Corrective Action Plans

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Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization conducted a review after the completion of the year end to ensure reconcile the total amounts charged to the grant back to accounting records to ensure compliance, howev...
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization conducted a review after the completion of the year end to ensure reconcile the total amounts charged to the grant back to accounting records to ensure compliance, however, this was not done in a timely enough manner to correct for misstatements. In the future the Organization will review support and reconcile on a more frequent basis.
View Audit 342835 Questioned Costs: $1
Finding 523541 (2023-004)
Significant Deficiency 2023
The Organization experienced substantial growth of programmatic activities which required the department to focus on ongoing maintenance and tracking. The Organization completed a significant components of year end close in the fall of 2023 and final review and adjustments in December 2024.The depar...
The Organization experienced substantial growth of programmatic activities which required the department to focus on ongoing maintenance and tracking. The Organization completed a significant components of year end close in the fall of 2023 and final review and adjustments in December 2024.The department is finalizing the year end close for the next year end close to be able to complete the audit and file within nine months from year end.
The Organization experienced substantial growth of programmatic activities which required the department to focus on ongoing maintenance and tracking. The Organization completed a significant components of year end close in the fall of 2023 and final review and adjustments to the SEFA were conducted...
The Organization experienced substantial growth of programmatic activities which required the department to focus on ongoing maintenance and tracking. The Organization completed a significant components of year end close in the fall of 2023 and final review and adjustments to the SEFA were conducted in January 2025. The department is finalizing the year end close for the next year end close and will focus on the completeness and accuracy of the SEFA.
Management will implement a process to ensure all payroll transactions are properly approved and that documentation is maintained.
Management will implement a process to ensure all payroll transactions are properly approved and that documentation is maintained.
Finding 523479 (2023-001)
Significant Deficiency 2023
We are in agreement with the auditors' finding. In the future, we will be prepared for the reporting requirements and the data collection form will be submitted within 30 days after the receipt of the auditor’s report or nine months after the end of the audit period. Moving forward, the SEFA will be...
We are in agreement with the auditors' finding. In the future, we will be prepared for the reporting requirements and the data collection form will be submitted within 30 days after the receipt of the auditor’s report or nine months after the end of the audit period. Moving forward, the SEFA will be prepared alongside other necessary documents to facilitate the audit process efficiently, and the audit submission will be completed on time. The organization has implemented new measures to monitor the progress of audit activities, including the preparation of the audit by their independent auditing firm, and ensure adequate time is allotted for submission and correspondences within the required deadlines.
We created a file for new vendors and/or transactions greater than $25K done outside of the consortium with saved W9s and subsequent business search for debarment.
We created a file for new vendors and/or transactions greater than $25K done outside of the consortium with saved W9s and subsequent business search for debarment.
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
View Audit 342736 Questioned Costs: $1
See Finding 2023-002
See Finding 2023-002
View Audit 342711 Questioned Costs: $1
See Finding 2023-001
See Finding 2023-001
Finding #2023-002 – Significant Deficiency. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93...
Finding #2023-002 – Significant Deficiency. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93.788, Opioid STR, Passed through the Texas Health and Human Services Commission, Contract #HHS000357900001, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the University of Texas Health Science Center, San Antonio, Contract #HHS000561800001, Contract year: 09/01/21 – 08/31/22. Other federal programs: U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/21 – 09/29/22, Contract #5H79TI080624-04, Contract year: 09/30/22 – 09/29/23, Passed through the City of Houston Health Department, Assistance Listing #93.243, Contract #H79SP080300, Contract years: 11/01/21 – 10/31/22, 11/01/22 – 10/31/23 and 06/08/21 – 06/30/23, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Passed through the Texas Health and Human Services Commission, Contract #HHS000130500019. Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23. Condition and context: Houston Recovery Center is required to submit monthly reimbursement requests for five of its federal programs; one program requires reimbursement requests based on achievement of certain milestones rather than time. Out of a sample of 17 requests for the five reimbursement programs, we found six did not have evidence of review and approval as required by Houston Recovery Center’s policies and procedures. Recommendation: Training should be provided to ensure that policies and procedures regarding independent review and approval are followed. Planned corrective action: Houston Recovery Center will strengthen its internal control policies and procedures over independent review and approval of grant payment requests by shifting the primary review and approval process from the Chief Executive Officer (CEO) to the Chief Operating Officer (COO). The COO has full knowledge of allowable costs and has more availability than the CEO, which will make it easier to ensure that our policies and procedures are followed on a consistent basis. The CEO will continue in this role as backup to the COO to ensure immediate access for needed approval. We believe we have a strong system in place used by our accounting department to ensure all expenses underlying the grant payment requests are reviewed, checked for accuracy, and properly approved which further supports the reimbursement policies and procedures. Responsible officer: Leonard Kincaid, Executive Director. Estimated completion date: November 1, 2023.
Finding #2023-001 – Material Weakness and Material Noncompliance. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, ...
Finding #2023-001 – Material Weakness and Material Noncompliance. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93.788, Opioid STR, Passed through the Texas Health and Human Services Commission, Contract #HHS000357900001, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the University of Texas Health Science Center, San Antonio, Contract #HHS000561800001, Contract year: 09/01/21 – 08/31/22. Other federal programs: U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/21 – 09/29/22, Contract #5H79TI080624-04, Contract year: 09/30/22 – 09/29/23, Passed through the City of Houston Health Department, Assistance Listing #93.243, Contract #H79SP080300, Contract years: 11/01/21 – 10/31/22, 11/01/22 – 10/31/23 and 06/08/21 – 06/30/23, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Passed through the Texas Health and Human Services Commission, Contract #HHS000130500019, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23. Condition and context: Houston Recovery Center has personnel funded by more than one grant award. The responsibilities for each position are examined and an assessment of time needed to perform each assigned task is made. The time allotment is then converted to a percentage of salary, documented on the personnel action form for each employee, and used to create the personnel section of each grant budget. Each grant is charged based on the percentages documented on the personnel action forms. In fiscal 2022, quarterly time studies were utilized to support that the budgeted estimates per the personnel action forms were reasonable and, if needed, adjustments were made in the general ledger. On July 1, 2022, Houston Recovery Center changed third-party payroll processors and the new processor did not provide the capability to charge time to more than one cost center. Therefore, while allocations are still made in the general ledger based on the percentages documented on the employee’s personnel action form, actual time worked by grant/cost center was not tracked. Additionally, a time study was not performed in the year ended June 30, 2023 to evaluate the reasonableness of time charged to the grants. Recommendation: Houston Recovery Center should establish policies and procedures to ensure that grants are charged based on actual time and effort expended. Planned corrective action: Management believes that the grants were reasonably charged in all material respects although the payroll provider was unable to allow us to use actual time and effort. Comparison of fiscal year 2022 actual time and effort with the fiscal year 2022 time studies revealed very small differences. However, Houston Recovery Center is in the process of changing to a payroll software provider where actual time can be tracked to each grant as supported by a timesheet. In addition, Houston Recovery Center is using Time Distribution Sheets (TDSs) where the employee is required to record their hours worked by grants. Training on the TDSs will be completed by November 1, 2023 for all employees on multiple awards as appropriate. TDSs will be turned in weekly and utilized until the payroll conversion is completed and is working as needed. Responsible officer: Leonard Kincaid, Executive Director. Estimated completion date: November 1, 2023.
Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principle...
Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024
View Audit 342657 Questioned Costs: $1
Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost ...
Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost Principles, Cash Management, and Matching, Level of Effort, and Earmarking Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024
Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022 - 8/30/2023 Procurement, Suspension and Debarment Material Weakness...
Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022 - 8/30/2023 Procurement, Suspension and Debarment Material Weakness in Internal Control over Compliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the formally documented policy did not include many of the necessary procurement provisions prior to its revision in February 2024. Provisions include a consistent control in place to check applicable vendors for potential suspension and/or debarment for covered transactions. In addition, current controls are to be documented to provide for a proper audit trail. Responsible Individual: Chief Financial Officer Corrective Action Plan: The policy was updated in February 2024 to include all federal requirements regarding procurement controls and suspension and debarment controls as proposed by the auditors. Completion Date: February 2024
Finding No.: 2023-027 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) For condition 1 the procurement processed was followed based off GAC Title 5 Chapter 5 §5213. For condition 2, the ...
Finding No.: 2023-027 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) For condition 1 the procurement processed was followed based off GAC Title 5 Chapter 5 §5213. For condition 2, the lease was procured by DOA. For condition 3, auditor to provide clarification regarding insufficiency of documentation.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-026 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Implementation of a Fixed Assets Module as part of the new FMIS system is near completion which will help automate ...
Finding No.: 2023-026 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) Implementation of a Fixed Assets Module as part of the new FMIS system is near completion which will help automate the tracking and reporting of capital assets. DOA will update the SOP for the Fixed Assets for capital asset reporting accordingly. In addition, the Agency will require all line agencies to designate a property manager to periodically track tagged assets on a revolving basis. Review of Assets acquired in FY2023 was completed, with FY2024 in progress. As noted previously, the process is hampered by difficulties in recruiting personnel.
Finding 523384 (2023-034)
Significant Deficiency 2023
Finding No.: 2023-034 Refunding of Overpayments Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and has developed a corrective action plan that includes a new Stan...
Finding No.: 2023-034 Refunding of Overpayments Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and has developed a corrective action plan that includes a new Standard Operating Procedure (SOP), 2024-005, for the Intake and Processing of Overpayment Checks. This new SOP addresses a gap in our process for tracking overpayment checks and refunding the Federal Share of Medicaid Overpayments to Providers. Furthermore, we are also in the process of updating SOP 2023-03, which focuses on Public Health Professional (PHPro) Entry for Provider Overpayment Checks and Recoupments, to improve our tracking and monitoring of overpayment checks and recoupment reconciliations. Currently, we are still addressing updates to this SOP and require additional time to work with BHCFA staff(s) to gather more information in finalizing the SOP. We intend to complete this SOP no later than February 28, 2025.
View Audit 342645 Questioned Costs: $1
Finding 523383 (2023-033)
Significant Deficiency 2023
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with t...
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with the Department of Administration (DOA) financial system. One of the primary challenges arises from transactions that are not processed within the designated reporting period, which impacts on our initial submissions to CMS. Any adjustments or transactions made after the quarter's close, which were not captured in our previous reports, contribute to this issue. We understand that addressing this finding is a critical part of our corrective action measures. We are currently working on updating the existing Standard Operating Procedure (SOP) 2023-01, which governs interactions between the Department of Public Health and Social Services (DPHSS) and DOA/Division of Accounts. Since November 2024, we have been collaborating with DOA to revise this SOP with the goal of reconciling Medicaid and CHIP expenditures, as well as aligning reports from CMS-64 with the new Guam Financial Management Information System (GFMIS). Currently, PMS staff is in the process in finalizing the DRAFT SOP. We intend to have the DRAFT SOP completed and forwarded to DOA by Friday, January 31, 2025. If there are no changes to the SOP, we will work to have the SOP signed by all parties no later than February 14, 2025.
Finding 523380 (2023-032)
Significant Deficiency 2023
Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau wil...
Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau will hold providers accountable by issuing a Letter of Warning (LOW) and a Correction Action Plan (CAP) from the Social Service Licensing Officer or Child Care Compliance Officer to ensure compliance with the standards. The Agency disagrees with Condition 1. License-exempt childcare providers will not have an annual DEH inspection since they are not required to obtain a sanitary permit.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds...
Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds under the Qualified and Eligible Child Care Providers, Provider Reporting and Monitoring, the ARP Act does not include specific reporting requirements for childcare providers receiving subgrants and any subgrant reporting requirements are at the discretion of the lead agency, page 21. Additionally, Lead Agencies that use other governmental or non-governmental subrecipients to administer the program must have written agreements in place outlining roles and responsibilities for meeting CCDF requirements. The contents of the written agreement may vary based on the role the subrecipient is asked to assume or the type of product undertaken, but must include, at a minimum, tasks to be performed, a schedule for completing tasks, a budget which itemizes categorical expenditures, and indicators or measures to assess performance. The Lead Agency has fulfilled this requirement in accordance with 45 CFR section 98.1.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-030 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due ...
Finding No.: 2023-030 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process. For condition 2, the Agency will report first-tier subawards to the FSRS system. However, it is noteworthy to mention that the system will be expiring as of March 2025.
Finding 523371 (2023-029)
Significant Deficiency 2023
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
View Audit 342645 Questioned Costs: $1
Finding 523368 (2023-028)
Significant Deficiency 2023
Finding No.: 2023-028 Matching, Level of Effort, Earmarking Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward. Howev...
Finding No.: 2023-028 Matching, Level of Effort, Earmarking Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward. However, the Matching Level of Effort (MOE) earmarking is not a requirement in accordance with the Supplemental Terms and Conditions for the Child Care Mandatory and Matching Funds of the Child Care & Development Fund's Cost Sharing or Matching (Non-Federal Share) of Program Funding, page 2. Item 6 identifies that a state match is not required while Item 8 identifies that the MOE threshold applies to states only.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-025 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any ...
Finding No.: 2023-025 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any subrecipient account a copy of the FATA report be attached, as well as, creating a check list of subrecipient monitoring requirements prior to any payments being made.
Finding No.: 2023-024 Matching, Level of Effort, Earmarking Responding Agency: Guam State Clearing House (GSC) Responsible Personnel: Stephanie Flores, Director (GSC) Agency agrees with the finding and will apply the recommendations moving forward.
Finding No.: 2023-024 Matching, Level of Effort, Earmarking Responding Agency: Guam State Clearing House (GSC) Responsible Personnel: Stephanie Flores, Director (GSC) Agency agrees with the finding and will apply the recommendations moving forward.
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