Corrective Action Plans

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Finding No.: 2024-053 Special Test and Provisions – Project Accounting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures in compliance with applicable spec...
Finding No.: 2024-053 Special Test and Provisions – Project Accounting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures in compliance with applicable special tests and provision requirements. GHS will also identify department personnel responsible.
Finding No.: 2024-052 Reporting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will work with DOA to make sure reports are submitted on time. GHS will also retain documentation of submitted reports.
Finding No.: 2024-052 Reporting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will work with DOA to make sure reports are submitted on time. GHS will also retain documentation of submitted reports.
Finding No.: 2024-049 Activities Allowed or Unallowed: Allowable Costs/Cost Principles Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director Guam Homeland Security (GHS) will make sure that proper supporting documentation is available. GHS will also identify...
Finding No.: 2024-049 Activities Allowed or Unallowed: Allowable Costs/Cost Principles Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director Guam Homeland Security (GHS) will make sure that proper supporting documentation is available. GHS will also identify department personnel responsible.
Finding No.: 2024-048 Eligibility Special Test and Provisions- Utilization Control Provider Eligibility (Screening and Enrolment) Provider Health and Safety Standards Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agr...
Finding No.: 2024-048 Eligibility Special Test and Provisions- Utilization Control Provider Eligibility (Screening and Enrolment) Provider Health and Safety Standards Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. To address the recommendation for a reconciliation process, DPHSS is in the process of forming a multi-agency technology initiative which will include: • Establishment of an Inter-Agency Data Hub: DPHSS, in collaboration with the Office of Technology (OTECH) and the Department of Administration (DOA), aims to establish a centralized Data Hub. This hub will facilitate real-time or scheduled data synchronization between the DPHSS medical management systems and DOA’s financial accounting records, which are managed in the Guam Financial Management Information System (GFMIS). The data hub is intended to ensure all claims paid are automatically after proper approvals and are then reconciled with the general ledger. • Inter-Agency Agreement and Coordination: DPHSS acknowledges that successful implementation of this Data Hub requires a unified commitment. DPHSS leadership is coordinating with the Director of DOA to discuss the technical requirements and administrative protocols. A formal Memorandum of Agreement (MOA) or a joint standard procedure will be sought, subject to the concurrence and approval by both Agency Directors. • Manual Interim Reconciliation: Until the Data Hub is fully operational, DPHSS will work with DOA to implement a monthly manual reconciliation process. This will involve a "crosswalk" review of claim batch totals against financial system postings to identify and resolve variances (such as voided checks or manual adjustments) in a timely manner. • Engagement with OTECH: Once the two directors agree on the framework, DPHSS will engage OTECH to design the data architecture necessary to ensure data integrity, security, and compliance with federal reporting standards. Estimated implementation timeframe: March 31, 2027
Finding No.: 2024-046 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS disagrees with this finding and provided documentation of grantor approval to use the FY 2024 award to pay prior year obligati...
Finding No.: 2024-046 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS disagrees with this finding and provided documentation of grantor approval to use the FY 2024 award to pay prior year obligations. The enclosed communication from Linda Gee, CMS, dated July 1, 2021, provides more information. 45 CFR 95.7 (https://www.ecfr.gov/cgi-bin/text-idx?node=pt45.1.95&rgn=div5#se45.1.95_17) provides that a state Medicaid agency (i.e. Guam Medicaid Agency) has up to two years to file for a claim that it made. DPHSS welcomes the opportunity to discuss and collaboratively identify the relevant information and guidance during an entrance conference for each year’s audit.
Finding No.: 2024-045 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. The Bureau of Economic Security (BES) recognized the finding as an issue and in response, held a bureau-wide t...
Finding No.: 2024-045 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. The Bureau of Economic Security (BES) recognized the finding as an issue and in response, held a bureau-wide training for both front desk personnel and eligibility specialists on December 22 - 23, 2025. This training focused on application handling including the timeliness of eligibility determinations and proper documentation maintenance procedures. The training reinforced use of a standardized application checklist that was developed to support application completeness. Staff were also trained in the correct method for uploading documents into the OnBase system, the bureau’s digital record archive, for secure storage and efficient retrieval. In January 2026, BES conducted a Customer Email Standard Operating Procedure (SOP) training to reinforce staff compliance with documentation requirements, including the use of document imaging process (DIP) to ensure customer documentation received via email is uploaded into the OnBase system within two business days. In addition, DPHSS is preparing additional training sessions, which are currently being developed, on topics such as Medicaid Basics 101, Customer Service, and Medicaid Eligibility. To assess compliance with the training, Eligibility Specialist Supervisors were tasked with periodically reviewing random samples of applications across all three centers to verify application completeness, including required documents. BES will further reinforce timeliness compliance by incorporating 45-day timeliness checks and targeted reviews of higher-risk cases into supervisory case reviews. Findings from these reviews will be used to inform corrective action and retraining as needed. DPHSS is also revising the document verification list in the Public Application form to help clients clearly identify required documentation needed to support eligibility determination and reduce the risk of missing or incomplete case files.
Finding No.: 2024-044 Special Test and Provisions Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. All applicable providers ...
Finding No.: 2024-044 Special Test and Provisions Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. All applicable providers were monitored and met necessary health and safety requirements. All supporting inspection reports and certifications exist and were provided to the auditors via a OneDrive link on February 9, 2026, following a subsequent request for information. Additionally, in accordance with the Rules and Regulations Governing Child Care Facilities Section 1.5.00 (a), Relative Care facilities are exempt from Sanitary Permits. BCCS requests a detailed breakdown of the $3,726,391 valuation to clarify if the audit team applied a total disallowance of payments or a weighted penalty for perceived documentation gaps. We maintain that this dollar amount is fundamentally inaccurate if the assessment did not properly factor in the specific regulatory exemptions applicable to these providers. Furthermore, BCCS questions the rationale used to assign such a substantial fiscal impact to an administrative-heavy finding, especially where the core program requirements and services were successfully fulfilled.
Finding No.: 2024-041 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. Eligibility determinations were conducted in accordance with federal and...
Finding No.: 2024-041 Eligibility Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director The Bureau of Child Care Services (BCCS) disagrees with this finding. Eligibility determinations were conducted in accordance with federal and local requirements. The exceptions noted are due to a subsequent request received by BCCS on January 20, 2026, and consequently responded to on January 29, 2026. Additional supporting documents were provided on February 9, 2026. Certain payment variances reflect allowable program exceptions.
Finding No.: 2024-038 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS ELC Program disagrees with the findings. Condition 1: The questioned labor costs of $16,668 align with payment of Core funded ...
Finding No.: 2024-038 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS ELC Program disagrees with the findings. Condition 1: The questioned labor costs of $16,668 align with payment of Core funded staff during that approved budget period for BP01. The PPE coincides with two draws for the ending and beginning of those fiscal years. Supporting documents were submitted twice, once on February 9, 2026, and February 20, 2026, including the Notice of Award (NOA) for this grant with issue date of July 9, 2024. Condition 2: The question of compliance with period of performance was justified through supporting documentations as reflected in the NOAs and extensions of NOAs which were provided twice February 9, 20206 and February 23, 2026. Program also noted that core funds have expanded authority to be utilized in subsequent budget periods throughout the 5-year cycle of the Cooperative Agreement. Upon auditor’s review, a correspondence email noted that the documents were received and findings were removed for all but on expense. Although all supporting NOAs were submitted for every expenditure amount, a follow up email with the last NOA for 6NU50CK000561-05-00 was provided again as an attachment.
Finding No.: 2024-037 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Implementation of a Fixed Assets Module as part of the new FMIS system that will help automate the tracking and reporting of Capital asse...
Finding No.: 2024-037 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Implementation of a Fixed Assets Module as part of the new FMIS system that will help automate the tracking and reporting of Capital assets, is near completion with final testing in progress. DOA will update the SOP for the Fixed Assets for capital asset reporting accordingly. Review of Assets acquired in FY2024 was completed, with FY2025 in progress. As noted previously, the process is hampered by difficulties in recruiting personnel.
Finding No.: 2024-035 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Guam EPA has implemented processes relevant to the monitoring and reconciliation of program income. As part of our Correction Action for the FY2023 ...
Finding No.: 2024-035 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Guam EPA has implemented processes relevant to the monitoring and reconciliation of program income. As part of our Correction Action for the FY2023 audit, which is a repeat finding in FY2024, Guam EPA is attaching a sample report of all program income collected through the Transaction Processing System (TPS) to include external payments received by DOA. Also, variances not captured by this report, consisting of payments/transactions submitted directly to DOA via electronic method of payments, are being reconciled by our staff and DOA.
Finding No.: 2024-034 Period of Performance Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Request to DOA will require immediate collaboration between Guam EPA and DOA to gather, reconcile, and provide all supporting documentation t...
Finding No.: 2024-034 Period of Performance Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Request to DOA will require immediate collaboration between Guam EPA and DOA to gather, reconcile, and provide all supporting documentation to support compliance with the period of performance in question.
Finding No.: 2024-031 Subrecipient Monitoring Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will create Standard Operating Procedures as well as a checklist, to assist in the monitoring of subrecipient compliance.
Finding No.: 2024-031 Subrecipient Monitoring Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will create Standard Operating Procedures as well as a checklist, to assist in the monitoring of subrecipient compliance.
Finding No.: 2024-030 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to make sure reports are submitted on time. BBMR will also retain documentation of submitted reports.
Finding No.: 2024-030 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to make sure reports are submitted on time. BBMR will also retain documentation of submitted reports.
Finding No.: 2024-028 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency disagrees with this finding. Please refer to a letter dated March 31, 2026, regarding Reports on Compliance September 30, 2024.
Finding No.: 2024-028 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency disagrees with this finding. Please refer to a letter dated March 31, 2026, regarding Reports on Compliance September 30, 2024.
Finding No.: 2024-024 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.
Finding No.: 2024-024 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.
Finding No.: 2024-022 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.
Finding No.: 2024-022 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.
Finding No.: 2024-020 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency disagrees with this finding. Please refer to a letter dated March 31, 2026, regarding Reports on Compliance September 30, 2024
Finding No.: 2024-020 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency disagrees with this finding. Please refer to a letter dated March 31, 2026, regarding Reports on Compliance September 30, 2024
Finding No.: 2024-018 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing the management of Federal Grants to ensure robust handover and succession plans are in place for future programs. The sudden passing of the ...
Finding No.: 2024-018 Eligibility Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing the management of Federal Grants to ensure robust handover and succession plans are in place for future programs. The sudden passing of the ERA Program Coordinator directly impacted overall management of the program.
Finding No.: 2024-017 Eligibility Responding Agency: Department of Labor (DOL) Responsible Personnel: David M. Dell’Isola In June 2024, GDOL established a policy workgroup to modernize internal procedures. Consequently, the AJC-024-Selective Service Registration policy was updated and formally appro...
Finding No.: 2024-017 Eligibility Responding Agency: Department of Labor (DOL) Responsible Personnel: David M. Dell’Isola In June 2024, GDOL established a policy workgroup to modernize internal procedures. Consequently, the AJC-024-Selective Service Registration policy was updated and formally approved on August 12, 2024. This updated guidance was distributed to all American Job Center (AJC) staff and case managers on August 15, 2024, to ensure future consistency in documentation and eligibility overrides.
Finding No.: 2024-016 Subrecipient Monitoring Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will create Standard Operating Procedures as well as a checklist, to assist in the monitoring of subrecipient compliance.
Finding No.: 2024-016 Subrecipient Monitoring Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will create Standard Operating Procedures as well as a checklist, to assist in the monitoring of subrecipient compliance.
Finding No.: 2024-015 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to keep soft copies of submitted and approved Federal Financial Reports (FFR) on hand.
Finding No.: 2024-015 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to keep soft copies of submitted and approved Federal Financial Reports (FFR) on hand.
Finding No.: 2024-014 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Implementation of a Fixed Assets Module as part of the new FMIS system that will help automate the tracking and reporting of Capital asse...
Finding No.: 2024-014 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Implementation of a Fixed Assets Module as part of the new FMIS system that will help automate the tracking and reporting of Capital assets, is near completion with final testing in progress. DOA will update the SOP for the Fixed Assets for capital asset reporting accordingly. Review of Assets acquired in FY2024 was completed, with FY2025 in progress. As noted previously, the process is hampered by difficulties in recruiting personnel.
Finding No.: 2024-011 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The DPHSS WIC Program disagrees with the findings. All supporting documents related to the findings were provided promptly o...
Finding No.: 2024-011 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The DPHSS WIC Program disagrees with the findings. All supporting documents related to the findings were provided promptly on March 3,2026 when request was received on February 26,2026. In accordance with WIC FY 2024 Closeout Guidance and the requirements under 2 CFR 200.344, the WIC Program is allowed 90 days after the end of the period of performance to submit all final financial reports, as well as 90 days to liquidate all obligations incurred during the period of performance. For FY 2024, the closeout timeline required that all obligations be liquidated no later than January 31, 2025. The program adhered to these federal requirements. All obligations were liquidated prior to the close of the fiscal year grant, and obligations were reported in the fiscal year in which they occurred, consistent with 7 CFR 246.17. Furthermore, the final closeout report was submitted within 120 days after the end of the fiscal year, fully complying with WIC closeout procedures. Based on the timely submission of all supporting documentation and adherence to federal closeout regulations, the DPHSS WIC Program maintains that the questioned costs were appropriately obligated, liquidated, and reported.
Finding 2024- 013: Terminated User Access Not Removed Timely Significant Deficiency In Internal Control Over Financial Reporting Criteria: Per 45 CFR 75.303(a), non-Federal entitles expendingHHS awards must establish and maintain effective internal controls over compliance with Federal states, regul...
Finding 2024- 013: Terminated User Access Not Removed Timely Significant Deficiency In Internal Control Over Financial Reporting Criteria: Per 45 CFR 75.303(a), non-Federal entitles expendingHHS awards must establish and maintain effective internal controls over compliance with Federal states, regulati ons, and the terms and conditions of the Federal award. Management must mainta in effective user access controls over financia l reporting systems. This Includes promptly removing or disabling access for terminated users and periodically reviewing user access to confirm it aligns with current employment status and job responsibilities. Condition: Testing of IT general controls identifiedinstances where terminated employees' user accounts or financial application access remained active beyond the termination date. MDCPS did not disable terminated user access or remove related application rights in a timely manner. Perspective: During our review of general IT controls, the auditor received a list of terminated employees. Of the 11 employees presented, 6 maintainedaccess to MACWIS after termination.Further, during the performance of a process walkthrough,it was noted that the former chief financial officer was still active in CapPlus and SPHARS. Personnel Responsiblefor Corrective Action: Nome: Shannon Rushton (Employee Seporotlon SOP) Title : Deputy Commissionerof Human Capitol Email: Shannon.Rushton@mdcps.ms.gov Phone Number: 601-359-2696 Name: Christopher Ray (CapPlus User Termination) Title: Deputy Director to the CFO Email: Christopher.Roy@mdcps.ms.gov Phone Number: 601-359-4043 Corrective Action Plan: MDCPS has reinforcedthe EmployeeSeparation St andard Operating Procedure(2.19.2.2) to ensure all system access is removed promptly upon employee separation. Human Resources will notify system administrators immedai tely upon employeetermination, and system administrators will disable all associated application access no later than th e employee's final day of employment. Human Resources will conduct periodic user access reviews to ensure procedures are properly Imp lemented. The Finance Division will ensure the cap Plus software's access and penn1ss1ons are monitored and maintained by the agency with assistance from Interactive Voice Application (IVA). Upon a Cap Plus user's termination , they will be removed from the Cap Plu s software upon their last day of employment or the removal of th eir dutie.s by the agency. These permissions do not require IT or Human Resource control as Cap Plus i s independent of all accounting, payroll, and HR software. Antldpated Completion Date: Empl oyee Separation SOP effectiveas of July 22, 2025. CapP lus user's termination procedures effective as of March 31, 2026.
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