Corrective Action Plans

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Assistance listing numbers and program names: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) 93.767 Children’s Health Insurance Program (CHIP) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact pers...
Assistance listing numbers and program names: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) 93.767 Children’s Health Insurance Program (CHIP) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Office of Inspector General Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Completion date: December 31, 2025 Agency’s Response: Concur In fiscal year 2023, the process of holding quarterly reviews of deferred cases did not occur due to resources being diverted to focus on Strike Force activities involved in addressing the behavioral health crisis. Additionally, Office of the Inspector General (OIG) announced a re-organization in December 2023 that resulted in permanent transitions to other teams for several staff. Teams were given time to finalize cases and move items to other investigators in order to limit disruption to cases. By April 2024, after the Strike Force initiative had been unwound and the member team structure changes for personnel were finalized, the member team restarted its process of quarterly deferred case reviews. At the first review in April 2024, cases in the deferred backlog that were not completed in the timeframe set for the reviews were postponed to the next quarterly review in July. AHCCCS OIG commits to a review of the current Deferred Process and will determine areas of improvement to include timeliness for deferred case review completion, quarterly completed deferred case review reports, and required documentation for all deferred case processes.
Assistance listing numbers and program names 93.268 Immunization Cooperative Agreements 93.268 COVID-19- Immunization Cooperative Agreements 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) ...
Assistance listing numbers and program names 93.268 Immunization Cooperative Agreements 93.268 COVID-19- Immunization Cooperative Agreements 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Agency: Department of Health Services (DHS) Name of contact person and title: Lora Andrikopoulos , Grants Administrator Anticipated completion date: June 30, 2026 Agency’s Response: Concur ADHS will continue to work with the CQI Team, Financial Services - Assurance Team, Procurement, Program Managers, Finance Managers, Grants, and other internal partners to update the FFATA process. The process moving forward will include a communication plan, updates to the current standard work, the creation of a new standard work if necessary for the subaward communication process, and additional training.
Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS...
Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Anticipated completion date: December 31, 2027 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiatives to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for comprehensive, system-wide strategies. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Actions Taken: ● Increased scrutiny of claims based on claims volume. ● Issued a moratorium on new provider registrations for impacted provider types. ● Prevented Reimbursement of Claims for Impossibly Rendered Services. ● Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment. ● Set thresholds for services to initiate a prepayment review. ● Required claims to be billed for specific dates of service rather than ranges. ● Flagged claims for services of the same style/overlapping codes. ● Created a prepayment review process for providers utilizing suspicious billing practices. ● Eliminated retroactive billing. ● Credible Allegation of Fraud suspensions include both provider entities and owners/ behavioral health (BH) practitioners. ● Implemented ID.Me identity verification for AHCCCS Online. ● Required providers to disclose any third-party billing relationships. ● BH Providers are now considered high-risk provider types for provider enrollment. ● Per Diem codes have been set to only be able to be billed once per day. ● Practitioners, including BH Technicians, can no longer be patients at the same provider. ● Worked with the Arizona Corporation Commission to flag suspicious registrations. ● Ensured AHCCCS coding adhered to National Correct Coding Initiative standards and confirmed no edits had been turned off. ● Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. ● Creation and publication of the Covered Behavioral Health Services Guide to connect all relevant AHCCCS policies and explain how they interact in the Behavioral Health System of Care. ● Robust changes to our AHCCCS Provider Enrollment System to address fraud, waste and abuse (FWA) issues. ● Update to the Behavioral Health Residential Facilities policy (to be published shortly) to provide greater detail and clarity for providers and members about what should and should not be included in services rendered by this provider type. ● Creation of the prepayment review process for fee for service claims and inclusion of data measurement to allow for agile modification going forward to respond to over utilization or abuse of codes. ● Creation of the Community Partner Assistor Organization Reviews to prevent abuse of access to the Health-e-Arizona Plus system. ● Designated pathways of partnering on large scale quality of care investigations between the Division of Fee for Service and managed care organizations to prevent unnecessary member impact. ● Social media campaign to encourage the public to report FWA/abuse & neglect. ● Requirement of all providers to transition to Electronic Funds Transfer. ● Removed the phone attestation option for American Indian Health Program (AIHP) enrollment, and are in the process of implementing the AIHP verification process with tribal partners and Indian Health Services based on utilization. ● Memorandums of Understanding with AZ Board of BH Examiners and Board of Nursing to promote interagency information sharing and referrals, as well as the close referral relationship with the Arizona Department of Health Services. ● Regular Public BH System Cross-Agency Collaboration meetings including all agencies, boards, commissions and the GO in the public health space ● Updates to the provider enrollment policy in AMPM 610, explicitly requiring many more disclosures of providers, and making it clear without full and transparent registration information, providers will be terminated or denied enrollment with AHCCCS. ● Implemented policies which required BH Professionals, required to oversee the clinical services provided at Behavioral Health Residential Facilities and Outpatient Behavioral Health Clinics, to be reported upon registration and be listed on claims submissions ● Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements ● Linking BHP to BH companies and facilities they work for Actions Remaining (but not limited to): Implementing eligibility integrity requirements for AIHP enrollment. ● Implementation of Alivia – a new AI powered data analytics platform for pre-pay and post-pay claims analysis, currently in the development and planning stage ● Conduct onsite quality of care reviews for patients in treatment longer than 90 days. ● Require medical records to define specialized services. ● Implement a new pre/post pay claims system. AHCCCS continuously monitors our systems and investigates instances of fraud, waste or abuse. Any areas of concern which are identified are then addressed and system improvements are made. Furthermore, AHCCCS utilizes data analysis to confirm that these system improvements are having the intended impacts and that provider networks remain robust.
Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 - Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 - Child Care Mandatory and Matching Funds of the ...
Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 - Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 - Child Care Mandatory and Matching Funds of the Child Care and Development Fund Agency: Department of Economic Security (DES) Name of contact person and titles Lacie Butler, Administrative Services Officer Anticipated completion date: May 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department is revising its procedures to ensure that it receives and retains documentation to support its provider’s expenditures, including Payment Disbursed Quickly (PDQ) submitted billings. Specifically, due to PDQ system limitations the Department is implementing additional validation procedures for these payments, and restricting the use of this system to limited providers to ensure future compliance. The Department is conducting an internal audit to validate that all required PDQ submissions are on file for Fiscal Year 2025; instances of non-compliance will be resolved in the same manner as an overpayment. The Department will continue to retain all records related to a federal award for a period of 3 years from the final expenditure report submission date.
Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 Child Care Mandatory and Matching Funds of the Chil...
Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 Child Care Mandatory and Matching Funds of the Child Care and Development Fund Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will review, correct, and /or complete any incomplete or inaccurate information for its subawards on the Federal Funding Accountability and Transparency Act Subaward Reporting System. The Department will follow the State’s accounting manual for reporting subaward actions equaling or exceeding $30,000 no later than month-end of the month following the subaward action. The Department has implemented procedures that ensure that the contracts team communicates all new contracts and contract amendments in the APP.
Cluster Name: Elementary and Secondary School Emergency Relief Assistance listing numbers and program names 84.425U COVID-19 – Education Stabilization Fund – American Rescue Plan Elementary and Secondary School Emergency Relief (ARP-ESSER) Agency: Arizona Department of Education (ADE) Name of contac...
Cluster Name: Elementary and Secondary School Emergency Relief Assistance listing numbers and program names 84.425U COVID-19 – Education Stabilization Fund – American Rescue Plan Elementary and Secondary School Emergency Relief (ARP-ESSER) Agency: Arizona Department of Education (ADE) Name of contact person and title: Braulio Garcia, Chief Procurement Officer Anticipated completion date: June 2026 Agency’s Response: Concur 1. Follow federal regulation, State law, and the Arizona Procurement Code for procurements related to federal grant awards. ADE will conduct all procurements related to federal grant awards in compliance with 2 CFR Part 200, State law, and the Arizona Procurement Code, using the same policies and procedures applied to non-federal funds, as required by federal regulations. ADE will ensure appropriate procurement methods are used and documentation is maintained. Competition Impracticable (CI) procurements will require prior review and approval by the State Procurement Office (SPO) before implementation, and ADE procurement staff will consult with the SPO as needed for technical assistance to ensure ongoing compliance. Implementation is ongoing and monitored through procurement file reviews and established internal controls. 2. Update and implement policies and procedures and responsible employees to use competitive procurement methods or otherwise obtain approval from the State Procurement Officer and to prepare written determinations for exceptions to using competitive procurement methods, such as noncompetitive waivers, when purchasing goods and services from third-party vendors. ADE Procurement is currently updating internal policies and procedures, which shall be implemented by June 30, 2026, to ensure appropriate procurement employees consistently use competitive procurement methods or obtain prior approval from the State Procurement Office (SPO) when exceptions apply. The updated procedures will require written determinations and justifications, such as a Competition Impracticable (CI), for all exceptions to competition and will clearly define responsibilities and approval requirements when purchasing goods and services from third-party vendors. Procurement staff will follow the revised procedures for all applicable procurements, and compliance will be monitored through procurement file reviews and established internal controls.
Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 – Education Stabilization Fund –Elementary and Secondary School Emergency R...
Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 – Education Stabilization Fund –Elementary and Secondary School Emergency Relief (ESSER) 84.425U COVID-19 – Education Stabilization Fund – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP-ESSER) Agency: Arizona Department of Education (ADE) Name of contact person and title: Matthew McClary, Grants Management Compliance Officer Nicole von Prisk, Deputy Associate Superintendent Anticipated completion date: October 2027 Agency’s Response: Concur The Arizona Department of Education has worked in cooperation with our vendor to correct outdated SQL queries that were identified and return only approved grant award amounts rather than all awarded amounts, regardless of approval status. This issue was causing several subaward amounts to incorrectly update. Moving forward, we are ensuring that the original award amounts are being queried and, in return, reported within SAM.gov (System for Award Management). Additionally, through the reconciliation process each month, correct award amounts will align with the corresponding Federal Award Identification Number (FAIN). Reports being submitted late: We have implemented an automated monthly reporting workflow/schedule which will help ensure required FFATA reporting is submitted timely. This process automation helps prompt monthly FFATA reporting uploads by leveraging office tools that are readily available and ensures monthly upload deadlines are met by automatically scheduling the task and requiring follow-up by the assignee. In January of 2024, the staff assigned to FFATA uploads changed again (for the fourth time in a year) and at that point a new staff member assumed responsibility for FFATA uploads. As numerous corrections needed were discovered through the reconciliation process, new reports were uploaded. Some of these were original uploads for entities that were missing SAM.gov (formerly FSRS) information altogether, and some were corrections to previously uploaded yet incorrect information. With each monthly upload, a new date was being captured and while some of the information was new entity award information, not all the information being updated was untimely. This has been a long and arduous process, and we look forward to not having continued FFATA findings, as we are making progress to correct award information for all federal grants moving forward from this point. Inaccurate and/or Incomplete Data: Our Compliance Officer conducts a monthly reconciliation of current SAM.gov award information in coordination with either the Lead Grants Coordinator or the Deputy Associate Superintendent. During this review, any missing, inconsistent, or duplicate data is identified and corrected prior to the upload into SAM.gov. Once the subawards have been uploaded, the reconciliation process is repeated to verify the accuracy of the information recorded within SAM.gov. Note: On October 30, 2025, we became aware that USASpending.gov was no longer updating subawards to correspond with the data we have submitted in SAM.gov. We raised a service desk ticket to USA Spending (Case 00089604), but the issue is ongoing. USA Spending has stated that they “are aware of an issue with the outbound API in SAM to USA Spending, but due to the lapse in funding, the SAM team working on this specific issue has been furloughed until funding is restored.” The reconciliation process where subawards uploaded to SAM.gov are compared to the data in USASpending.gov continues to be heavily impacted until this service is restored. To ensure accurate documentation and timely resolution of system related challenges encountered when submitting subawards in SAM.gov, the Compliance Officer has implemented a formal Incident Tracking process. All technical issues are logged at the time they occur, and each incident is subsequently submitted to the Federal Service Desk (FSD.gov). Upon submission, the incident is assigned an official Incident Request ID along with a corresponding date and time stamp, enabling effective monitoring and follow‑up. Grants Management will establish, implement, and enforce internal and external controls to ensure that risk is minimized and can be appropriately evaluated during any monitoring conducted by the agency. The internal and external controls that will be implemented will establish guidelines addressing conflicts of interest, related-party transactions, and insufficient segregation of duties. Implementation will be based on reference materials provided by the U.S. Department of Education Office of Inspector General, as well as technical assistance from organizations with legal and governmental expertise. ADE’s software will be updated appropriately.
Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Sarka J. Whi...
Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Sarka J. White, Deputy Associate Superintendent Anticipated completion date: December 2027 Agency’s Response: Concur Monitoring of CMO We will update protocols and implement an annual monitoring process specifically for charter schools with CMO relationships by integrating defined procedures to evaluate additional conflicts of interest, related party transactions, and segregation of duties concerns, while assigning a programmatic risk label in addition to the one assessed by Grants Management. To ensure accurate identification and appropriate separation of responsibilities, Title I and Title II will incorporate procedures for detecting CMO associations within both the grant review process and programmatic monitoring functions, supported by coordinated information sharing across relevant departments. Updated policies will also include requirements for disclosure of organizational associations and embed these indicators into the LEA level risk framework that determines monitoring frequency and representation based on assessed risk. Checks and balances will include programmatic follow-up on these disclosures prior to review of funding applications and or any assistance provided. Title I and Title II will revise monitoring tools to include CMO specific review steps, provide targeted staff training on identifying CMO relationships and apply enhanced oversight procedures, and carry out funding and program approval activities and monitoring activities. These can be in the form of financial and performance report reviews, Grant approvals, Data submissions, technical assistance, and onsite or virtual visits, in alignment with the strengthened risk-based model. Completion will be demonstrated through finalized procedures, documented staff training, and the application of revised monitoring methods during the next annual grant and monitoring cycle. Monitoring – Programmatic – Grant Monitoring We have revised LEA monitoring policies and procedures to incorporate coordinated processes between departments for clear identification of charter schools with CMO relationships, require now disclosure of organizational associations, and strengthen oversight of conflicts of interest, related party transactions, and segregation of duties risks. Updated procedures also define a structured, risk-based monitoring framework that assigns LEA monitoring levels, representation, and monitoring frequency based on assessed risk, independent of CMO affiliation, while integrating new indicators into monitoring tools to support consistency through equal representation and ensuring each LEA is treated as an individual LEA without respect to associations. Staff have and will continue to receive targeted training on the revised requirements, and completion will be demonstrated through the approval and publication of updated procedures, documented staff training, and application of the enhanced risk-based monitoring approach during the next LEA monitoring cycle.
Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Anticipat...
Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Anticipated completion date: December 31, 2026 Agency’s Response: Concur The Office agrees with this finding and will continue to take corrective action to bring the program fully into compliance with Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Federal grant reporting requirements. The Office recognizes the importance of transparency in the use of Federal grants and has taken significant corrective action to resolve any inaccuracies in Federal grant reporting. The Office has implemented specific actions to ensure reporting inaccuracies and program expenditure understatements/overstatements do not occur. During fiscal year 2025 and 2026, the Office has taken corrective action to improve SLFRF reporting processes, including conducting weekly reviews and monthly reconciliations as outlined: ● Award Reconciliation — The Office has conducted a comprehensive review and extensive reconciliation of all awards to identify reporting inaccuracies. This reconciliation will continue as an ongoing process through the SLFRF closeout. ● Expenditure Reconciliation — The Office staff responsible for preparing the SLFRF quarterly reports is completing the reconciliation of all expenditures to the State’s accounting records, which are the official expenditures for the program. This will continue as an ongoing process through the SLFRF closeout. ● Enhanced Reporting Mechanisms—The Office will review, correct, and/or resubmit any inaccurately reported information. The staff responsible for preparing the SLFRF quarterly reports is no longer reconciling to the Office’s internal grants-management system. Reports will be compiled from the State’s accounting records, which are the official record of expenditures made for the program. The Office will investigate and resolve any differences prior to submitting the report to the federal agency. This will continue as an ongoing process through the SLFRF closeout. ● Update Procedures—Based on the comprehensive review noted in the response above, the Office is continuing to implement improved reporting procedures to ensure the accurate submission of grant expenditure data. This includes revised standardized templates, improved guidelines, and enhanced communication channels to improve reporting accuracy. ● Ongoing Training — Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of reporting errors. During fiscal years 2025 and 2026, staff engaged in 18 professional development opportunities, including monthly federal reporting calls, grants management webinars and trainings, internal training sessions, state accounting system training, and participation in a Microsoft data conference. These ongoing efforts reflect our commitment to staying current with compliance requirements and best practices. The Office will continue to strengthen internal controls to prevent similar issues in the future. This involves strengthening oversight, providing additional training to staff members in reporting processes, and implementing regular quality assurance checks. As of this date, the Office has allocated sufficient resources to comply with the award terms and program reporting requirements by establishing the Grants Technology and Data team dedicated to overseeing the necessary SLFRF program reporting procedures. The Office is committed to eliminating any risk through a full reconciliation of expenditures by the end of the program, which occurs during fiscal year 2027.
Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (OSPB) Arizona Department of Housing (ADOH) Arizona Department of Water Resources (ADWR) Arizona Office of Tourism (AOT) Industr...
Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (OSPB) Arizona Department of Housing (ADOH) Arizona Department of Water Resources (ADWR) Arizona Office of Tourism (AOT) Industrial Commission of Arizona (ICA) Name of contact persons and titles: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Keon Montgomery, ADOH Assistant Deputy Director of Programs Will Palmisano, ADWR Finance and Administration Assistant Director Mary-Ellen Kane, AOT Assistant Deputy Director Sylvia Simpson, ICA Chief Financial Officer Anticipated completion date: See below Agency’s response: Concur OSPB anticipated completion date: April 2027 As indicated by the auditors, OSPB has demonstrated compliance with subrecipient monitoring requirements in FY24. The audit report limits OSBP’s inclusion in this finding to the questioned costs ($1,623,846) identified by OSPB through its subrecipient monitoring. However, the identification of questioned costs is not evidence of a deficiency in OSPB’s subrecipient monitoring; rather, the opposite, it demonstrates that OSPB has sound internal controls and an effective subrecipient monitoring system in place. Accordingly, OSPB will continue with the existing comprehensive subrecipient monitoring framework as outlined below: ● On-going Grantee Support - The Office provides a variety of subrecipient support including technical assistance, Communities of Practice(COP), and regular status check meetings. ● Training - Office staff facilitate ongoing training and provide resources and guides to improve understanding of compliance requirements and provide tools to support proper grants management. ● Financial Report-Reimbursement Requests—The Office reviews the grantee's financial reports to ensure costs align with the approved budget, program objectives, and federal cost principles. ● Performance Reports—The Office reviews the submission of programmatic reports to track progress on grant goals. ● Single Audit Reports—The Office confirms any required subrecipient Single Audits, reviews a copy of the most recent Single Audit Reporting Package (SARP), issues any necessary management decisions, and conducts follow-up monitoring of Corrective Action Plans. ● Risk Assessment (RA)—The Office conducts a Risk Assessment (RA) of grantees when applying for grants to inform the grant award decision and possible grantee oversight or restrictions. Additionally, the Office conducts an annual RA of any grantee currently awarded funding. ● Monitoring Reviews - The Office utilizes the RA results to prioritize high risk grantees to be reviewed through a desk or on-site monitoring. Medium risk grantees will receive additional support and will be referred to our Compliance and Reporting team for further review if additional concerns arise. The Office has implemented all past recommendations and OSPB is committed to continuing these ongoing efforts to actively reduce the risks of waste, fraud, and abuse of federal dollars through our subrecipient monitoring process. OSPB will continue Coronavirus State and Local Fiscal Recovery Funds subrecipient monitoring and follow-up through the grant closeout in April 2027. ADOH anticipated completion date: March 2026 The ADOH has begun to develop and implement formal, documented subrecipient risk assessment procedures to ensure monitoring activities are aligned with assessed levels of risk. This will include establishing standardized criteria to evaluate subrecipient risk and documenting risk determinations. These enhancements are also consistent with recommendations identified in the State’s most recent Sunset Audit, and the Agency has already begun implementation of these procedures. The ADOH will update policies and procedures accordingly and provide staff training to ensure consistent application. These actions will strengthen internal controls and ensure compliance with applicable subrecipient monitoring requirements. The ADOH will implement procedures to strengthen subrecipient monitoring related to Single Audit requirements. This will include verifying submission to the Federal Audit Clearinghouse, obtaining and retaining copies of all applicable Single Audit reports, and maintaining a tracking mechanism to document receipt and review. The ADOH will also establish procedures to review audit findings and ensure appropriate follow-up, including verification of subrecipient corrective actions, and will support consistent implementation. ADWR anticipated completion date: December 31, 2026 Before approving an application from an eligible subrecipient for federal grant monies, ADWR as a passthrough entity, will conduct a risk assessment of the subrecipient as part of the initial award approval. ADWR will create a standardized checklist that will enable ADWR to make an informed decision regarding what monitoring tasks will be necessary consistent with 2 CFR 200.332. Once an eligible subrecipient applies for federal grant monies, ADWR will require the applicant subrecipient to fill out the checklist and establish a monitoring program consistent with the results. ADWR will develop staff training and a standard work to implement this program. If the award spans more than one year, the results of any applicable single audits will inform ADWR if changes to the monitoring program for a particular subrecipient are required. As part of a program standard work, ADWR will send a questionnaire to subrecipients regarding federal award expenditures and remind them of any single audit requirements as well as expected completion date of any applicable audits. Failure of any prescribed monitoring items will trigger award review and possible reclassification of risk, additional monitoring, and/or withholding of pending reimbursements until the subrecipient remedies an issue. AOT anticipated completion date: March 20, 2026 AOT has established a process to verify that subrecipients who receive a grant award greater than $750,000.00 are able to provide a current single audit. AOT will provide sub recipients additional written documentation identifying required completion dates and any additional instructions required. Processes and procedures have been developed and implemented. The program has concluded and no further action will be taken. AOT has established a process to ensure the required backup documentation provided by the subrecipient is acceptable for reimbursement. AOT will continue to communicate with OSPB on updates to policy to ensure the processes and procedures are being implemented within federal and state funding guidelines. The program has concluded and no further action will be taken. ICA anticipated completion date: December 31, 2025 The ICA concurs with the finding regarding subrecipient monitoring. The ICA’s involvement as a pass-through entity for the SLFRF program was a unique, one-time occurrence designed to facilitate the equitable distribution of funds to Arizona fire districts based on a methodology approved by the Office of Strategic Planning and Budgeting (OSPB). The ICA does not expect to serve as a pass-through entity for federal funds in the future. While the ICA implemented rigorous validation steps, including the thorough review of payroll records, receipts, and attestations prior to any reimbursement, the agency recognizes that formal risk assessments and subaward agreements were not executed at the onset of the program. The ICA became aware of these specific documentation deficiencies through the audit process after the program had already ended on December 31, 2025. The ICA will address the underlying control deficiency by updating its internal grant management procedures to ensure in the event the agency was to act as a pass-through entity again, formal risk assessments and standardized subaward agreements would be completed by the subrecipient as part of the requirements to receive federal monies. Additionally, the ICA has since obtained 100% of the required single audit reports from the applicable subrecipients and has verified that all necessary corrective actions for unrelated findings have been addressed.
Assistance listing numbers and program names: 21.023 COVID-19 Emergency Rental Assistance Program 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Dire...
Assistance listing numbers and program names: 21.023 COVID-19 Emergency Rental Assistance Program 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Division will review and confirm that benefits payments paid to or on behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Update existing policies and procedures to include a post-review of the benefits subsystem’s automated review of eligibility requirements, such as verifying the income thresholds and geographic location aligned with the Division’s written policies and procedures, and supported by required documentation. The Division should correct any inaccurate eligibility determinations identified during the post-review. Emergency Rental Assistance Program policies and procedures require validation of eligibility based upon substantiating applicant documentation, including household income and geographic location. The Division will update Division policy to include a post-review process to identify and correct any errors or discrepancies. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Division will allocate sufficient staffing resources to evaluate program benefits applications and provide training on eligibility requirements and allowable benefit payments. 4. Work with the federal agencies to resolve the $64,131 in program funds that were spent in violation of federal regulations, policies and procedures, and may need to be returned to the federal agencies. The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Division will review and confirm that benefits payments paid to or on behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Update existing policies and procedures to include a post-review of the benefits subsystem’s automated review of eligibility requirements, such as verifying the income thresholds and geographic location aligned with the Division’s written policies and procedures, and supported by required documentation. The Division should correct any inaccurate eligibility determinations identified during the post-review. Emergency Rental Assistance Program policies and procedures require validation of eligibility based upon substantiating applicant documentation, including household income and geographic location. The Division will update Division policy to include a post-review process to identify and correct any errors or discrepancies. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Division will allocate sufficient staffing resources to evaluate program benefits applications and provide training on eligibility requirements and allowable benefit payments. 4. Work with the federal agencies to resolve the $64,131 in program funds that were spent in violation of federal regulations, policies and procedures, and may need to be returned to the federal agencies. The Division will coordinate with applicable federal agencies to resolve these unallowable costs.
Assistance listing number and program name: 21.027 Coronavirus State and Local Fiscal Recovery Funds Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Respon...
Assistance listing number and program name: 21.027 Coronavirus State and Local Fiscal Recovery Funds Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Include information required by federal regulations in its subawards to subrecipients, including federal award identification information and any additional requirements the Department imposed on the subrecipients to meet its responsibilities under the federal award. The Department will analyze and improve its information dissemination practices to ensure that all information required by federal regulations is included in the subawards to subrecipients. This will include the federal award identification information and any further requirements the Department imposes on the subrecipients to meet the responsibilities under the federal award and applicable state laws. 2. Perform required monitoring of its subrecipients and their compliance with the award terms and program requirements. The Department will revise its agency-wide policies and procedures related to single audit requirements for pass-through entities to include guidance regarding how to establish effective subrecipient monitoring procedures. The Department will also offer additional subrecipient monitoring guidance for programs administered by divisions with existing subrecipient monitoring findings. A divisional Monitoring and Compliance Policy and Procedure Manual is currently being developed to ensure compliance with these regulations across all program areas, including those subject to the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Grant. 3. Develop, implement, and train all divisions on entity-wide written subrecipient-monitoring policies and procedures requiring all divisions to: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward by including in its award terms with subrecipients information necessary for the subrecipient to administer the program in accordance with federal requirements. Required information includes federal award identification, all requirements of the subaward, any additional requirements the Department imposes on the subrecipient for the Department to meet its responsibilities under the federal award, indirect cost rate, and audit and closeout requirements. b. Assess the risk of each subrecipient’s noncompliance and carry out monitoring activities based on those risk assessments such as providing training or technical assistance on program-related matters, and performing on-site reviews, selective audits, and/or other monitoring procedures. c. Review financial and performance reports. d. Verify subrecipients receive timely single audits, if required; follow up on and ensure that corrective action is taken on any audit findings that could potentially affect the program; and issue management decisions for any audit findings pertaining to the federal award. e. Maintain documentation of monitoring procedures demonstrating they were performed, including the monitoring procedures’ results and any Department actions taken, if appropriate. In addition to the revisions in policy and procedures outlined in Recommendation #2 above, the Department will train staff responsible for administering compliance requirements for pass-through entities. This training will include instructions to formulate a risk assessment, review controls related to compliance requirements, review timely single audit submittal, follow up on audit findings, issue management decisions for findings, and maintain adequate documentation of monitoring procedures. Furthermore, the training will be inclusive of proper information dissemination practices aimed at ensuring every subaward is clearly identified to the subrecipient as a subaward by including in its award terms with subrecipients information necessary for the subrecipient to administer the program in accordance with federal requirements. The training and revised procedures will be provided to all staff responsible for administering programs with pass-through entities. 4. Allocate sufficient resources, such as staffing, to comply with the award terms and program requirements, and designate individuals within each division to perform necessary subrecipient-monitoring procedures. The Department will conduct analyses to determine resources needed, including staffing, to ensure compliance with applicable requirements. For example, the Department will assess the efficiency of its subrecipient-monitoring procedures, estimate future workloads, determine staffing needed to meet those workloads, and assign sufficient staff the responsibility for ensuring compliance with each requirement outlined in the federal award. The Department will also ensure the staff responsible for administering the compliance requirements prioritize this responsibility and communicate anticipated compliance deficiencies to management.
Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: C...
Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will prepare and retain detailed documentation, including system reports, queries, screenshots, and other evidence, to support the program information reported to the federal agency for each Emergency Rental Assistance Program (ERAP) award. DES will also abide by its ERAP policies and procedures to retain all records related to the award for a period of 5 years after all federal funds are expended. The Department sunset the ERAP program on October 13th, 2023, due to an exhaustion of ERA 1 and ERA 2 funding.
Assistance listing number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Department of Economic Security (DES) Office of Economic Opportunity (OEO) Name of contact persons and titles: David Almaraz, DES DERS Business Admi...
Assistance listing number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Department of Economic Security (DES) Office of Economic Opportunity (OEO) Name of contact persons and titles: David Almaraz, DES DERS Business Administrator Stephen Sifuentes, OEO Finance Administrator Senior Anticipated completion date: See below Agency’s Response: Concur DES Anticipated completion date: December 31, 2026 The Department will address the audit recommendations by amending its ISA subaward with the Arizona Office of Economic Opportunity. The Department will also adjust its subrecipient monitoring schedule, procedures and offer training and assistance on conference-related requirements to the Arizona Office of Economic Opportunity. OEO Anticipated completion date: June 30, 2027 The Office of Economic Opportunity (OEO) acknowledges the finding regarding the use of WIOA Dislocated Worker Formula Grant funds for conference meals and promotional items. To address these concerns, OEO has undertaken proactive measures to strengthen internal controls, enhance oversight, and improve compliance with federal cost principles. As such, OEO will utilize these findings to strengthen its existing system, address any identified deficiencies, and continue to enhance fiscal management. Through these corrective actions, the OEO is committed to full compliance and the effective stewardship of federal funds. 1. Ensure Summit costs charged to the WIOA federal program are appropriate, necessary, and managed to minimize charges to the federal award. The OEO acknowledges the auditors’ findings regarding the management of Summit costs charged to the Workforce Innovation and Opportunity Act (WIOA) federal program. OEO is committed to ensuring that all expenditures are appropriate, necessary, and managed with the highest level of fiscal responsibility to ensure charges are necessary and allowable to the federal award. To address this finding, OEO will collaborate closely with the Arizona Department of Economic Security (ADES) to develop and implement comprehensive formal policies and procedures governing the State Workforce Development Board and WIOA funded events including Summit expenditures. Our joint efforts will focus on implementing a documented review and approval process to ensure costs charged to the federal award are supported by documentation and evaluated in accordance with 2 CFR §§ 200.403. As part of this corrective action, the process will integrate cost-containment measures into the planning and approval of the events budget planning phase. This will include requiring staff to assess whether proposed costs are necessary, reasonable, allocable and limited to helping the workforce development system achieve the purpose of the Workforce Innovation and Opportunity Act (WIOA). OEO and ADES will conduct working sessions to develop, implement, and monitor these protocols, with the goal of finalizing a standardized procedure for all WIOA-funded event expenditures. This approach ensures consistency across agencies and establishes clear oversight to prevent recurrence. 2. Develop and implement written procedures, including a standardized review process, to ensure that costs charged to the WIOA federal program are allowable prior to requesting reimbursement from DES. The OEO recognizes the importance of verifying the allowability of expenditures prior to the reimbursement phase. We concur that a standardized documented review process is necessary to maintain fiscal integrity and compliance of WIOA federal program funding and federal regulations. OEO, in partnership with the ADES, will develop and formalize written internal control procedures designed to vet all costs before they are submitted to ADES for reimbursement. The proposed standardized review process will align with existing practices for monitoring and expending federal funds as described under WIOA for the State Workforce Development Board and will include: ● Pre-submission verification: Implementation of an internal review checklist based on 2 CFR 200 Subpart E Cost Principles and applicable State policy. This will ensure that every line item is: ○ Allowable under both WIOA statutory requirements and federal cost principles. ○ Allocable to the specific federal award in proportion to the benefits received. ○ Compliant with the State of Arizona Accounting Manual ○ Documented with sufficient supporting evidence (pictures, invoices, receipts, and justifications) to withstand audit scrutiny. ● Standardized approval workflow: Establishment of a clear designated approval framework. ● Policy Integration: These procedures will be codified into an OEO Fiscal Manual, providing staff with a clear roadmap for processing WIOA-related expenditures. OEO will coordinate with ADES technical assistance teams to ensure our internal review templates align with ADES’s appropriate reimbursement systems. This collaborative design phase will ensure that once a request reaches ADES, it has already undergone a vetting process, thereby reducing errors. 3. Work with federal grantor and/or DES to resolve the $90,015 of questioned costs associated with the 2024 Summit and any subsequently held Summits. OEO will collaborate with the ADES, the primary grant recipient, to establish the most appropriate course of action for resolving any unallowable expenditures. Initially, OEO will work with ADES to precisely define the actual allowable amount based on programmatic cost allowability, which may require consultation with the original federal grantor, for final clarification on disputed cost. Subsequent steps for resolution will be guided by ADES’s direction and the requirements of the federal grantor.
Assistance listing numbers and program names 10.558 Child and Adult Care Food Program Agency: Arizona Department of Education (ADE) Name of contact person and title: Cara Alexander, Deputy Associate Superintendent Anticipated completion date: December 2026 Agency’s Response: Concur We have an establ...
Assistance listing numbers and program names 10.558 Child and Adult Care Food Program Agency: Arizona Department of Education (ADE) Name of contact person and title: Cara Alexander, Deputy Associate Superintendent Anticipated completion date: December 2026 Agency’s Response: Concur We have an established process in place for collecting the information necessary to determine total fiscal year expenditures for federal awards (the questionnaire) for entities that do not participate in any federal programs housed within the ADE's Grants Management Enterprise. The policy and procedures will be updated by April 1, 2026, to the following: (1) include additional internal controls such as the annual Child and Adult Care Food Program renewal process and serious deficiency process; and (2) detail the procedures to review single audit reports for findings related to the program and issue management decision letters when applicable. Finally, training will be provided to personnel responsible for collecting and reviewing the questionnaires and single audit reports when submitted.
2024-004 - Subrecipient Monitoring - Material Weakness/Noncompliance Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Commun...
2024-004 - Subrecipient Monitoring - Material Weakness/Noncompliance Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000073444, C000075689, C000082264, C000086078, and PEMA-2022-007 Condition/Context: The County does not have a formal risk assessment or oversight program in place to monitor its subrecipients as required under the Uniform Guidance, including ensuring that financial information reconciles between the underlying expenditure reports and the subrecipient/County audit reports. Recommendation: We recommend that the County revisit its policies and procedures related to subrecipient monitoring and ensure that there are formal subaward agreements with all subrecipients, prepare a formal, initial, risk assessment of each potential subrecipient and document its monitoring activities of each subrecipient. Views of Responsible Officials and Planned Corrective Actions: Management understands and is working to implement these policies, procedures and activities on a prospective basis. The County has been having quarterly meetings with subrecipients to go over reporting.
2024-003 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economi...
2024-003 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000073444, C000075689, C000082264, C000086078, and PEMA-2022-007 Condition/Context: The County’s December 31, 2023 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Views of Responsible Officials and Planned Corrective Actions: Management understands and is working to better anticipate the needs and timing and availability of staff/information to complete the audit. The County has a third party that compiles the information to give to the auditors for auditing. The County is hoping with this that the information being audited will be timelier to get the audit completed.
2024-002 – (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Com...
2024-002 – (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000073444, C000075689, C000082264, C000086078, and PEMA-2022-007 Condition/Context: While the County has informal policies and procedures surrounding the administration of its federal programs, these policies and procedures have not been formally documented to ensure compliance with the areas of allowability of costs, cash management or subrecipient monitoring as required under the Uniform Guidance. Recommendation: We recommend that County management prepare the required written policies/procedures related to allowability of costs, cash management and subrecipient monitoring outlined with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management understands and is working to formally document the required elements of its policies and procedures pursuant to the Uniform Guidance.
Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficienc...
Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficiency, Noncompliance Condition: City of Bloomington completed quarterly reporting in a timely manner. However, the reports did not have evidence of segregation of duties and the cumulative expenses stated on the report did not agree to the cumulative expenditures reported on previous SEFAs. Context: During our testing procedures over CSLFRF reporting, we noted that segregation of duties is not present in the Federal reporting process. The Deputy Controller prepared and submitted the reports without a secondary review taking place. As a result, the City did not report cumulative expenditures for the grant that were consistent with the expenditures reported on the SEFA. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has already implemented a policy effective third quarter of 2025 to ensure a documented two-person review process and reconciliation of costs to the report. Responsible party and timeline for completion: The Controller is responsible for overseeing the implementation of the corrective action plan and will ensure the appropriate personnel are involved in the review and reconciliation process. The corrective action plan has already been implemented effective for the third quarter of 2025.
Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Procurement – Suspension and Debarment Audit Fi...
Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Procurement – Suspension and Debarment Audit Findings: Material Weakness, Noncompliance Condition: The City did not have internal controls in place to ensure compliance with the procurement and suspension and debarment requirements. The City had not designed or implemented adequate policies or procedures to ensure that proper procurement procedures for small purchase and simplified acquisition procurement thresholds were followed. Context: For one out of three samples selected for the small purchase procurement threshold, three quotes and rationale for selecting the vendor were not documented. Small purchase procurements require three competing quotes and rationale for selection of the vendor. The procurement was for park improvement design services. The City was unaware that professional services are required to follow the federal procurement process. Per grant requirements, all grant funded expenditures require appropriate procurement, regardless of whether it is a good or service. For two out of three samples selected for suspension and debarment testing, the City did not have support that vendors procured under CSLFRF funding were not suspended or debarred. Views of Responsible Officials and Planned Corrective Actions: The City had already been checking and documenting the check for suspension and disbarment of all vendors – however, the check was being performed at the time of vendor onboarding, which may have been in a previous period. Management agrees with the finding and has already started taking the steps to implement a procedure for checking procurement and suspension and debarment for each contract that expends American Rescue Plan Act Coronavirus State and Local Fiscal Recovery Funds or any other Federal funds at the time of award. Responsible party and timeline for completion: The Controller is responsible for overseeing the implementation of the corrective action plan and will ensure the appropriate personnel are involved in the procurement and suspension and debarment process. The corrective action plan is in effect immediately. Further, the Controller will conduct an internal audit on or around June 30, 2026, to ensure that the new procedures have been implemented correctly.
The California Consortium for Urban Indian Health (CCUIH) respectfully submits this corrective action plan in response to the finding related to the late completion of the FY 2024 A‐133 audit. The delay resulted from administrative transitions and staffing challenges within the Finance Department du...
The California Consortium for Urban Indian Health (CCUIH) respectfully submits this corrective action plan in response to the finding related to the late completion of the FY 2024 A‐133 audit. The delay resulted from administrative transitions and staffing challenges within the Finance Department during the audit period. These circumstances affected the timely preparation of required schedules, supporting documentation, and responses to auditor requests. CCUIH has taken the following corrective actions to address the issue: · All FY 2024 audit requirements have now been completed and submitted. · Internal processes for audit preparation have been reviewed to identify gaps and inefficiencies. To prevent recurrence, CCUIH will implement the following measures: · Establish a revised annual financial reporting and audit preparation calendar with clearly defined internal deadlines. · Cross‐train finance staff to ensure continuity during staffing transitions or absences. · Strengthen oversight procedures for audit readiness, including periodic internal check‐ins leading up to the audit period. · Develop written procedures outlining roles, responsibilities, and timelines for audit preparation. The anticipated completion date for all corrective actions is June 30, 2026. The parties responsible for implementing and monitoring this corrective action plan are: · Kescia Turner, Director of Finance · Jennifer Ruiz, Executive Director
1 The California Consortium for Urban Indian Health (CCUIH) respectfully submits this corrective action plan in response to the fiscal year 2024 independent audit in response to the finding related to finding 2024‐001, a lack of segregation of duties. The finding cited insufficient separation of dut...
1 The California Consortium for Urban Indian Health (CCUIH) respectfully submits this corrective action plan in response to the fiscal year 2024 independent audit in response to the finding related to finding 2024‐001, a lack of segregation of duties. The finding cited insufficient separation of duties within CCUIH's accounting and disbursement processes, concluding that the organization's small staff size contributed to a concentration of duties that increases the risk of errors or irregularities going undetected. In preparing this corrective action plan, staff conducted a three‐way cross‐reference analysis of: (1) the audit finding itself, (2) the General Disbursement Questionnaire completed CCUIH staff and dated January 28, 2026, and (3) the CCUIH Accounting Procedures Manual, recently updated in June 2025. This analysis confirmed six specific control gaps contributing to the deficiency. Taken together, these gaps reveal a pattern in which documented policies have not kept pace with changes in CCUIH's operational practices. However, many of the identified issues have already been addressed or are partially complete. This Corrective Action Plan (CAP) establishes specific remediation steps for each of the identified control gaps, assigns responsible parties, and sets target completion. The plan is designed to be implementable within CCUIH's current staffing constraints by redistributing responsibilities rather than requiring additional headcount. This document serves as the formal management response to Finding 2024‐001 and should be maintained in the organization's file and provided to the external auditor during subsequent audit engagements. Since the audit period, CCUIH has taken several organizational steps that address the deficiency. These include new and re‐structuring of personnel resources: · A new Executive Director was hired. · An Associate Director position was established. The Director of Operations position has been eliminated, and the former Administrative Specialist (Nicole Garcia) has been reclassified as Operations Coordinator. A Junior Accountant was hired in January 2026 and now prepares all bank and credit card reconciliations A contract with a new outsourced Human Resources and Payroll Processing Provider called Singlepoint Outsourcing has been signed and is beginning integration. Services include assistance with compliance. CCUIH has adopted Bill.com as its accounts payable processing platform, which system‐enforced approval workflow requiring Department Director authorization invoices are paid. These developments represent meaningful progress; however, actions are planned to ensure a comprehensive resolution to this finding. Action Items corrective actions address each of the six identified control gaps. Each action includes responsible party, target completion date, performance measure, and current implementation status. Internal Control Gap Corrective Action Responsible Party Target Completion Date COO/CFO Custody vs. Reporting Separation Functioning Update the policy manual to reflect current job description titles and ensure a separation of duties from those responsible for entering financial transactions, approving, and reporting on them. Since January 2026, the Junior Accountant has prepared all bank and credit card reconciliations, and the Director of Finance independently reviews and signs off on them. This practice must be codified in the manual with the following requirements: (a) the Junior Executive Director; Director of Finance; Junior Accountant 6/30/2026 3 and credit card reconciliations monthly; (b) the Director of Finance reviews, approves, and signs each reconciliation; (c) reconciliations are submitted monthly to the Executive Director for independent review; and (d) the Executive Director's monthly review is documented with a signed acknowledgment form. Invoice Approval Authority Create and adopt a written Disbursement Authorization Matrix that defines dollar thresholds and required approvers at each level. Executive Director; Director of Finance Electronic Payment Approvals Update policy manual to reflect that two verified electronic approvals suffice the requirement equivalent to two signatures on manual checks. Procurement Controls Draft a formal Procurement Policy compliant with 2 CFR 200.317–200.327 (Uniform Guidance procurement standards) that includes: Micro‐purchase threshold ($10,000 per 2 CFR 200.320 or as established by the organization) Small purchase threshold requiring documented price quotes (e.g., $10,001–$250,000: minimum 3 quotes) Formal sealed bid /competitive proposal requirements above the simplified acquisition threshold Sole source justification and approval requirements Conflict of interest disclosure requirements SAM.gov debarment and suspension verification procedures before awarding contracts or issuing purchase orders The policy must be adopted by the Board of Directors and incorporated 4 into the Accounting Procedures Manual. Implement a purchase order (PO) system — either within QuickBooks or via a simple numbered PO form — for all non‐recurring purchases above $1,000. POs must be pre‐approved per the Authorization Matrix (Action 2.1) before goods or services are ordered. POs must be matched to invoices and receiving documentation before payment. 5 Concentration of Accounts Payables Functions: Update the policy manual and confirm that job descriptions reflect a division of responsibilities for the processing and reconciliation of accounts payables and receivables. 6 Independent Review of Approval Workflow: Update policy manual to implement a monthly Director of Finance review of disbursement activity, reconciliations, and financial reports. The Director of Finance is designated as the Corrective Action Plan Coordinator and is responsible for tracking implementation progress across all corrective actions. The following monitoring framework is established to ensure timely implementation and accountability: ● Monthly status updates will be provided by the Director of Finance to the Executive Director, documenting progress on each action item, any obstacles encountered, and any proposed timeline adjustments. ● Quarterly status updates will be provided to the Board of Directors, incorporated into a quarterly internal controls report. ● External auditor notification: This CAP will be provided to the external auditor, who will test corrective action implementation during the FY2025 audit (year ending June 30, 2025) and/or FY2026 audit (year ending June 30, 2026).Completion criteria: This CAP will be considered fully implemented when all actions are marked "Completed" and the external auditor removes or downgrades Finding 2024‐001 in a subsequent audit cycle.
Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.029 Cause: Controls over SEFA preparation and federal award identification were not sufficient to ensure all pass-through federal awards (including ARPA CPF) were captured with required identifiers (federal agency, ALN 21.029, p...
Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.029 Cause: Controls over SEFA preparation and federal award identification were not sufficient to ensure all pass-through federal awards (including ARPA CPF) were captured with required identifiers (federal agency, ALN 21.029, pass-through name/number) before year-end reporting. Effect: An initially incomplete SEFA increases the risk that major programs are not properly identified for testing, which could result in modification of opinion due to incomplete SEFA, which ultimately could result in a delayed audit. Recommendation: We recommend CCAC implement and document SEFA preparation controls to ensure completeness and accuracy over maintaining a central grant repository containing award documents with federal agency, performing year-end SEFA reconciliation, and obtaining written ALN/FAIN confirmations from pass-through entities for any awards lacking federal identifiers and retaining those confirmations in the grant file. Views of Responsible Officials: There is no disagreement with the audit finding. See below for actions taken to remedy the finding. Management Response: Christina Cultural Center experienced a SEFA completeness finding during a year with bookkeeping turnover, which affected the initial compilation of federal award activity. In response, management worked closely with the audit team to confirm the complete listing of awards, validate pass-through entity details, and support accurate SEFA presentation. The organization has also identified cross-training as a key next step to strengthen continuity and reduce key-person dependency going forward.
Finding Reference: 2024-008 Finding Title: Noncompliance and Significant Deficiency, Data Collection Form CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Joseph Psioda, Controller, Financial Affairs, (312) 322-6346 Planned Corrective Actions: 1. Submi...
Finding Reference: 2024-008 Finding Title: Noncompliance and Significant Deficiency, Data Collection Form CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Joseph Psioda, Controller, Financial Affairs, (312) 322-6346 Planned Corrective Actions: 1. Submission of Federal Reporting Package: Management will implement procedures to ensure the timely completion and submission of the annual audit, reporting package, and data collection form. This will include establishing a detailed audit timeline with interim milestones, strengthening coordination among departments responsible for required data and information, and proactively monitoring federal reporting deadlines. Management will also develop contingency plans to address delays in complex audit areas to minimize the risk of future reporting delays. These procedures will be implemented for the 2025 audit cycle to ensure timely submission to the Federal Audit Clearinghouse. Anticipated Completion Date: 06/30/2026
Finding Reference: 2024-007 Finding Title: Timecard Approval Controls – Payroll Charge to Federal Grant, Significant Deficiency CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Scott Dolude, Director of Payroll, Financial Affairs, (312) 322-6526 Planne...
Finding Reference: 2024-007 Finding Title: Timecard Approval Controls – Payroll Charge to Federal Grant, Significant Deficiency CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Scott Dolude, Director of Payroll, Financial Affairs, (312) 322-6526 Planned Corrective Actions: 1. Timecard Approval Requirements for Federal Grants: Management will reinforce payroll control procedures to require that all employee timecards charged to Federal grants are reviewed and approved by designated supervisors in a timely manner and in accordance with established payroll deadlines. Specifically, that all required approvals must be completed prior to payroll processing and fiscal period close to ensure the allowability, accuracy, and proper allocation of costs charged to Federal awards. By June 30, 2026, management will send an email to all impact supervisory and management personnel responsible for time review and approval processes. 2. Documentation Standards and Audit Trail: Management will establish formal documentation standards to ensure that evidence of supervisory review and approval, including approval dates, is consistently retained in a secure, centralized system. These standards will support a clear and retrievable audit trail demonstrating compliance with the payroll documentation and allowability requirements of 2 CFR §200.430(i). 3. Monitoring and Compliance Oversight: Management will implement periodic monitoring procedures to assess compliance with timecard review and approval requirements. These procedures will include exception reporting, timely follow-up on identified deficiencies, and management review of monitoring results. Corrective actions will be implemented, as necessary, to address recurring or systemic issues related to untimely, incomplete, or undocumented approvals. Based on the results of monitoring processes, Director of Payroll and Timekeeping will conduct organizational, departmental, or team-based follow-up to address non-compliance or other issues. Anticipated Completion Date: 06/30/2026
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