Corrective Action Plans

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Response: Management agrees with the finding and implemented procedures to ensure the supporting documentation for the 2025 UDS report was retained. Responsible Party: Ann Rogers, Chief Executive Officer Estimated Completion Date: September 30, 2026
Response: Management agrees with the finding and implemented procedures to ensure the supporting documentation for the 2025 UDS report was retained. Responsible Party: Ann Rogers, Chief Executive Officer Estimated Completion Date: September 30, 2026
Response: Management agrees with the finding and will work to assure that the 2025 audit is submitted to the Federal Audit Clearinghouse by the due date of September 30, 2026. Responsible Party: Ann Rogers, Chief Executive Officer Estimated Completion Date: September 30, 2026
Response: Management agrees with the finding and will work to assure that the 2025 audit is submitted to the Federal Audit Clearinghouse by the due date of September 30, 2026. Responsible Party: Ann Rogers, Chief Executive Officer Estimated Completion Date: September 30, 2026
Auditor’s recommendation: The Organization’s internal control over financial reporting should be modified to present financial statements in accordance with US GAAP through reduction in audit adjusting journal entries and improve the timing of the six-month period end closing process. Auditee’s resp...
Auditor’s recommendation: The Organization’s internal control over financial reporting should be modified to present financial statements in accordance with US GAAP through reduction in audit adjusting journal entries and improve the timing of the six-month period end closing process. Auditee’s response: The Organization is continuing to develop effective internal controls over financial reporting to ensure that financial statements are prepared in accordance with US GAAP on a timely basis.
Auditors’ recommendation: The Organization should modify its operations to the extent possible to improve operating results and stay in compliance with the loan agreement and debt workout agreement with the USDA. Auditee’s response: The Organization recognizes the challenges it is facing and conside...
Auditors’ recommendation: The Organization should modify its operations to the extent possible to improve operating results and stay in compliance with the loan agreement and debt workout agreement with the USDA. Auditee’s response: The Organization recognizes the challenges it is facing and considers its plan a sound approach to reaching compliance with the loan provisions in the debt workout agreement and loan agreement with the USDA.
Auditor’s recommendation: The Organization’s internal control over financial reporting should be modified to present financial statements in accordance with US GAAP through reduction in audit adjusting journal entries and improve the timing of the year end closing process. Auditee’s response: The Or...
Auditor’s recommendation: The Organization’s internal control over financial reporting should be modified to present financial statements in accordance with US GAAP through reduction in audit adjusting journal entries and improve the timing of the year end closing process. Auditee’s response: The Organization is continuing to develop effective internal controls over financial reporting to ensure that financial statements are prepared in accordance with US GAAP on a timely basis.
Auditors’ recommendation: The Organization should modify its operations to the extent possible to improve operating results and stay in compliance with the loan agreement and debt workout agreement with the USDA. Auditee’s response: The Organization recognizes the challenges it is facing and conside...
Auditors’ recommendation: The Organization should modify its operations to the extent possible to improve operating results and stay in compliance with the loan agreement and debt workout agreement with the USDA. Auditee’s response: The Organization recognizes the challenges it is facing and considers its plan a sound approach to reaching compliance with the loan provisions in the debt workout agreement and loan agreement with the USDA.
Corrective action the auditee plans to take in response to the finding: The violation of Suspension and Debarment came from the hiring of a contract service provider in relation to a grant funded project, but was not specifically a Public Works contract. The City of Anacortes' past practice has been...
Corrective action the auditee plans to take in response to the finding: The violation of Suspension and Debarment came from the hiring of a contract service provider in relation to a grant funded project, but was not specifically a Public Works contract. The City of Anacortes' past practice has been to verify Suspension and Debarment for all public works projects, regardless of funding source. The City of Anacortes is committed to ensuring compliance with all applicable statutes and regulations, and therefore has made the organizational change to centralize grant management with contract management, to heighten awareness of those grant requirements relative to let contracts. Additionally, the City has made the commitment to expand the Suspension and Debarment check to all contracts, not just public works, to ensure future compliance can be illustrated.
Management agrees that the amount needs to be deposited as soon as possible.
Management agrees that the amount needs to be deposited as soon as possible.
VIDCOE will establish and document capitalization thresholds and procedures for identifying, recording, and depreciating capital assets, including maintaining a fixed asset register with periodic reconciliations. Procedures will also be implemented to ensure prepaid expenses are recorded appropriate...
VIDCOE will establish and document capitalization thresholds and procedures for identifying, recording, and depreciating capital assets, including maintaining a fixed asset register with periodic reconciliations. Procedures will also be implemented to ensure prepaid expenses are recorded appropriately and amortized over the periods benefited. In addition, grant accounting policies will be strengthened to ensure that funds received in advance are recorded as refundable advances and recognized as revenue only as allowable expenditures are incurred, in compliance with grant agreements and federal requirements. To further strengthen internal controls, VIDCOE will implement formal supervisory review and reconciliation procedures, including routine account reconciliations and financial statement reviews, to ensure transactions are properly classified, supported, and recorded. VIDCOEs’ Management expects to fully implement all corrective actions by July 30, 2026.
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.: 2024-051 Period of Performance 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 over compliance with applicable period of Performance require...
Finding No.: 2024-051 Period of Performance 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 over compliance with applicable period of Performance requirements, as well as retention of all grant agreements. GHS will also identify department personnel responsible.
Finding No.: 2024-050 Matching, Level of Effort, Earmarking 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 with applicable matching and earmarking requi...
Finding No.: 2024-050 Matching, Level of Effort, Earmarking 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 with applicable matching and earmarking requirements. GHS will also identify department personnel responsible.
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.: 2024-047 Special Test and Provisions Provider Eligibility (Screening and Enrolment) Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. DPHSS is aware that deficiencies exist with the...
Finding No.: 2024-047 Special Test and Provisions Provider Eligibility (Screening and Enrolment) Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. DPHSS is aware that deficiencies exist with the Medicaid provider enrolment process. DPHSS’s response to this deficiency is addressed in its modernization plan, which will automate certain provider enrolment functions. In March 2024, DPHSS performed site visits for 21 providers, and since then has continued to perform site visits year-round. Memorandums regarding provider compliance topics have also been communicated to providers and published on the provider portal, including information regarding criminal background checks. DPHSS is currently contracted with a consultant that is assisting in the implementation of compliant provider enrolment operations, which includes policy revisions, updates to provider applications and disclosure forms, development of standard operating procedures, and training for both staff and providers. In addition, DPHSS is currently in the process of establishing a Medicaid Program Integrity Unit (PI Unit) with a mission to conduct independent and objective Medicaid program integrity functions adherent to federal and local laws. The PI Unit will also assist DPHSS in addressing and managing Medicaid related Corrective Action Plans.
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.: 2024-043 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Bureau of Child Care Services (BCCS) disagrees with this finding. BCCS maintains that it enforces strict monitoring controls over co...
Finding No.: 2024-043 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Bureau of Child Care Services (BCCS) disagrees with this finding. BCCS maintains that it enforces strict monitoring controls over compliance with reporting requirements and that the variances noted are not a result of inaccurate data entry but that is due to the cumulative reporting until the end of the grant period. BCCS’ ACF-696 quarterly reports are reported cumulatively through the grant's liquidation end date, and any quarterly reported variances are reconciled by the end of the grant period. During a Reporting Walkthrough meeting with Ernst & Young Senior Auditor, on November 17, 2025, BCCS discussed detailed reporting requirements, processes, and procedures. During this meeting, the agency communicated how responsible personnel review accounting records and perform the reconciliation of required reports.
Finding No.: 2024-042 Matching, Level of Effort, Earmarking 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 and maintains that it has enhanced monitoring c...
Finding No.: 2024-042 Matching, Level of Effort, Earmarking 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 and maintains that it has enhanced monitoring controls to ensure compliance with all applicable earmarking requirements. BCCS reports expenditures on a cumulative basis until the grant’s liquidation end date. This reporting structure provides the necessary flexibility to reconsolidate cost categories, ensuring that final totals align with mandated spending thresholds by the end of the grant period. Furthermore, BCCS maintains that Quality Rating and Improvement System (QRIS) initiatives and other quality-enhancing activities were actively conducted throughout the performance period. To ensure a thorough reconciliation of these expenditures, BCCS formally requests the supporting documentation and specific sample set used by the auditors to conclude that these activities were not sufficiently documented or performed. We are prepared to provide evidence of these programmatic activities to demonstrate compliance with earmarking requirements.
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.: 2024-040 Activities Allowed or Unallowed: Allowable Costs/Cost Principles 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. The questioned tran...
Finding No.: 2024-040 Activities Allowed or Unallowed: Allowable Costs/Cost Principles 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. The questioned transactions relate to a major system migration from the AS400 to the D365 system, which temporarily impacted the traceability of certain records. During this transition, some data identifiers were reformatted to fit the new system's structure. However, this was a synchronization issue rather than a lack of oversight, and BCCS maintains that all costs are allowable, necessary, and reasonable under CCDF requirements. Supporting documents exist and were provided after a subsequent request on February 9, 2026, via One Drive link.
Finding No.: 2024-039 Procurement, Suspension, and Debarment Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) GSA will continue to verify vendor eligibility through SAM.gov prior to contract award. Documentation of th...
Finding No.: 2024-039 Procurement, Suspension, and Debarment Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) GSA will continue to verify vendor eligibility through SAM.gov prior to contract award. Documentation of the verification will be retained in the procurement file for each transaction. GSA has revised IFB templates to include the required debarment and suspension certification language in accordance with 2 CFR 200.214. Effective immediately, all new contracts will include this clause prior to execution. For local vendors that may not appear in federal systems, GSA will require a debarment and suspension certification as part of the contracting process and maintain this documentation within the procurement record.
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.
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