Corrective Action Plans

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The Department agrees with the finding. During fiscal year 2024–2025, DHSEM experienced significant turnover within the Finance Bureau, which disrupted established processes for the timely preparation and submission of required SF-425 Federal Financial Reports as required under 2 CFR 200.328. While ...
The Department agrees with the finding. During fiscal year 2024–2025, DHSEM experienced significant turnover within the Finance Bureau, which disrupted established processes for the timely preparation and submission of required SF-425 Federal Financial Reports as required under 2 CFR 200.328. While financial transactions continued to be recorded in the Department’s accounting system, staffing vacancies limited the Department’s capacity to compile, review, and submit certain quarterly reports within the required 30-day timeframe. The untimely submissions primarily impacted reporting periods ended March 31, 2025, and June 30, 2025. The Department acknowledges that reports were not submitted within required deadlines during that period; however, DHSEM is current with all federal financial reporting as of FY2026.To prevent recurrence, DHSEM has strengthened internal controls over federal financial reporting. The Department has implemented a formal supervisory review process for all SF-425 reports prior to submission to ensure completeness, accuracy, and compliance with federal requirements. DHSEM has also established cross-training within the Finance Bureau to ensure alternate personnel are capable of preparing, reviewing, and submitting required reports in the event of staff vacancies or absences.Additionally, the Department has conducted federal financial reporting trainings for Finance and Grants staff and has worked closely with FEMA representatives to ensure alignment with reporting requirements and expectations. DHSEM is revising and formalizing written financial management and reporting policies and procedures to incorporate supervisory review controls, alternate personnel assignments, escalation protocols for reporting deadlines, and standardized documentation of report preparation.These actions are intended to strengthen compliance with federal reporting requirements and ensure timely and accurate submission of financial reports going forward.
Finding Number: 2025-001 Management’s Response The management of Elevate Youth Services (EYS) acknowledges the importance of maintaining a formalized process for tracking and fulfilling grant reporting requirements. Context: EYS’s VCRHYP Program Director position experienced significant turnover ove...
Finding Number: 2025-001 Management’s Response The management of Elevate Youth Services (EYS) acknowledges the importance of maintaining a formalized process for tracking and fulfilling grant reporting requirements. Context: EYS’s VCRHYP Program Director position experienced significant turnover over several years, which led the Executive Director to absorb responsibility for completing required semiannual and annual financial and program reports. This continued through FY22–FY24, and remained the case until the Executive Director’s departure on June 30, 2024. In FY25, new and existing EYS leadership assumed responsibility for both financial and program reporting. A primary focus of that year was building a stronger financial and management framework — one that is efficient and aligned with regulatory and grant requirements. This included a successful transition to accrual-based accounting and the development or revision of grant program management tools, including budget and monitoring systems. FY25 represented a significant investment in laying the foundation for reporting practices consistent with GAAP and sound grant management. That said, FY25 was also a year of competing demands. The work of building and revising systems while managing ongoing operations created delays in the timeliness of both financial and program reporting. Corrective Action Plan Management Oversite The Executive Director and Director of Finance will work with the VCRHYP Program Director to develop a shared reporting calendar with scheduled prompts to support timely submission. Additionally, the Manager of Quality Assurance and Data Systems will support leadership in building a Grant Lifecycle Tracking Module within EYS’s database. EYS is committed to strengthening the timeliness and accuracy of all financial and program reporting going forward.
Lawrence County Schools has taken the appropriate corective actions and continues to follow procedures for mileage reimbursement. These procedure include documentation requirements, verification of mileage calculations, and review for accuracy by LCSS personnel.
Lawrence County Schools has taken the appropriate corective actions and continues to follow procedures for mileage reimbursement. These procedure include documentation requirements, verification of mileage calculations, and review for accuracy by LCSS personnel.
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Due to staffing shortages within the Supplemental Nutrition and Assistance Program office (SNAPO), this has and will continue to be an area of focus for improvement and will be an action item ...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Due to staffing shortages within the Supplemental Nutrition and Assistance Program office (SNAPO), this has and will continue to be an area of focus for improvement and will be an action item for the fiscal year 2026. Corrective Action Taken or Planned: SNAPO intends to conduct regular fiscal reviews of all contracts beginning March 2026. Completion Date: August 31, 2026 Responding Official(s): Ginet Hayes, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator
Views of Responding Officials: The Department agrees with the finding, will implement corrective action, and will work with the appropriate parties to address this issue. Corrective Action Taken or Planned: The EBT accounts will be reconciled daily, and once completed, will be reviewed and signed of...
Views of Responding Officials: The Department agrees with the finding, will implement corrective action, and will work with the appropriate parties to address this issue. Corrective Action Taken or Planned: The EBT accounts will be reconciled daily, and once completed, will be reviewed and signed off by the accounting supervisor. If discrepancies are found, they will be checked against the detailed Fidelity National Information Services (FIS) and the Office of Enterprise Technology (OET) reports. Expected Completion Date: June 2026 Responding Official(s): Joey Wong, Fiscal Management Office Accounting Supervisor
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: We have implemented a training plan and discussed efficiencies by operations staff to improve accuracy and timeliness. This has been a priority since Januar...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: We have implemented a training plan and discussed efficiencies by operations staff to improve accuracy and timeliness. This has been a priority since January 2025. We will be transitioning to a new eligibility system starting October 2026 which should assist in improving the accuracy. Expected Completion Date: Ongoing Responding Official(s): Ginet Hayes, Benefit, Employment, and Support Services Division Supplemental Nutrition and Assistance Program Administrator
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Child Care Regulation Program Office reviewed the program expenditures that were categorized as Infant and Toddler quality activities and found several ...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The Child Care Regulation Program Office reviewed the program expenditures that were categorized as Infant and Toddler quality activities and found several expenditures that were not being categorized as Infant and Toddler quality activities for Grant Year 2022. Instead, the expenditure was categorized as Quality expenditures. We are currently working with the Fiscal Management Office to reconcile the difference and will update the ACF 696-report. Expected Completion Date: March 11, 2026. Responding Official(s): Dayna Luka, Benefit, Employment, and Support Services Division Child Care Regulation Program Administrator
Views of Responsible Officials: The Department agrees with the finding and will implement corrective action. Upon review of the case, it was determined that the caseworker did not trigger a renewal in the Kauhale On-Line Eligibility Assistance System (KOLEA) when the member called to renew by phone....
Views of Responsible Officials: The Department agrees with the finding and will implement corrective action. Upon review of the case, it was determined that the caseworker did not trigger a renewal in the Kauhale On-Line Eligibility Assistance System (KOLEA) when the member called to renew by phone. The member reported income to the worker and was advised to provide verification; however, the worker did not trigger a renewal in the system, which prevented an N01 notice from being sent to request verification. The case remained open because the worker did not trigger a Verification Line Item (VLI) for income for the member in KOLEA. The case was later processed through a system data fix, and the member was ex parte renewed and given a new certification period. Corrective Action Taken or Planned: The Eligibility Renewals: Processing DHS 1100B-2 Form Job Aid will be updated to provide instructions for processing non-ex parte renewals completed by phone. Steps on how to properly trigger a renewal in KOLEA will be added to the existing guidance, including detailed screenshots. These updates will enable workers to process renewals consistently, whether they are submitted via form or conducted by phone. The additions to the Job Aid will ensure that a renewal is triggered correctly in the system and that request for verification N01 notices are triggered appropriately when non-ex parte renewals are completed by phone. Expected Completion Date: March 18, 2026 Responding Official(s): Lori-Lei Aponte, Med-QUEST Eligibility and Enrollment Administrator
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. No comments regarding the case in which income was not considered when eligibility determination was made and benefits calculated. According to documents found in the electronic case file, the...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. No comments regarding the case in which income was not considered when eligibility determination was made and benefits calculated. According to documents found in the electronic case file, the household reported on their annual recertification application that a household member is employed and copies of pay statements were provided. Corrective Action Taken or Planned: Eligibility staff will be reminded to: 1. Thoroughly review the DHS 1240, Application for Financial and SNAP Assistance, for all initial and annual recertifications; 2. Conduct an IEVS check and document on form DHS 1006, Eligibility Determination; 3. Complete the DHS 1006 based on information provided on the DHS 1240 and with the information obtained during the applicant/recipient’s eligibility interview; and 4. Follow up on any missing information or any discrepancies with information provided by the applicant/recipient and information obtained through third-party queries. Expected Completion Date: October 1, 2026 Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
Views of Responsible Officials: The Department agrees with the finding and will implement corrective action. The program personnel are familiar with grant reporting requirements. For the federal fiscal year 2025, there were 62 federal Temporary Assistance for Needy Families(TANF)-funded contracts th...
Views of Responsible Officials: The Department agrees with the finding and will implement corrective action. The program personnel are familiar with grant reporting requirements. For the federal fiscal year 2025, there were 62 federal Temporary Assistance for Needy Families(TANF)-funded contracts that were required to be reported in accordance with the Federal Funding Accountability and Transparency Act (FFATA), but two contracts were inadvertently overlooked and were not entered into SAM.gov (replaced now obsolete FFATA Sub-award Federal Reporting System or FSRS). Corrective Action Taken or Planned: The program office implemented internal procedures which conform to the FFATA reporting requirements. 1. A “TANF FFATA Report Template” was created by the program office. 2. Program specialists (contract monitors) are required to complete the “TANF FFATA Report Template” and submit to the program administrator within seven (7) days after a federal-funded contract is executed. 3. Program administrator enters the contract information into SAM.gov following the receipt of the completed “TANF FFATA Report Templates” from the program specialists. Program administrator will take additional steps to ensure the “TANF FFATA Report Template” is received for all federally funded TANF contracts and create a checklist to ensure all contracts have been entered into the SAM.gov, ensuring to avoid any inadvertently missed contracts. Expected Completion Date: July 1, 2026 Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The program office will continue to issue reminders to the eligibility staff, during the monthly Statewide Branch Joint Section Meetings, which are attended...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Corrective Action Taken or Planned: The program office will continue to issue reminders to the eligibility staff, during the monthly Statewide Branch Joint Section Meetings, which are attended by the Branch Administrators, Section Administrators who have direct oversight of the Processing Centers, and Processing Center Supervisors. Reminders will include specific topics and common errors found during informal case reviews such as, but not limited to, Temporary Assistance for Needy Families (TANF) application processing, interpretation and application of TANF policies, and eligibility determinations. The program office issued TANF Program Operational Procedure (POP) 01-002, Upfront Universal Engagement (UFUE) for TANF and TAONF Applicants, in 2022. TANF POP 01-002 provides eligibility staff guidance on processing applications for families who are required to meet the upfront requirements prior to eligibility determination. In conjunction with TANF POP 01-002, First-To-Work (FTW) POPs 02-101 and 02-102, issued in 2022, provide FTW staff guidance on the UFUE requirements for TANF applicants. A reminder will be issued to the eligibility and FTW staff on TANF POP 01-002 and FTW POPs 02-101 and 02-102. Delays to applicants’ ability to fulfill the UFUE requirements as a condition of eligibility may impact applications being processed and eligibility determinations being made timely. Completion Date: Ongoing Responding Official(s): Catherine Scardino, Benefit, Employment, and Support Services Division Temporary Assistance for Needy Families Program Administrator
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding duri...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Moving forward, it would be beneficial for CWS to hold entrance and exit interviews. The entrance interview would be sharing the tool with the auditors, and the exit interview would be explaining major audit findings and discussion to the final report. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Reviewing their work to ensure diligent compliance with policies and procedures. B. Supervisor coaching, support and review of records/documents for completeness. C. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staff is securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Locate or reprint and file missing “Certificate of Approvals.” C. Locate missing clearances in records not provided for review or re-run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. 3. CWS has identified the Eligibility Unit (FPPEU) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit by following checklists and securing missing documentation, updating inaccurate information and verifying that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Strategies will be developed with Supervisors to support coaching/supervision to ensure appropriate documentation is reviewed to catch and correct errors. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (SSA) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1-5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Completion Date: May 31, 2026 Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator; Lavina Forvilly, Social Services Division Assistant Program Administrator; and Corey Pablo, Social Services Division Management Information Compliance Unit Supervisor
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding duri...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Moving forward, it would be beneficial for CWS to hold entrance and exit interviews. The entrance interview would be sharing the tool with the auditors, and the exit interview would be explaining major audit findings and discussion to the final report. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Reviewing their work to ensure diligent compliance with policies and procedures. B. Supervisor coaching, support and review of records/documents for completeness. C. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staff is securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated and ensuring filed in eligibility record. C. Locate or reprint and file missing “Certificate of Approvals.” D. Locate missing clearances in records not provided for review or re-run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. E. For young person(s) in Imua Kakou (IK) who turned 18 while in care, i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document (reason for) continuation of monthly subsidy payments after youth turned 18. 3. CWS has identified the Eligibility Unit (FPPEU) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staff (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit by following checklists and securing missing documentation, updating inaccurate information and verifying that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Strategies will be developed with Supervisors to support coaching/supervision to ensure appropriate documentation is reviewed to catch and correct errors. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (SSA) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1-5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Completion Date: May 31, 2026 Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator; Lavina Forvilly, Social Services Division Assistant Program Administrator; and Corey Pablo, Social Services Division Management Information Compliance Unit Supervisor
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Child Welfare Services will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Corrective Action Taken or Planned: 1. Social Se...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Child Welfare Services will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Corrective Action Taken or Planned: 1. Social Services Division (SSD) will contact providers stated above in writing to request the Single Audit Summary Report. Once received, SSD will submit the reports to Accuity, LLC. 2. SSD staff responsible for collecting the Single Audit Summary report will complete refresher training related to the Federal Audit Reporting requirements. 3. POS will send a reminder to providers to submit a Single Audit Report in compliance with Special Conditions of their contract once expending over $1,000,000 in the Fiscal Year in compliance with the Federal Audit Requirements. Completion Date: May 31, 2026 Responding Official(s): Stacie Pascual, Social Services Division Child Welfare Services Program Development Administrator; Elliot Plourde, Social Services Division Assistant Program Administrator; Joshua Selman, Social Services Division Purchase of Services (POS) Program Specialist; Elladine Olevao, Acting Social Services Division Administrator; Lavina Forvilly, Social Services Division Assistant Program Administrator; and Corey Pablo, Social Services Division Management Information Compliance Unit Supervisor
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding duri...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Although there was better communication with the auditors this year, Child Welfare Services (CWS) will continue to communicate and share information with auditors to improve understanding during the Title IV-E reviews. Moving forward, it would be beneficial for CWS to hold entrance and exit interviews. The entrance interview would be sharing the tool with the auditors, and the exit interview would be explaining major audit findings and discussion to the final report. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Reviewing their work to ensure diligent compliance with policies and procedures. B. Supervisor coaching, support and review of records/documents for completeness. C. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated and ensuring filed in eligibility record. B. Locate or reprint and file missing “Certificate of Approvals.” C. Locate missing clearances in records not provided for review or re-run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. 3. CWS has identified the Eligibility Unit (FPPEU) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staff (Licensing, CWS and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit by following checklists and securing missing documentation, updating inaccurate information and verifying that all necessary documentation is present. i. Staff may be given individual training or coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (DOC) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Strategies will be developed with Supervisors to support coaching/supervision to ensure appropriate documentation is reviewed to catch and correct errors. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (MICU) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (SSA) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1-5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. Completion Date: May 31, 2026 Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator; Lavina Forvilly, Social Services Division Assistant Program Administrator; and Corey Pablo, Social Services Division Management Information Compliance Unit Supervisor
Reporting Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review reports prior to submission including the reconciliations and underlying records that support the amounts in the report. ...
Reporting Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review reports prior to submission including the reconciliations and underlying records that support the amounts in the report. Action taken in response to finding: An internal audit and review of the UDS reporting supporting files will be implemented as of April 1, 2026 to ensure accuracy of the documentation and calculations. Name(s) of the contact person(s) responsible for corrective action: John Robinson, CFO Planned completion date for corrective action plan: April 1, 2026 and it will continue moving forward.
Period of Performance Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review and monitor expenditures charged near the beginning and end of grant periods to ensure the expenditures incur...
Period of Performance Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review and monitor expenditures charged near the beginning and end of grant periods to ensure the expenditures incurred are within the authorized federal award grant period. Action taken in response to finding: A procedure was implemented March 2026 to perform an internal audit of the expenditures charged within the pre-and-post 30 days of a grant year transition to ensure expenses are occurring within the appropriate grant year prior to draw submission and will continue moving forward. A remedy of $87,554.96 was implemented over two grant draws within the grant year to address the population of period of performance crossing expenses. Name(s) of the contact person(s) responsible for corrective action: John Robinson, CFO Planned completion date for corrective action plan: New policy and procedure implemented in March 2026 and will be carried forward.
Allowable Activities and Costs Allowable Activities and Costs Health Center Cluster - Behavioral Health Expansion – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all payroll and non-payroll expenses cha...
Allowable Activities and Costs Allowable Activities and Costs Health Center Cluster - Behavioral Health Expansion – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all payroll and non-payroll expenses charged to the grant prior to submitting the drawdown request to HRSA and implement a consistent process for identifying the specific expenses being charged to each grant in order to avoid a cost being allocated more than one. Action taken in response to finding: The process has been changed as of August 1, 2025 before the end of the grant period of performance and will continue forward. Name(s) of the contact person(s) responsible for corrective action: John Robinson, CFO Planned completion date for corrective action plan: August 1, 2025
Inclusive Ventures Small Business Program – Assistance Listing No. 59-059 Recommendation: We recommend that management develop and implement written procedures to track, record, and report program income, including interest earned on Federal advances. 2660 Riva Road, Suite 200, Annapolis, MD 21401 􀆔...
Inclusive Ventures Small Business Program – Assistance Listing No. 59-059 Recommendation: We recommend that management develop and implement written procedures to track, record, and report program income, including interest earned on Federal advances. 2660 Riva Road, Suite 200, Annapolis, MD 21401 􀆔 t (410) 222-7410 􀆔 f (410) 222-7415 􀆔 www.aaedc.org Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We recognize the importance of maintaining clear, consistent procedures to ensure that all program income, including interest earned on Federal advances, is properly tracked, recorded, and reported in compliance with applicable requirements. To address this recommendation, management will develop and implement formal written procedures that outline the processes and responsibilities for identifying, documenting, and reporting program income. These procedures will include guidance on calculating and recording interest earned on Federal funds, as well as periodic reconciliation and review controls to ensure accuracy and completeness. In addition, relevant staff will be trained in the new requirements to promote consistent application and ongoing compliance. Name(s) of the contact person(s) responsible for corrective action: Lisa Grunder, Vice President of Administration Planned completion date for corrective action plan: March 23, 2026.
Inclusive Ventures Small Business Program – Assistance Listing No. 59-059 Recommendation: We recommend that management follow their written procurement policies and controls to ensure it maintains documentation of procurement, suspension and debarments checks and that the documentation is available ...
Inclusive Ventures Small Business Program – Assistance Listing No. 59-059 Recommendation: We recommend that management follow their written procurement policies and controls to ensure it maintains documentation of procurement, suspension and debarments checks and that the documentation is available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Anne Arundel Economic Development Corporation implemented a Federal Grant Procurement Policy on March 18, 2025. The purpose of this Procurement Policy is to ensure all procurement activities conducted with funds from federal grants are executed in compliance with federal regulations, promote transparency, fairness, and competitiveness and provide the best value for the resources available. Name(s) of the contact person(s) responsible for corrective action: Lisa Grunder, Vice President of Administration Planned completion date for corrective action plan: March 23, 2026.
Corrective Action Plan for Finding 2025-001 Community Care agrees with this finding. The Accounts Payable person will provide the information for new vendors to the Accountant. In turn the Accountant will check to make sure the vendor is not excluded or disqualified from doing business with an entit...
Corrective Action Plan for Finding 2025-001 Community Care agrees with this finding. The Accounts Payable person will provide the information for new vendors to the Accountant. In turn the Accountant will check to make sure the vendor is not excluded or disqualified from doing business with an entity that receives federal funds. The Accountant will then inform the Accounts Payable person if the vendor is able to do business with Community Care. There will be a check off list that includes dates these were checked and communicated with Accounts Payable. Community Care will work on going through our current vendor list to ensure they are not disqualified to do business with us because of the federal funding. The initial phase of this will be done each week with the information from any payments to vendors before the payments go out. Started this week. Responsible Official: Brenda L. Volz, Accountant Date of Corrective Action: Current vendors have been reviewed and there are no vendors found on SAM exclusionary lists. Community Care will add this step to its purchasing policies and procedures to be in effect April 1, 2026.
Corrective Action Plan for Finding 2025-003 Community Care agrees with this finding in that 1 of 8 files did not have service plan within 30 days of intake. Due to the transient nature of youth experience homelessness youth may come and go with days or weeks inactivity making it difficult to have 10...
Corrective Action Plan for Finding 2025-003 Community Care agrees with this finding in that 1 of 8 files did not have service plan within 30 days of intake. Due to the transient nature of youth experience homelessness youth may come and go with days or weeks inactivity making it difficult to have 100% compliance with service plan creation. Additionally, not all youth use the internal case management due to having an external case manager. Responsible Official: David McCluskey, Executive Director Date of Corrective Action: Effective April 1, 2026, systems are in place and efforts will continue to encourage youth to participate in service planning practices.
Corrective Action Plan for Finding 2025-002 Community Care agrees with this finding. There are three bullets in the finding. Each are accurate and related to a lack of workforce and skilled labor availability. Although CC has greatly reduced the turnover rate hiring remains challenging. Responsible ...
Corrective Action Plan for Finding 2025-002 Community Care agrees with this finding. There are three bullets in the finding. Each are accurate and related to a lack of workforce and skilled labor availability. Although CC has greatly reduced the turnover rate hiring remains challenging. Responsible Official: David McCluskey, Executive Director Date of Corrective Action: Effective April 1, 2026, hiring activities/efforts are on-going. Additionally, DHHS has adjusted the terms of deliverables in the recently published Visitation service Request for Proposal that will better fit workforce availability and aid in transportation activities of both parents and children.
Finding Reference 2025-003 Personnel Responsible for Corrective Action: Policies and procedures will be supervised by Tracie Thomas (Chief Operating Officer). Policies and procedures will be implemented and maintained by Laura Froese (Accounting Manager), Westen Gehring (Grants Specialist), and Bren...
Finding Reference 2025-003 Personnel Responsible for Corrective Action: Policies and procedures will be supervised by Tracie Thomas (Chief Operating Officer). Policies and procedures will be implemented and maintained by Laura Froese (Accounting Manager), Westen Gehring (Grants Specialist), and Brenna Wilcox (Accounting Specialist). Anticipated Completion Date: Immediately. Views of Responsible Officials and Planned Corrective Action: Concur. Corrective Actions Planned: The Land Institute identified that the exception noted occurred during the initial implementation phase of updated procurement policies developed in response to the FY23 Single Audit finding. The instance was due to a breakdown in timing and communication rather than a deficiency in the policies themselves. To prevent recurrence, The Land Institute has implemented a pre-award procurement control requiring that all sole source justifications and suspension and debarment verifications be completed, reviewed, and approved prior to contract execution and prior to any costs being charged to a federal award. Finance and Grants personnel will verify completion of required documentation before processing payments or coding expenses to federal awards. Training has been provided to relevant staff to reinforce procurement requirements, including timing and documentation expectations. Ongoing monitoring procedures have been implemented to ensure continued compliance.
Finding Reference 2025-002 Personnel Responsible for Corrective Action: Drafting of policy, procedures, and forms will be completed by Westen Gehring (Grants Specialist) and Laura Froese (Accounting Manager), with input and final approval provided by Tracie Thomas (Chief Operating Officer) Anticipat...
Finding Reference 2025-002 Personnel Responsible for Corrective Action: Drafting of policy, procedures, and forms will be completed by Westen Gehring (Grants Specialist) and Laura Froese (Accounting Manager), with input and final approval provided by Tracie Thomas (Chief Operating Officer) Anticipated Completion Date: The Effort Verification Policy and related procedures will be finalized by July 1, 2026, for implementation in Fiscal Year 2027. Retroactive effort certification for the period July 1, 2025 through March 31, 2026 will be completed by June 30, 2026. Monthly implementation tests of the new policies and procedures will begin with the April 2026 reporting period. Views of Responsible Officials and Planned Corrective Action: Concur. Corrective Actions Planned: The Land Institute will implement a formal effort reporting system effective July 1, 2026 (Fiscal Year 2027), including finalized policies, procedures, and standardized effort certification forms designed to ensure compliance with 2 CFR 200.430 As part of the transition to this system, retroactive effort certifications will be completed for Fiscal Year 2026 for the period of July 1, 2025 through March 31, 2026 to support payroll costs previously charged to federal awards. The months of April through June 2026 will be utilized as an implementation and testing period to establish and refine the monthly effort certification process. During this time, The Land Institute will complete effort certifications on a monthly basis, reflecting an after-the-fact determination of actual work performed across all institutional activities, and integrate the certification process into month-end close procedures. This phased implementation approach will allow management to validate processes, ensure accuracy and completeness of certifications, and make any necessary adjustments prior to full implementation in Fiscal Year 2027. Training will be provided to all applicable staff to ensure understanding of effort reporting requirements and compliance expectations. Finance and Grants personnel will monitor compliance and timeliness of certifications, and ongoing monitoring controls will be implemented to ensure continued compliance.
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