required to obtain a sanitary permit.

View Audit 342645 Questioned Costs: $1

Finding 523377 (2023-031)

Material Weakness 2023

Government of Guam

GU

Questioned Costs Subrecipient Monitoring Reporting

Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds...

Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds under the Qualified and Eligible Child Care Providers, Provider Reporting and Monitoring, the ARP Act does not include specific reporting requirements for childcare providers receiving subgrants and any subgrant reporting requirements are at the discretion of the lead agency, page 21. Additionally, Lead Agencies that use other governmental or non-governmental subrecipients to administer the program must have written agreements in place outlining roles and responsibilities for meeting CCDF requirements. The contents of the written agreement may vary based on the role the subrecipient is asked to assume or the type of product undertaken, but must include, at a minimum, tasks to be performed, a schedule for completing tasks, a budget which itemizes categorical expenditures, and indicators or measures to assess performance. The Lead Agency has fulfilled this requirement in accordance with 45 CFR section 98.1.

View Audit 342645 Questioned Costs: $1

Finding 523374 (2023-030)

Material Weakness 2023

Government of Guam

GU

Subrecipient Monitoring Reporting

Finding No.: 2023-030 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due ...

Finding No.: 2023-030 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process. For condition 2, the Agency will report first-tier subawards to the FSRS system. However, it is noteworthy to mention that the system will be expiring as of March 2025.

View Audit 342645

Finding 523371 (2023-029)

Significant Deficiency 2023

Government of Guam

GU

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.

View Audit 342645 Questioned Costs: $1

Finding 523367 (2023-025)

Material Weakness 2023

Government of Guam

GU

Subrecipient Monitoring Reporting

Finding No.: 2023-025 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any ...

Finding No.: 2023-025 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any subrecipient account a copy of the FATA report be attached, as well as, creating a check list of subrecipient monitoring requirements prior to any payments being made.

View Audit 342645

Finding 523362 (2023-020)

Material Weakness 2023

Government of Guam

GU

Subrecipient Monitoring

Finding No.: 2023-020 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the cr...

Finding No.: 2023-020 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any subrecipient account a copy of the FFATA report be attached, as well as, creating a check list of subrecipient monitoring requirements prior to any payments being made.

View Audit 342645

Finding 523361 (2023-019)

Material Weakness 2023

Government of Guam

GU

Subrecipient Monitoring Reporting HUD Housing Programs

Finding No.: 2023-019 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) An awardee could not report the required information in FSRS unless the federal awarding agency has registered the award. The US Treasury has no...

Finding No.: 2023-019 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) An awardee could not report the required information in FSRS unless the federal awarding agency has registered the award. The US Treasury has not advised the Government that they have registered the Capital Projects Fund award.

View Audit 342645

Finding 523360 (2023-018)

Significant Deficiency 2023

Government of Guam

GU

Subrecipient Monitoring § 200.331

Finding No.: 2023-018 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Government continues to disagree with the auditor. The language of CFR 200.331(c) is clear that it is the judgement of the pas...

Finding No.: 2023-018 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Government continues to disagree with the auditor. The language of CFR 200.331(c) is clear that it is the judgement of the pass-through entity that is important. The auditor does not explain the reasoning for reaching a different opinion. Many jurisdictions have engaged third-party administrators for programs without concluding that they become sub-recipients.

View Audit 342645

Finding 523358 (2023-016)

Significant Deficiency 2023

Government of Guam

GU

Reporting Subrecipient Monitoring

Finding No.: 2023-016 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Du...

Finding No.: 2023-016 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process.

View Audit 342645

Finding 523357 (2023-015)

Significant Deficiency 2023

Government of Guam

GU

Questioned Costs Subrecipient Monitoring Eligibility

Finding No.: 2023-015 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) All documents were provided to HAF for client’s eligibility for the program. However, due to a move, file was misplaced. Records Management SO...

Finding No.: 2023-015 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) All documents were provided to HAF for client’s eligibility for the program. However, due to a move, file was misplaced. Records Management SOPs will be updated to have all documentation stored electronically.

View Audit 342645 Questioned Costs: $1

Finding 523356 (2023-014)

Significant Deficiency 2023

Government of Guam

GU

Reporting Subrecipient Monitoring

Finding No.: 2023-014 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Du...

Finding No.: 2023-014 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process.

View Audit 342645

Finding 523352 (2023-010)

Material Weakness 2023

Government of Guam

GU

Subrecipient Monitoring Reporting

Finding No.: 2023-010 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The subrecipients were not listed in the FFATA Subaward Reporting System (FSRS). This was an oversight on our part and have corrected this actio...

Finding No.: 2023-010 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The subrecipients were not listed in the FFATA Subaward Reporting System (FSRS). This was an oversight on our part and have corrected this action. The FSRS was updated to include the subrecipients to the Guam Department of Administration Guam Broadband Infrastructure Program (Federal Award ID Number 66-08-I2208). Moving forward, we will ensure to report first-tier subawards of $30,000 or more to the Federal funding Accountability and Transparency Act Subaward Reporting System. This has been remedied as the Agency did the reporting in FSRS in FY24.

View Audit 342645

Finding 523340 (2023-002)

Significant Deficiency 2023

Choice in Aging

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the ...

This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the 2024 audit. Responsible contact person is Caitlin Cole, Human Resources manager.

View Audit 342622

Finding 523268 (2023-013)

Significant Deficiency 2023

Pottawatomie County

OK

Subrecipient Monitoring Reporting Period of Performance § 200.1 § 200.303 § 200.329 § 200.344

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 342527

Finding 523267 (2023-012)

Significant Deficiency 2023

Pottawatomie County

OK

Subrecipient Monitoring § 200.332

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 342527

Finding 523266 (2023-011)

Material Weakness 2023

Pottawatomie County

OK

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

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 342527

Finding 523265 (2023-010)

Material Weakness 2023

Pottawatomie County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a risk assessment plan. We will implement controls to help make sure we are in compliance with all grant requirements and federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance ...

We will work to implement a risk assessment plan. We will implement controls to help make sure we are in compliance with all grant requirements and federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 342527

Finding 523111 (2023-002)

Material Weakness 2023

Douglas County

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding ref number: 2023-002 Finding caption: The County’s internal controls were inadequate for ensuring compliance with federal procurement requirements. Name, address, and telephone of County contact person: Leah Hurd 140 19th St NW East Wenatchee, WA 98802 (509) 888-6595 Corrective action the a...

Finding ref number: 2023-002 Finding caption: The County’s internal controls were inadequate for ensuring compliance with federal procurement requirements. Name, address, and telephone of County contact person: Leah Hurd 140 19th St NW East Wenatchee, WA 98802 (509) 888-6595 Corrective action the auditee plans to take in response to the finding: The County now recognizes the need for phone interviews and sole source public interest findings. Anticipated date to complete the corrective action: Done

View Audit 342413

Finding 523110 (2023-001)

Material Weakness 2023

Douglas County

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding ref number: 2023-001 Finding caption: The County’s internal controls were inadequate for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of County contact person: Leah Hurd 140 19th St NW East Wenatchee, WA 98802 (509) 888-6595 Corrective...

Finding ref number: 2023-001 Finding caption: The County’s internal controls were inadequate for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of County contact person: Leah Hurd 140 19th St NW East Wenatchee, WA 98802 (509) 888-6595 Corrective action the auditee plans to take in response to the finding: The County has hired a Grants and Public Relations Specialist. This position provides technical assistance to county staff and outside contractors to ensure compliance with grant requirements. Unfortunately, some of the contracts were entered into before this position was filled. This should no longer be an issue. Anticipated date to complete the corrective action: Done

View Audit 342413

Corrective Action Plans

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