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Finding 2024-002—Activities Allowed or Unallowed Repeat Finding—See Finding 2023-003, 2022-004 Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements, which should include a periodic analysis comparing actual time spent on th...
Finding 2024-002—Activities Allowed or Unallowed Repeat Finding—See Finding 2023-003, 2022-004 Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements, which should include a periodic analysis comparing actual time spent on the CDBG program versus the budgeted allocations and evaluating need for adjustments. Action Taken: Effective June 30, 2025, the City adopted additional procedures for the review of payroll-related reimbursements by the Grants Accountant and Grants Manager prior to funds being drawn. Time spent on the CDBG program will be evaluated at least annually by the Grants Manager and Grants Accountant as part of the budget process.
Views of Responsible Officials – Finding 2024-001 – Procurement, Debarment, and Suspension: The Town of Van Buren acknowledges the finding regarding the lack of documented procurement steps related to suspension and debarment verification, as well as the absence of federally required contract clause...
Views of Responsible Officials – Finding 2024-001 – Procurement, Debarment, and Suspension: The Town of Van Buren acknowledges the finding regarding the lack of documented procurement steps related to suspension and debarment verification, as well as the absence of federally required contract clauses. This occurred during a time when the Town was newly implementing federal grant administration procedures following the adoption of a procurement policy. As noted in the auditor’s report, this is a repeat finding; however, improvements have been made, and the Town is committed to further strengthening our internal controls to ensure full compliance with federal procurement standards. Corrective Action Plan – Finding 2024-001: To address this finding and mitigate the risk of noncompliance with federal procurement regulations, the Town will take the following actions: 1. Procurement File Checklists: Develop and implement a standardized procurement checklist that includes verification of debarment/suspension via SAM.gov, inclusion of all federally required contract provisions, and documentation of cost or price analysis. 2. Contract Review Procedures: All federally funded contracts will be subject to internal review by the Town Manager or a designated compliance officer prior to execution to ensure inclusion of required language and documentation. 3. Staff Training: Town personnel involved in procurement activities will receive annual training specifically covering 2 CFR 200.214 and 2 CFR 200.317–200.327, with emphasis on federal requirements for third-party contracts. 4. SAM.gov Verification: All vendors selected for federally funded projects will be screened through SAM.gov and appropriate documentation (screenshot or printout) will be placed in the procurement file. These measures will ensure that the Town of Van Buren maintains full compliance with federal procurement standards going forward. Responsible Official: Luke Dyer, Town Manager Town of Van Buren Date: June 28, 2025 Anticipated Completion Date: July 1, 2025
Corrective Action Plan – Finding 2024-002 – Reporting Town of Van Buren – CFDA 21.027 – Coronavirus State and Local Fiscal Recovery Funds Audit Period: Fiscal Year Ended June 30, 2024 Views of Responsible Officials: The Town of Van Buren acknowledges the auditor’s finding regarding the lack of docum...
Corrective Action Plan – Finding 2024-002 – Reporting Town of Van Buren – CFDA 21.027 – Coronavirus State and Local Fiscal Recovery Funds Audit Period: Fiscal Year Ended June 30, 2024 Views of Responsible Officials: The Town of Van Buren acknowledges the auditor’s finding regarding the lack of documentation for quarterly performance reports required under 2 CFR 200.329. However, it is important to clarify that, during the grant period, the Town communicated with Efficiency Maine Trust regarding these expectations. Efficiency Maine Trust, as the pass-through entity, confirmed that such federal performance reporting was not required to be submitted back to them by the Town as part of their grant process. Additionally, upon review of the contract provided to the Town, it was noted that the Town was inaccurately listed as a "co-recipient" of the SLFRF (State and Local Fiscal Recovery Funds). After multiple discussions with representatives from the U.S. Department of the Treasury – SLFRF team, it was confirmed that this designation was erroneous. The Town of Van Buren was not a co-recipient but rather a beneficiary of the ARPA funds administered by Efficiency Maine Trust. As a beneficiary, the Town was not responsible for direct federal reporting to Treasury, and this misclassification contributed to the confusion regarding reporting responsibilities. Corrective Action Plan: To prevent similar issues in the future and ensure full compliance with all federal award terms and conditions, the Town will implement the following measures: 1. Clarification of Role: All future grant agreements will be reviewed to confirm whether the Town is operating as a recipient, subrecipient, or beneficiary, and appropriate obligations will be documented. 2. Federal Reporting Procedures: For grants that include federal reporting obligations, the Town will establish an internal checklist outlining the specific reporting requirements and due dates upon award acceptance. 3. Training and Compliance: Staff responsible for grant administration will receive annual training on 2 CFR Part 200 requirements, including those relating to reporting and roles under federal awards. 4. Documentation and Recordkeeping: All communications with pass-through entities and federal agencies relating to grant requirements will be documented and retained as part of the grant file. By implementing these internal control enhancements, the Town aims to prevent future findings and ensure clarity in grant compliance responsibilities.
Finding 2024-001 Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Prevention and Treatment of Substance Abuse Federal Financial Assistance Listing Number: 93.959 Finding Summary: The Organization must establish and maintain effective internal controls over ...
Finding 2024-001 Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Prevention and Treatment of Substance Abuse Federal Financial Assistance Listing Number: 93.959 Finding Summary: The Organization must establish and maintain effective internal controls over federal awards that provides assurance that the organization is managing the federal award in compliance with federal statutes, regulation, and conditions of the federal award. The Organization did not have documented review completed prior to invoice payments being made or reimbursement requests being submitted to ensure all costs incurred were allowed and in the correct period of performance under the program. Responsible Individuals: Carlie Stevens, Wellcome Manor Finance Manager; Karen Klabunde, Wellcome Manor Center Director Corrective Action Plan: On a monthly basis, the Finance Manager will provide the month’s expenditures, receipts, reimbursement requests, and recap spreadsheet to the Center Director. The Center Director will agree all items to the grant and sign the recap spreadsheet to document her review and approval. Anticipated Completion Date: December 31, 2025
Management agrees with the finding and will ensure that the required deadline is met in the future.
Management agrees with the finding and will ensure that the required deadline is met in the future.
Finding 2024-244: The Department’s original Schedule of Expenditures of Federal Awards submitted to the Office of the State Controller underreported the amount disbursed to subrecipients by $3,500,000 under the Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) program. Related to Prior Findi...
Finding 2024-244: The Department’s original Schedule of Expenditures of Federal Awards submitted to the Office of the State Controller underreported the amount disbursed to subrecipients by $3,500,000 under the Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) program. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: The Department will improve training and the review process for the SEFA closing package to ensure appropriate reporting of subrecipient expenditures on the SEFA. The Department will review the FY 2025 SEFA closing package that was submitted to the Office of the State Controller to ensure the appropriate subrecipient expenditures were reported. Anticipated Corrective Action Date: November 30, 2025 Responsible for Corrective Action: Sascha Marston Financial Officer (208) 287-4819 Sascha.marston@idwr.idaho.gov
Finding 2024-243: The Division did not properly evaluate costs related to the Rehabilitation Services- Vocational Rehabilitation Grants to States and direct costs were incorrectly recorded as indirect costs for the grant. Related to Prior Finding: N/A Agency’s view: Agree 7.1 Corrective Action Plan:...
Finding 2024-243: The Division did not properly evaluate costs related to the Rehabilitation Services- Vocational Rehabilitation Grants to States and direct costs were incorrectly recorded as indirect costs for the grant. Related to Prior Finding: N/A Agency’s view: Agree 7.1 Corrective Action Plan: Establish and Document Clear Cost Classification Procedures: Develop written procedures defining and distinguishing between direct and indirect costs. 7.2 Strengthen Internal Controls Over Cost Allocation: Implement review and approval controls to verify proper cost classification before posting transactions to Luma or inclusion in the indirect cost pool. 7.3 Enhance Staff Training and Knowledge: Provide targeted training for fiscal staff to ensure understanding of allowable cost principles and consistent application of cost classification policies. 7.4 Ensure Documentation Retention and Review: Maintain complete documentation supporting all cost allocations, including approval records, cost pool calculations, and reconciliations. 7.5 Perform Regular Monitoring and Verification: Conduct periodic reviews of both direct and indirect cost transactions to confirm classification accuracy and identify any required adjustments. Anticipated Corrective Action Date: 04/01/2026 Responsible for Corrective Action: Eric Bjork, Fiscal Officer
Finding 2024-242: The Division did not accurately report federal grant expenditures on the Schedule of Expenditures of Federal Awards (SEFA) Closing Package. Related to Prior Finding: N/A Agency’s view: Agree 6.1 Corrective Action Plan: Develop and Implement Written SEFA Procedures: Create formal wr...
Finding 2024-242: The Division did not accurately report federal grant expenditures on the Schedule of Expenditures of Federal Awards (SEFA) Closing Package. Related to Prior Finding: N/A Agency’s view: Agree 6.1 Corrective Action Plan: Develop and Implement Written SEFA Procedures: Create formal written procedures describing how SEFA amounts are compiled, reconciled, reviewed, and approved prior to submission within Grants Management Manual. 6.2 Strengthen Internal Controls and Oversight: Implement internal review and approval steps that require documented verification of SEFA amounts against Luma accounting records. 6.3 Ensure Accurate Grant Coding: Review and correct all federal grant fund transactions not assigned to specific grants, ensuring proper coding and allocation in Luma. 6.4 Training and Staff Development: Provide training to fiscal staff on SEFA preparation, reconciliation, and documentation requirements. 6.5 Establish Continuous Monitoring: Perform periodic reviews of federal expenditure coding and SEFA data to identify discrepancies before year-end reporting. Anticipated Corrective Action Date: 04/01/2026 Responsible for Corrective Action: Eric Bjork, Fiscal Officer
Finding 2024-241: The Division did not verify that vendors receiving payments from the Rehabilitation Services – Vocational Rehabilitation Grants to States program, were not suspended or debarred prior to making federal grant payments. Related to Prior Finding: N/A Agency’s view: Agree 5.1 Correctiv...
Finding 2024-241: The Division did not verify that vendors receiving payments from the Rehabilitation Services – Vocational Rehabilitation Grants to States program, were not suspended or debarred prior to making federal grant payments. Related to Prior Finding: N/A Agency’s view: Agree 5.1 Corrective Action Plan: Policy Development and Alignment: Revise the Division’s procurement and grant management procedures to include mandatory ongoing verification and documentation of suspension and debarment status for all vendors involved in covered transactions. 5.2 Systematic Verification Process: Implement a standardized process to verify vendor eligibility by: 5.2.1 Checking the System for Award Management (SAM.gov) exclusion list. 5.2.2 Retaining a copy of the verification record or certification in the procurement or vendor file. 5.2.3 Incorporating a suspension/debarment verification clause into agreements, contracts, authorizations for purchase, and purchase orders. 5.3 Ongoing Monitoring: Establish a control to periodically re-verify vendor status at least annually to identify changes in eligibility after the initial onboarding. 5.4 Training and Accountability: Provide training to all fiscal staff on: 5.4.1 Federal suspension and debarment requirements. 5.4.2 Verification methods and documentation expectations. 5.4.3 Proper retention of evidence. 5.4.4 Compliance Reviews: Implement periodic internal compliance reviews to ensure continued adherence to suspension and debarment verification requirements. Anticipated Corrective Action Date: 04/01/2026 Responsible for Corrective Action: Eric Bjork, Fiscal Officer
Finding 2024-240: The Division is not following Idaho Administrative Rules for Purchasing as required by federal requirements. Related to Prior Finding: N/A Agency’s view: Agree 4.1 Corrective Action Plan: Policy Alignment: Review and revise internal procurement policies and procedures to align with...
Finding 2024-240: The Division is not following Idaho Administrative Rules for Purchasing as required by federal requirements. Related to Prior Finding: N/A Agency’s view: Agree 4.1 Corrective Action Plan: Policy Alignment: Review and revise internal procurement policies and procedures to align with IDAPA 38.05.01, 2 CFR 200.317, and 2 CFR 200.303 requirements. 4.2 Training and Awareness: Provide training to all staff to ensure understanding of: 4.2.1 Purchasing thresholds and categories (small, informal, and formal purchases). 4.2.2 Documentation and approval requirements. 4.2.3 Process and documentation requirements for purchases requiring exemptions. 4.3 Internal Control Strengthening: Develop and implement internal control mechanisms to ensure compliance with State and Federal purchasing requirements. 4.4 Monitoring and Accountability: Establish a quality assurance and compliance monitoring process to perform monitoring of procurement transactions to verify compliance with Division policies and procedures. Anticipated Corrective Action Date: 06/30/2026 Responsible for Corrective Action: Contracts and Vendor Relations Officer, To be Hired Position Oversight: MiKayla Monaghan, Internal Operations and Stakeholder Relations Manager
Finding 2024-239: The Division does not have documented control procedures in place to ensure compliance with period of performance requirements for the Rehabilitation Services-Vocational Rehabilitation Grants to States. Related to Prior Finding: N/A Agency’s view: Agree 3.1 Corrective Action Plan: ...
Finding 2024-239: The Division does not have documented control procedures in place to ensure compliance with period of performance requirements for the Rehabilitation Services-Vocational Rehabilitation Grants to States. Related to Prior Finding: N/A Agency’s view: Agree 3.1 Corrective Action Plan: Document Control Procedures: Develop and implement formal, written procedures (Grants Management Manual Chapter) for verifying that expenditures are assigned to the correct period of performance in both Aware and Luma. 3.2 Training: Train IDVR team members on policies and procedures tied to Period of Performance. Anticipated Corrective Action Date: 04/01/2026 Responsible for Corrective Action: Eric Bjork, Fiscal Officer
Finding 2024-238: The Division did not comply with Matching, Level of Effort, and Earmarking requirements for the fiscal year 2022 Rehabilitation Services-Vocational Rehabilitation Grants to States program. Related to Prior Finding: N/A Agency’s view: Agree 2.1 Corrective Action Plan: Develop and Im...
Finding 2024-238: The Division did not comply with Matching, Level of Effort, and Earmarking requirements for the fiscal year 2022 Rehabilitation Services-Vocational Rehabilitation Grants to States program. Related to Prior Finding: N/A Agency’s view: Agree 2.1 Corrective Action Plan: Develop and Implement Written Policy (Grants Management Manual Section) and Procedures: Establish documented procedures for monitoring and validating compliance with state match funds, maintenance of effort (MOE), and earmarking requirements for each active RSA grant. 2.2 Training and Staff Accountability: Train fiscal and leadership staff responsible on grant calculation methods, documentation standards, and compliance monitoring for matching and level of effort requirements. 2.3 Ongoing Monitoring: Conduct annual compliance reviews before report submission to verify that all level of effort and earmarking requirements are satisfied and adequately supported. Anticipated Corrective Action Date 04/01/2026 Responsible for Corrective Action: Eric Bjork, Fiscal Officer
Finding 2024-237: The Division could not provide supporting documentation for amounts reported on the Rehabilitation Services Administration (RSA) reports required under the Rehabilitation Services- Vocational Rehabilitation Grants to States. Related to Prior Finding: N/A Agency’s view: Agree 1.1 Co...
Finding 2024-237: The Division could not provide supporting documentation for amounts reported on the Rehabilitation Services Administration (RSA) reports required under the Rehabilitation Services- Vocational Rehabilitation Grants to States. Related to Prior Finding: N/A Agency’s view: Agree 1.1 Corrective Action Plan: Establish Accurate Reporting Procedures: Develop and implement procedures for preparing, reviewing, and approving all RSA financial reports, including step-by-step reconciliation. 1.2 Ensure Documentation and Audit Trail: Maintain comprehensive supporting documentation for all amounts reported, including detailed reconciliations, adjustments, and source data, in accordance with requirements for traceable and verifiable records. 1.3 Strengthen Internal Controls and Oversight: Implement Strategic Leadership review of all reports prior to submission to the Rehabilitation Services Administration to confirm data accuracy and compliance with reporting requirements. 1.4 Complete a Restatement of RSA-17 Reports: Review previously submitted RSA-17 reports for fiscal years 2022–2024, determine accurate expenditure amounts, and coordinate with RSA to correct and resubmit revised reports, if necessary. Anticipated Corrective Action Date: 04/01/2026 Responsible for Corrective Action: Eric Bjork, Fiscal Officer
Finding 2024-236: The review and approval of quarterly special reports for the Unemployment Insurance (UI) program were not consistently documented, and the reports were submitted after the required deadline. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: The department h...
Finding 2024-236: The review and approval of quarterly special reports for the Unemployment Insurance (UI) program were not consistently documented, and the reports were submitted after the required deadline. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: The department has taken measures to ensure proper documentation of the review process: Step 1: Provide a designated place on the UI-3 back-up documentation and quarterly report work papers for reviewer to sign off directly in the work papers. Step 2: The individual who enters the report into the federal system will not proceed with entering the report into the system unless the workpapers have the review and approval in the workpapers. The department is taking several steps to provide for a faster month-end close: Step 3: Process Mapping of Cost Accounting Closing a. As part of our strategic planning initiative, document the new closing process in Luma through process maps b. Review process maps internally in accounting and with executive leadership to help identify areas where efficiencies could be achieved c. Implement identified areas of efficiency Step 4: Assess potential for expedited close on quarter-end months a. Cost Accounting manager, supervisor and financial executive officer to review calendar and timing of payroll for quarter-end closings b. Cost Accounting manager, supervisor, and financial executive officer to develop plans for expedited close with potential for overtime, pulling additional resources from other teams and any other options that may help shorten the close period to allow us to file quarterly federal reports timely. Anticipated Corrective Action Date: Step 1. – Add sign-off field to UI-3 workpapers • Completed June 30, 2025 Step 2 – File UI-3 reports only once review is properly captured • Completed June 30, 2025 Step 3.a. – Create cost accounting closing process maps • Completed August 31, 2025 Step 3. b. – Meet with executive staff to review and identify potential efficiencies • Completed September 30, 2025 Step 3. c. – Implement process improvements • To be completed by December 31, 2025 Step 4. a. – Meet to review payroll and closing calendar for quarter-ends and develop plan to overcome calendar issues • Completed November 5, 2025 Step 4. b. – Implement plan to overcome calendar issues • Begin implementing with December 31, 2025, quarter close (January 2026) Responsible for Corrective Action: Carrie Peterman. (208) 696-2533. Carrie.peterman@labor.idaho.gov 317 W. Main Street, Boise, ID 83735
Finding 2024-235: Quarterly financial reports for the Social Security Disability (DI) grant were submitted after the required deadline. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: The department is taking several steps to provide for a faster month-end close: Step 1: P...
Finding 2024-235: Quarterly financial reports for the Social Security Disability (DI) grant were submitted after the required deadline. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: The department is taking several steps to provide for a faster month-end close: Step 1: Process Mapping of Cost Accounting Closing a. As part of our strategic planning initiative, document the new closing process in Luma through process maps b. Review process maps internally in accounting and with executive leadership to help identify areas where efficiencies could be achieved c. Implement identified areas of efficiency Step 2: Assess potential for expedited close on quarter-end months a. Cost Accounting manager, supervisor and financial executive officer to review calendar and timing of payroll for quarter-end closings b. Cost Accounting manager, supervisor, and financial executive officer to develop plans for expedited close with potential for overtime, pulling additional resources from other teams and any other options that may help shorten the close period to allow us to file quarterly federal reports timely. Anticipated Corrective Action Date: Step 1. a. – Create cost accounting closing process maps • Completed August 31, 2025 Step 1. b. – Meet with executive staff to review and identify potential efficiencies • Completed September 30, 2025 Step 1. c. – Implement process improvements • To be completed by December 31, 2025 Step 2. a. – Meet to review payroll and closing calendar for quarter-ends and develop plan to overcome calendar issues • Completed November 5, 2025 Step 2. b. –Implement plan to overcome calendar issues • Begin implementing with December 31, 2025, quarter close (January 2026) Responsible for Corrective Action: Carrie Peterman. (208) 696-2533. Carrie.peterman@labor.idaho.gov 317 W. Main Street, Boise, ID 83735
Finding 2024-234: Payroll adjustments lacked sufficient internal controls. Agency’s View: The Department Agrees with this Finding Corrective Action: The department has established internal controls to ensure appropriate separation of duties and proper documentation of all reviews. When an accounting...
Finding 2024-234: Payroll adjustments lacked sufficient internal controls. Agency’s View: The Department Agrees with this Finding Corrective Action: The department has established internal controls to ensure appropriate separation of duties and proper documentation of all reviews. When an accounting adjustment is required, staff prepare the adjustment using either an Infor Spreadsheet Designer (ISD) template or an Excel template. ISD is used for adjustments involving large volumes of data. Because ISD-generated adjustments cannot be reviewed within the system after entry, the completed template is sent to a Financial Specialist Principal (or higher) for review prior to upload. Email approval is obtained and attached to the adjustment record when it is entered into the system. For adjustments involving smaller amounts of data, staff use the Excel template. The Excel template, original GL lines, supporting documentation, and any other relevant information are attached when the adjustment is entered. After the manual adjustment is submitted, it is automatically routed to a Financial Specialist Principal (or higher) for approval before final posting. These procedures ensure that all adjustments undergo an independent review and that documentation is consistently maintained. Anticipated Corrective Action Date: Completed July 31, 2024 Responsible for Corrective Action: Magnum Forkner, Financial Manager magnum.forkner@dhw.idaho.gov 208-332-7241
Finding 2024-233: The submission of a Child Care and Development Fund (CCDF) financial report was not completed timely. Agency’s View: The Department Agrees with this Finding Corrective Action: The Department has seen an increased time commitment related to financial grant reporting since the implem...
Finding 2024-233: The submission of a Child Care and Development Fund (CCDF) financial report was not completed timely. Agency’s View: The Department Agrees with this Finding Corrective Action: The Department has seen an increased time commitment related to financial grant reporting since the implementation of Luma in July 2023. This was particularly relevant in SFY 2024 as Luma implementation, training and interfaces were still evolving, resulting in a tremendous increase in time commitments without the corresponding staff increases needed. In many cases, this resulted in late filings and/or filing reports that were not reviewed in sufficient detail. The Division of Financial Services continues to work through the inefficiencies encountered and design processes that include sufficient review and other internal controls while also allowing for timely completion of required reports. One FTE was transferred from another team to the Cash and Grants team. This position is expected to assist in completing preliminary tasks so that Grant Reporters have necessary data at their fingertips when drafting financial reports. As Department staff continue to learn nuances of the Luma system, both accuracy and timeliness of financial reporting is expected to improve. Anticipated Corrective Action Date: 6/30/2026 Responsible for Corrective Action: Dena Darpli, Financial Manager dena.darpli@dhw.idaho.gov 208-334-4909
Finding 2024-232: An incorrect Federal Medical Assistance Percentage (FMAP) rate was applied while calculating the federal and state share of expenditures for the Child Care and Development Fund (CCDF) financial report resulting in an understatement of $1,064,932 of the federal share of costs. Agenc...
Finding 2024-232: An incorrect Federal Medical Assistance Percentage (FMAP) rate was applied while calculating the federal and state share of expenditures for the Child Care and Development Fund (CCDF) financial report resulting in an understatement of $1,064,932 of the federal share of costs. Agency’s View: The Department Agrees with this Finding Corrective Action: The Department's Grant Reporting team has been developing additional internal controls to put in place with the utilization of the Luma ERP. These controls include conducting reconciliations between internal workpapers and Luma records as well as reconciling to external parties such as the Payment Management System. This has streamlined our approach and has allowed management more opportunity to review items with higher risk factors, such as the quarterly change in FMAP rates during the stepdown from enhanced FMAP rates during COVID. We believe these increased focused efforts will alleviate issues like this in the future and are ongoing as the Department identifies opportunities for advancements in our own processes and working with SCO to implement better Luma reports and controls within the grant reconciliation process. Anticipated Corrective Action Date: 6/30/2026 Responsible for Corrective Action: Dena Darpli, Financial Manager dena.darpli@dhw.idaho.gov 208-334-4909
Finding 2024-231: Supporting documentation for subrecipient risk assessments for the Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises program was not available for review. Related to Prior Finding: 2023-222 Agency’s Vi...
Finding 2024-231: Supporting documentation for subrecipient risk assessments for the Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises program was not available for review. Related to Prior Finding: 2023-222 Agency’s View: The Department Agrees with this Finding Corrective Action: The Division of Public Health updates its standard operating procedures annually and communicates updates to staff. The DPH Federal Compliance Officer is conducting monthly trainings to cover all required steps in the process and will begin conducting mini audits in calendar year 2026 to ensure all steps are being followed consistently. Anticipated Corrective Action Date: 5/1/2026 Responsible for Corrective Action: Traci Berreth, Division Administrator traci.barreth@dhw.idaho.gov 208-334-5774
Finding 2024-230: The Department did not provide documented support to verify the accuracy of a LIHEAP performance report. Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This proc...
Finding 2024-230: The Department did not provide documented support to verify the accuracy of a LIHEAP performance report. Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This process was shared with LSO following receipt of the FY23 review findings. Supporting documents can be provided again as needed. Anticipated Corrective Action Date: Completed 03/25/2025 Responsible for Corrective Action: Kristin Matthews, Programs Bureau Chief, Self Reliance kristin.matthews@dhw.idaho.gov 208-334-5553
Finding 2024-229: Low-Income Home Energy Assistance Program (LIHEAP) special reports did not include a review for accuracy and compliance prior to submission. Related to Prior Finding: 2023-210 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that inc...
Finding 2024-229: Low-Income Home Energy Assistance Program (LIHEAP) special reports did not include a review for accuracy and compliance prior to submission. Related to Prior Finding: 2023-210 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This process was shared with LSO following receipt of the FY23 review findings. Supporting documents can be provided again as needed. Anticipated Corrective Action Date: Completed 04/08/2024 Responsible for Corrective Action: Kristin Matthews, Programs Bureau Chief, Self Reliance kristin.matthews@dhw.idaho.gov 208-334-5553
Finding 2024-228: The review of the Low-Income Home Energy Assistance Program (LIHEAP) earmarking compliance requirements was not documented. Related to Prior Finding: 2023-212 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining a...
Finding 2024-228: The review of the Low-Income Home Energy Assistance Program (LIHEAP) earmarking compliance requirements was not documented. Related to Prior Finding: 2023-212 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This process was shared with LSO following receipt of the FY23 review findings. Supporting documents can be provided again as needed. Anticipated Corrective Action Date: Completed 03/25/2025 Responsible for Corrective Action: Kristin Matthews, Programs Bureau Chief, Self Reliance kristin.matthews@dhw.idaho.gov 208-334-5553
Finding 2024-227: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Related to Prior Finding: 2023-211 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that inc...
Finding 2024-227: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Related to Prior Finding: 2023-211 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This process was shared with LSO following receipt of the FY23 review findings. Supporting documents can be provided again as needed. Anticipated Corrective Action Date: 03/06/2025 Responsible for Corrective Action: Kristin Matthews, Programs Bureau Chief, Self Reliance kristin.matthews@dhw.idaho.gov 208-334-5553
Finding 2024-226: The Bureau of Facility Standards within the Department failed to complete timely health and safety surveys for three long-term care facilities. Agency’s View: The Department Agrees with this finding. Corrective Action: During SFY24, Bureau of Facility Standards (BFS) was still comi...
Finding 2024-226: The Bureau of Facility Standards within the Department failed to complete timely health and safety surveys for three long-term care facilities. Agency’s View: The Department Agrees with this finding. Corrective Action: During SFY24, Bureau of Facility Standards (BFS) was still coming out of the COVID response for recertification time frames and actively recruiting new health facility surveyors to ensure proper multidisciplined teams were available to complete the overdue surveys. BFS also contracted with Healthcare Management Solutions, LLC. to supplement overdue recertification surveys. On October 3, 2025, during the government shutdown, we were able to complete the final overdue surveys to be compliant with 15.9 months between surveys. Due to the government shutdown, CMS paused recertification surveys for nursing facilities. This may restrict our ability to maintain the required recertification timeline of 15.9 months. We have recruited and maintained staffing posture but are still actively recruiting to round out of staffing to meet the statutory timelines. Anticipated Corrective Action Date: 10/31/2026 Responsible for Corrective Action: Nate Elkins, Programs Bureau Chief, Licensing & Certification nate.elkins@dhw.idaho.gov 208-364-1874
Finding 2024-225: Amounts reported as provided to subrecipients by financial services on the Schedule of Expenditures of Federal Assistance (SEFA) are not properly supported. Related to Prior Finding: 2023-208 Agency’s view: The agency agrees with this finding. Corrective Action Plan: For major gran...
Finding 2024-225: Amounts reported as provided to subrecipients by financial services on the Schedule of Expenditures of Federal Assistance (SEFA) are not properly supported. Related to Prior Finding: 2023-208 Agency’s view: The agency agrees with this finding. Corrective Action Plan: For major grants, Financial Services staff will send a summary of transactions coded as subrecipient payments to the program manager to review prior to inclusion in the SEFA closing package. The review will be requested to be twofold: to ensure that everything that should be included as a subrecipient payment is and to ensure that nothing that should not be considered a subrecipient payment is included. This process helps to identify that we are reporting the accurate amount of expenditures for each subrecipient Anticipated Corrective Action Date: Completed 9/5/2025 Responsible for Corrective Action: Dena Darpli, Financial Manager dena.darpli@dhw.idaho.gov 208-334-4909
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