Corrective Action Plans

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View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will implement procedures to identify all federal awards expended, including funds passed through state and local governments. For each grant and contract, management will review the executed agreeme...
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will implement procedures to identify all federal awards expended, including funds passed through state and local governments. For each grant and contract, management will review the executed agreement and related funder documentation for indicators of federal funding, including an Assistance Listing Number, a federal award identification number, the originating federal agency, the pass-through entity identifying number, and references to the Uniform Guidance, and should confirm the federal funding status with the pass-through entity when it is not clear. Management will maintain a centralized listing of awards that is reconciled to the general ledger and reviewed for completeness in preparing the schedule of expenditures of federal awards. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Completion Date: July 31,2026
2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards...
2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards Committee, which is responsible for regularly reviewing Policies and Procedures and approving or recommending changes, reviewed and approved the following policy revisions at its November 19, 2024 meeting to maintain compliance with federal regulation standards. 0.1.02.65 Provider Procurement and Best Value Purchasing 01.02.85 Procuring Employment Services Providers, Independent Contractors and Network Providers. The approved policies were also presented at the LCCMH Full Board meeting on November 21, 2024. All LCCMH Staff were advised on December 2, 2024, to review the revised policies and procedures. On April 22, 2025, SAMSHA provided LCCMH written notification identifying the 2023 citation for procurement as resolved. Responsible Party: Emma McQuillan, Chief Financial Officer Completion Date: 12/5/2024
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Correct...
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City concurs with this finding. City has hired additional resources to perform review of subrecipient transactions. On a monthly basis, the new position will review system generated reports to timely capture reportable subrecipient transactions. Additionally, the City has an ongoing quarterly meeting with all grant managers. Training will be provided to grant managers to ensure proper identification of subrecipient contracts and proper entry into the SAM.gov system. Anticipated Completion Date: December 31, 2026
The Board of County Commissioners will ensure that the reports are accurate and reported in the proper period.
The Board of County Commissioners will ensure that the reports are accurate and reported in the proper period.
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.
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.
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compli...
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that 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.
The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the...
The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the Town will take the following steps: Before sending any future reports to the federal government, the Finance Department will match the report numbers directly to the Town's official accounting records (the general ledger). A second person in the finance department will review and sign off on the report before it is submitted. We will save copies of the accounting records and the signed approval forms to show future auditors. Planned Implementation Date of Corrective Action: September 1, 2026 Person Responsible for Corrective Action: Town Accountant/ Finance Director
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.
Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit i...
Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: In September 2025, the Organization began its transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. This went live in December 2025. We included mandatory eligibility fields and document upload requirements before service can begin. We developed SOPs to include a standardized eligibility checklist to be completed for all new and returning participants. Staff were trained on Pantry Soft usage, eligibility requirements and document retention stands. The Executive Team performed spot checks on these records but will begin documenting this procedure.
Management's Response and Corrective Action Plan Fiscal Year 2025 Single Audit Finding Reference: 2025-001 & 2025-004 o Classification: Material Weakness in Internal Control Over Financial Reporting / Compliance o Target Completion Date: 120 Days (from the issuance of the final audit report o Respon...
Management's Response and Corrective Action Plan Fiscal Year 2025 Single Audit Finding Reference: 2025-001 & 2025-004 o Classification: Material Weakness in Internal Control Over Financial Reporting / Compliance o Target Completion Date: 120 Days (from the issuance of the final audit report o Responsible Officials: Finance Director, Director of Information Systems and the Municipal Advisor Management's Response & Corrective Action Plan: Concurrence with the Findings: The Management of the Municipality of Corozal concurs with the conditions and recommendations outlined in Findings 2025-001 and 2025-004 We acknowledge that the recent migration of our core accounting system compromised the system's operational and technical capacity to generate balanced trial balances, reconcile subsidiary ledgers, and streamline the automatic production of the Schedule of Expenditures of Federal Awards (SEFA). Corrective Actions to be Implemented: To resolve these deficiencies systematically and ensure full compliance with Government Auditing Standards and the Uniform Guidance (2 CFR 200), the Municipality will execute the following action plan within a strict 120-day timeframe: 1. System Re-alignment & Expert Remediation (Led by: Director of Information Systems and the Municipal Advisor): The Municipality will immediately retain specialized software implementation engineers and municipal accounting consultants to trace the migration mapping errors. This team will re-align the platform's database structure to correct the corrupted historical financial data and prior-period balances. 2. Opening Balance Reconstruction (Led by: Finance Director & Municipal Advisor): A formal data-clearing project will be established to reconstruct, cross-reference, and validate all opening balances transferred from the legacy system against the prior year's audited financial statements to restore data integrity. 3. Interim Manual Tracking for Federal Programs (Led by: Finance Director): To address the risks highlighted in Finding 2025-004 the Finance Department will immediately implement an interim manual spreadsheet tracking matrix. This will ensure all federal expenditures across all active Assistance Listings (ALN) are manually reconciled with federal drawdowns and physical invoices until the core accounting database is completely functional. 4. Closing Controls & Migration Policies (Led by: Joint Committee): We will design and implement rigid monthly closing routines and formal trial balance reviews. Furthermore, we will establish strict IT transition frameworks requiring dual-system running periods and mandatory data-integrity sign-offs before any future application or ledger upgrades are deployed. Should you have any questions or require additional information, please do not hesitate to contact the undersigned at (787) 859-3060, ext. 1703. Sincerely Jose A Rivera Miranda Finance Director
Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 202...
Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 2025 – December 31, 2025 The findings from the December 31, 2025 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2025-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Jim Erchul, Executive Director, 651-774-6995 Anticipated Completion Date: Ongoing
Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended Decem...
Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended December 31, 2025. Summary of finding: Testing of 40 patient encounters identified 2 instances in which the sliding fee discount schedule (SFDS) was not applied in accordance with established requirements. These instances included the incorrect application of the sliding fee scale and the failure to apply the discount when required. As a result, certain patients were undercharged or overcharged for services received. Planned corrective action: CFHC management concurs with the finding. CFHC has policies and procedures in place to ensure compliance. CFHC will provide additional training to the Patient Services Representatives and Billing Clerks to ensure the existing policies and procedures are followed. The CFHC Billing Manager will develop additional reviews to discover, correct, and educate when non-compliance is suspected. CFHC will provide targeted trainings as necessary for site level personnel. Monitoring and review will be an ongoing effort as the positions responsible for real-time compliance tend to be highly transitory. Additional review steps have already been implemented and will become part of the typical workflows to monitor compliance. Anticipated Completion Date: June 1, 2026 Contact Person: Jim Merrill, Chief Financial Officer Email: jmerrill@cfamhc.org Phone: 360-703-6701 Name and Address of Independent Public Accounting Firm: Aprio, LLP 3 Centerpointe Dr, Ste 300 Lake Oswego, OR 97035
NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS; COMMUNITY DEVELOPMENT BLOCK GRANTS/STATES PROGRAM AND NON-ENTITLEMENT GRANTS IN HAWAII, AL No. 14.228, GRANT No. MT-CDBG-21PF-14, YEAR ENDED JUNE 30, 2025 Name of contact person: County Commissioners Corrective Action: With input from the engineering fi...
NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS; COMMUNITY DEVELOPMENT BLOCK GRANTS/STATES PROGRAM AND NON-ENTITLEMENT GRANTS IN HAWAII, AL No. 14.228, GRANT No. MT-CDBG-21PF-14, YEAR ENDED JUNE 30, 2025 Name of contact person: County Commissioners Corrective Action: With input from the engineering firm, the county will develop and implement procedures that will provide reasonable assurance that procurement of goods and services are made in compliance with applicable federal regulations and other procurement requirements specific to a federal award or subaward. Proposed Completion Date: April 30, 2026
Management will ensure that inspections are documented in each tenant file and will utilize the PHA-Web alert system to monitor any past due inspections and will conduct inspections and upload the file to the HUD PIC System. The HUD Supervisor will use the comment sections on the NSPIRE form and not...
Management will ensure that inspections are documented in each tenant file and will utilize the PHA-Web alert system to monitor any past due inspections and will conduct inspections and upload the file to the HUD PIC System. The HUD Supervisor will use the comment sections on the NSPIRE form and note any deficiencies. If there are no deficiencies, the file will state in the comment section that there are no deficiencies and reference the area’s positive outcome.
Finding 2025-003 — Questioned Costs Related to Expenditures Exceeding Approved Grant Budget Corrective Action Plan Management acknowledges that expenditures under the OASH HEALS award exceeded the approved grant budget by $8,158.59. To prevent similar instances in the future and strengthen complianc...
Finding 2025-003 — Questioned Costs Related to Expenditures Exceeding Approved Grant Budget Corrective Action Plan Management acknowledges that expenditures under the OASH HEALS award exceeded the approved grant budget by $8,158.59. To prevent similar instances in the future and strengthen compliance with Uniform Guidance, management will implement the following corrective actions:  Implement monthly budget-to-actual reviews for each federal award to monitor expenditures against approved budget categories and award ceilings.  Establish a monitoring process with alerts when expenditures approach approved budget limits, allowing management to take timely corrective action.  Require prior written approval from the grantor before incurring expenditures that would exceed approved budget limits or require budget revisions.  Assign responsibility to the Accounting Manager to review grant expenditures monthly and report any potential budget overruns to the Executive Director before additional costs are incurred.  Work with OASH to resolve the current over-award of $8,158.59 and retain documentation of the agency's allowability determination and any required corrective actions. Responsible Party Executive Director; Accounting Manager; Program Directors/Managers. Completion Date Budget monitoring procedures implemented immediately; resolution with OASH targeted by August 31, 2026. Questioned Costs $8,158.59
Finding 2025-002 — Subrecipient Monitoring and Required Documentation Corrective Action Plan During fiscal year 2025, the Organization did not consistently obtain or retain: (i) written pre-award risk assessments for subrecipients; (ii) Single Audit reports for subrecipients expending $750,000 or mo...
Finding 2025-002 — Subrecipient Monitoring and Required Documentation Corrective Action Plan During fiscal year 2025, the Organization did not consistently obtain or retain: (i) written pre-award risk assessments for subrecipients; (ii) Single Audit reports for subrecipients expending $750,000 or more in federal awards; or (iii) Unique Entity Identifier (UEI) confirmations via SAM.gov, as required under 2 CFR §§200.331–200.333. The affected pass-through activity totaled approximately $542,500 across three major federal programs (CFDA 93.310, 93.137, and 93.185). Management will implement the following corrective actions: • Establish a centralized subrecipient monitoring file for each subaward relationship, organized by program and award year, and confirm each subrecipient’s active UEI registration in SAM.gov at the time of award and annually thereafter. • Conduct and document a formal pre-award risk assessment using the Subrecipient Risk Assessment Questionnaire, covering prior federal experience, financial stability, internal controls, audit history, and SAM.gov registration. Perform and document a written subrecipient-vs.-contractor determination consistent with 2 CFR §200.331 before entering into or renewing any agreement. • Ensure all subaward agreements include the required award information, compliance responsibilities, reporting requirements, record retention provisions, and audit access provisions under 2 CFR §200.332. • Use the Subrecipient Desk Review Checklist to document quarterly monitoring, including review of progress reports, invoices, deliverables, indirect cost calculations, and personnel timesheets. Require supporting documentation before approving payments. • Maintain an annual Single Audit tracking log to verify federal expenditure thresholds and document collection, review, and resolution of any subrecipient audit findings. • Train program managers and accounting personnel on Uniform Guidance subrecipient monitoring requirements and present updated procedures to the Board/Finance Committee for formal adoption. Responsible Party Executive Director; Accounting Manager; Program Managers; Treasurer/Finance Committee. Completion Date Management has already begun implementation. Full implementation of the monitoring checklist and centralized files expected by September 30, 2026. Review of open FY2025/FY2026 subrecipient files and documentation requests by September 30,2026.
During the 2025 audit, the auditors discovered that a secondary review of eligibility determinations did not occur in a timely manner. The lack of internal control opened the possibility that an individual was incorrectly determined to be eligible to receive benefits and this error would not have be...
During the 2025 audit, the auditors discovered that a secondary review of eligibility determinations did not occur in a timely manner. The lack of internal control opened the possibility that an individual was incorrectly determined to be eligible to receive benefits and this error would not have been identified or corrected in a timely manner. Federal Regulations establish requirements for internal control over compliance with Federal program requirements. 2 CFR Section 200.303 requires non-Federal entities to establish and maintain effective internal control over Federal awards that provides reasonable assurance the entity is managing the award in compliance with Federal statutes, regulations, and the terms and conditions of the award. These requirements include the design, implementation, and operation of control activities to ensure compliance with applicable compliance requirements, including eligibility. As eligibility is a key compliance requirement identified in the OMB Compliance Supplement, the County is required to implement a review process and system of internal controls that allows management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, errors or noncompliance in eligibility determinations on a timely basis. The Department of Human Services (DHS) has implemented a monthly review process to audit a random sample of the IV-E cases. The review includes verification of timely and accurate determinations, client information, supporting documentation, and system entries, with results documented and approved by the reviewer. DHS Division leadership will monitor compliance to ensure the reviews are conducted each month. DHS believes this additional review procedure will provide the needed internal controls over IV-E determination.
Finding #2025-013 14.267 Continuum of Care GU0011L9C002112, GU0011L9C002213, GU0011L9C002314, GU0037L9C002302, GU0031L9C002203 Matching, Level of Effort, and Earmarking Views of Responsible Officials and Planned Corrective Action Management’s Position: Management concurs with the finding. Management...
Finding #2025-013 14.267 Continuum of Care GU0011L9C002112, GU0011L9C002213, GU0011L9C002314, GU0037L9C002302, GU0031L9C002203 Matching, Level of Effort, and Earmarking Views of Responsible Officials and Planned Corrective Action Management’s Position: Management concurs with the finding. Management has not fully implemented formalized policies and procedures to ensure centralized tracking, periodic reconciliation, and supervisory review of matching contributions in accordance with established control expectations. Responsibilities for monitoring matching activity are decentralized with each planner, and periodic management review of cumulative matching, supporting documentation, and source allowability is not consistently performed. As a result, matching balances may remain interim and not fully supported, increasing the risk of noncompliance with applicable matching, level of effort, and earmarking requirements at each time of reimbursement and not final until grant closeout. Responsible Party: Katherine Taitano, Chief Planner Anticipated Date of Completion: Ongoing effort and as training is made available
Finding #2025-012 14.267 Continuum of Care GU0018L9C002209, GU0026L9C002305, GU0028L9C002204, GU0037L9C002201, GU0031L9C002203 Procurement and Suspension and Debarment Views of Responsible Officials and Planned Corrective Action Management’s Position: Management concurs with the finding. Management ...
Finding #2025-012 14.267 Continuum of Care GU0018L9C002209, GU0026L9C002305, GU0028L9C002204, GU0037L9C002201, GU0031L9C002203 Procurement and Suspension and Debarment Views of Responsible Officials and Planned Corrective Action Management’s Position: Management concurs with the finding. Management would like to clarify that verification of suspension and debarment status was performed through SAM.gov prior to the execution of subrecipient agreements. Historically, the process involved reviewing the entity’s suspension and debarment status directly through SAM.gov, and maintaining an electronic copy of the verification was not established as a standard documentation practice because the information was available for verification through SAM.gov. As changes have occurred to the availability and accessibility of historical SAM.gov records, management recognizes the importance of maintaining independent documentation of the verification performed. While the required verification was conducted, documentation evidencing the verification results was not consistently retained within the applicable procurement or subrecipient files. As a result, management was unable to provide sufficient supporting documentation during the audit to demonstrate completion of the required verification. Corrective Actions: Management will require retention of supporting documentation from SAM.gov verification, including the date of review and evidence of the verification results, within the applicable procurement or subrecipient file. The responsible program personnel will ensure that suspension and debarment verification is completed and documented prior to execution of applicable subrecipient agreements. The applicable procurement and subrecipient files will include SAM.gov verification documentation to support compliance with federal suspension and debarment requirements. Responsible Party: Katherine Taitano, Chief Planner Anticipated Date of Completion: The updated procedures and documentation requirements have been implemented.
Finding #2025-011 14.267 Continuum of Care Period of Performance Views of Responsible Officials and Planned Corrective Action Management’s Position: Condition 1, 2, & 4 Management concurs with the finding. The questioned cost relates to a payroll charge that was initially assigned to a subsequent Co...
Finding #2025-011 14.267 Continuum of Care Period of Performance Views of Responsible Officials and Planned Corrective Action Management’s Position: Condition 1, 2, & 4 Management concurs with the finding. The questioned cost relates to a payroll charge that was initially assigned to a subsequent CoC Planning Grant during the payroll reimbursement process because funding was available under that grant after the prior funding source had been exhausted. During the drawdown review, management identified that the pay period occurred prior to the start of the grant’s period of performance and therefore was not eligible to be charged to that federal award. Upon identification of the issue, the payroll cost was excluded from the reimbursement request and was not included in a federal drawdown. The appropriate corrective action was to reclassify the expense from the CoC Planning Grant to a local funding source. However, at the time the issue was identified, the accounting staff responsible for overseeing payroll reimbursements and related accounting adjustments were in the process of transitioning responsibilities. As a result, while the ineligible cost was not reimbursed with federal funds, the required accounting reclassification was not completed until the subsequent fiscal year. Corrective Actions: Management has strengthened and formalized its payroll reimbursement review procedures to ensure that grant period-of-performance requirements are verified prior to classification of payroll expenses. Management has also established procedures for documenting and tracking identified exceptions to ensure that required accounting adjustments are completed timely and reviewed by supervisory personnel. The RPE Accounting Department will be responsible for ensuring payroll reimbursement classifications are reviewed for compliance with applicable grant period-of-performance requirements. Accounting personnel responsible for payroll reimbursements and related accounting adjustments will maintain documentation of identified exceptions and ensure required adjustments are completed and reviewed by supervisory personnel. Condition 3 Management does not concur with the finding. Explanation of Disagreement: The Manual Journal Voucher (MJV) referenced by the auditor reflects a reclassification of payroll costs between federal grants. While the payroll expenditure relates to a pay period ending June 14, 2025, the expenditure was not ultimately charged to the grant with a period of performance ending December 31, 2024. The purpose of the MJV was to remove the payroll expenditure from the original grant and reclassify it to the appropriate federal grant. The corresponding entry within the same journal voucher charged the expenditure to a grant whose period of performance encompassed the payroll pay period. As a result, the payroll expenditure was not charged to a federal award outside of its period of performance. Management believes the exception resulted from reviewing only one side of the reclassification entry rather than the complete transaction. The supporting MJV demonstrates that the expenditure was removed from the grant with the expired period of performance and reassigned to the appropriate federal award. Accordingly, management respectfully requests reconsideration of this exception. Responsible Party: Katherine Taitano, Chief Planner Anticipated Date of Completion: Condition 1, 2, & 4 The enhanced payroll reimbursement review procedures and exception tracking procedures have been implemented.
Finding #2025-008 14.239 HOME Investment Partnerships (HOME) Program Special Tests and Provisions – Houisng Quality Standards Views of Responsible Officials and Planned Corrective Action Management’s Position: #1 Management concurs with the finding and acknowledges the deficiency identified. Correct...
Finding #2025-008 14.239 HOME Investment Partnerships (HOME) Program Special Tests and Provisions – Houisng Quality Standards Views of Responsible Officials and Planned Corrective Action Management’s Position: #1 Management concurs with the finding and acknowledges the deficiency identified. Corrective action has been initiated. #2 Disagree, the inspection report was only requested for one of the units, submitted on March 12, 2026. Supporting documentation is available for review for the other units upon request. Explanation of Disagreement: For Item #2, GHURA completed onsite inspections for the two acquisition units reviewed. As these units required no rehabilitation, only one inspection was necessary. The remaining two units are new construction projects currently under development. GHURA has conducted ongoing progress inspections and maintained inspection reports prepared by a third-party inspector throughout the construction process. Units are scheduled to be completed 2nd quarter FY2027 at which time the final inspections will be conducted to ensure compliance with program requirements. Corrective Actions: Item #1 - Guam initiated HOME rental monitoring and technical assistance for the three rental developments currently within their compliance periods. Consistent with the schedule provided to HUD by GHURA, RPE conducted entrance meetings with the Subrecipient organization’s deputy director and key staff on June 17, 2026. The Subrecipient was notified of physical inspections scheduled for June 22, 23, and 25, 2026, to be conducted by GHURA AE. One complex, containing more than ten (10) HOME-assisted units, will also undergo financial viability monitoring. File reviews, interviews, and document collection are currently underway. Item #1 – RP&E has initiated this action and will continue as required moving forward. Responsible Party: Jo Lyn Terlaje, Community Development Manager Anticipated Date of Completion: Item #1 - The monitoring process will conclude within 30 days of the entrance meeting, on July 17, 2026, at which time a letter outlining the monitoring results will be issued.
Finding #2025-007 14.239 HOME Investment Partnerships (HOME) Program Eligibility Views of Responsible Officials and Planned Corrective Action Management’s Position: #1 Management concurs and acknowledges that approving the matter without a more thorough evaluation was an oversight. #2 Management dis...
Finding #2025-007 14.239 HOME Investment Partnerships (HOME) Program Eligibility Views of Responsible Officials and Planned Corrective Action Management’s Position: #1 Management concurs and acknowledges that approving the matter without a more thorough evaluation was an oversight. #2 Management disagrees. HOME maximum subsidy per 3-bedroom unit is $338,419.00. Total HOME investment is $112,500.00. Corrective Actions: Corrective actions include strengthening internal controls and oversight. Management will implement a more comprehensive review process moving forward. This process will include additional supervisory review, verification of supporting documentation, confirmation of regulatory and policy compliance, and consultation with appropriate program and legal staff, when necessary, before approvals are granted. Management will also establish review checklists and documentation standards to ensure that all relevant factors are consistently evaluated and adequately documented. Moving forward, the Community Development Division will undergo a more rigorous evaluation process standardized review checklists and documentation requirements will be implemented to promote consistency, accountability, and proper recordkeeping. Management will monitor compliance with these enhanced procedures to reduce the risk of future deficiencies, oversights and ensure approvals are supported by adequate due diligence. Responsible Party: Jo Lyn Terlaje, Community Development Manager Anticipated Date of Completion: Final approval checklists will be implemented by August 1, 2026.
Finding #2025-005 14.225 CDBG – Endtitlement Grants Cluster B19ST660001, B20ST660001, B20SW660001, B21ST660001, B22ST660001, B23ST660001, B24ST660001 Reporting - Federal Funding Accountability and Transparency Act Views of Responsible Officials and Planned Corrective Action Management’s Position: Ma...
Finding #2025-005 14.225 CDBG – Endtitlement Grants Cluster B19ST660001, B20ST660001, B20SW660001, B21ST660001, B22ST660001, B23ST660001, B24ST660001 Reporting - Federal Funding Accountability and Transparency Act Views of Responsible Officials and Planned Corrective Action Management’s Position: Management partially concurs with the finding. Management acknowledges that documenting FFATA lagged in some instances during the earlier periods reviewed. In some instances, challenges with the reporting system complicated our ability to submit timely reports. This was discussed with the audit team. A review of additional requests by the auditor was not completed in time to be incorporated into this commentary. Explanation of Disagreement: FFATA submissions in FSRS are often complicated by limitations in the reporting system. For example, validation of an awardee’s address was often an impediment to completing the FFATA submission. The result is the inability to complete the reporting process. Responsible staff would make multiple varied attempts to enter verified information that would be rejected. In an effort to comply, responsible staff make attempts to resolve this either through the funder or the reporting system. Corrective Actions: To strengthen FFATA reporting, management will review its established processes of pre-award through award documentation. Management will review assigned responsibilities to ensure confirmation of FFATA submission. The RPE Division is responsible for FFATA reporting into SAM.gov. Specific responsibilities to oversee this process are assigned and necessary accesses assigned. Responsible Party: Katherine Taitano, Chief Planner Anticipated Date of Completion: Immediate. The processes of FFATA reporting are in place for all FFTA submissions. Personnel are assigned to ensure the FFTA process is executed and documented for all funded activities.
Finding #2025-004 14.225 CDBG – Endtitlement Grants Cluster B23ST660001, COVID-19 B20SW660001, B20ST660001 Reporting - CDBG Financial Summary Report Views of Responsible Officials and Planned Corrective Action Management’s Position: Management partially concurs with the finding. Management acknowled...
Finding #2025-004 14.225 CDBG – Endtitlement Grants Cluster B23ST660001, COVID-19 B20SW660001, B20ST660001 Reporting - CDBG Financial Summary Report Views of Responsible Officials and Planned Corrective Action Management’s Position: Management partially concurs with the finding. Management acknowledges that supporting documentation explaining differences between the PR26 – CDBG Financial Summary Report, PR26 – CDBG-CV Financial Summary Report, and the Authority’s accounting records can be further strengthened. However, management does not concur that the identified differences resulted in noncompliance with CDBG expenditure requirements or applicable Public Service (PS) and Planning and Administration (PA) expenditure limitations. Explanation of Disagreement: Management notes that the PR26 report referenced in the finding is not the final CDBG Financial Summary Report submitted for Program Year 2024. Management requests that the PR26 report submitted in response to audit request #204 be considered for purposes of evaluating the reported CDBG financial activity. Management also notes that the FY2025 expense detail does not represent the full amount of CDBG expenditures reflected in FY2025 draw activity. This is because certain payroll expenditures incurred during FY2024 were drawn during FY2025 and are therefore included in FY2025 cash activity reported through HUD. Management notes that the purpose of the PR26 reports is to summarize CDBG and CDBG-CV financial activity and demonstrate compliance with applicable program expenditure limitations, including the Public Service and Planning and Administration caps. Management has reviewed these calculations and confirmed, in coordination with HUD representatives, that the applicable caps were not exceeded. Management further notes that differences between the PR26 reports and the Authority’s accounting records may occur due to differences in reporting methodologies. The PR26 reports are prepared based on cash activity reported through HUD, while the Authority’s financial records are maintained on an accrual basis. As a result, differences may occur due to timing of draws, prior-period expenditures drawn during the current reporting period, and other applicable reconciling items. Based on the above, management maintains that the identified differences are attributable to reporting basis and timing differences rather than noncompliance with CDBG expenditure requirements. The final CDBG Financial Summary Reports and supporting documentation have been provided for the auditor’s consideration. Corrective Actions: Management will enhance existing PR26 preparation procedures by maintaining supporting documentation identifying significant reconciling items between HUD-reported activity and the Authority’s accounting records. The purpose of this documentation will be to explain differences resulting from reporting methodology, timing of draws, prior-period expenditures drawn during the current reporting period, and other applicable reconciling items. The RPE Accounting Department, will be responsible for maintaining supporting documentation for PR26 reporting and documenting significant reconciling items. Supervisory review will continue to be performed prior to submission of future PR26 reports to ensure reported information is supported and appropriately documented. Responsible Party: Katherine Taitano, Chief Planner Anticipated Date of Completion: The enhanced documentation procedures will be implemented beginning with the next PR26 reporting cycle.
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