Corrective Action Plans

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Consistent with RIGL 40-8-13.4, the Rhode Island Medicaid State Plan includes the following: Annual review. EOHHS will review the DRG payment method at least annually, making updates as appropriate through the rule-making process. The scope of the annual review will include at least the DRG algorith...
Consistent with RIGL 40-8-13.4, the Rhode Island Medicaid State Plan includes the following: Annual review. EOHHS will review the DRG payment method at least annually, making updates as appropriate through the rule-making process. The scope of the annual review will include at least the DRG algorithm version, the DRG Relative Weights, the DRG Base Price(s), the outlier thresholds, outlier payment parameters, policy adjustors and the age adjustors. With respect to the DRG Base Price, EOHHS will take into consideration at least the following factors in deciding what change, if any, to implement: changes or levels of beneficiary access to quality care; the Center for Medicare and Medicaid Services (CMS) Inpatient Hospital Prospective Payment System Market Basket Update without productivity adjustment for the current federal fiscal year; technical corrections to offset changes in DRG Relative Weights or policy adjustors; changes in how hospitals provide diagnosis and procedure codes on claims; and budget allocations.” EOHHS annually reviews the inpatient hospital rate components in conjunction with annual market basket adjustments for the upcoming fiscal year. For example, this review for SFY 2027 occurred on June 18, 2026. However, in response to this finding, EOHHS will request amendment to the Rhode Island General Laws through the FY 2028 budget process. Then, upon enactment, it will then pursue a state plan amendment (SPA) to more specifically align with current practices. If CMS opposes the amendment, then EOHHS could pursue an update to the DRG model. Doing so would first require procurement of actuarial services to analyze six months of inpatient claims in order to determine new rates. Following the analysis, significant work in the MMIS would be needed to implement the rate and update the DRG grouper. MMIS work is estimated to require about 1,000 project hours. Additionally state funding would be needed to implement this change; as EOHHS does not currently have funding to accommodate this work, it would seek budget authority before moving forward. Anticipated Completion Date: FY 2028 Contact Person:Patricia Arruda, Interdepartmental Project Manager, Executive Office of Health and Human Services patricia.arruda@ohhs.ri.gov
A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s T...
A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s TPL data is not good enough to reject encounter claims from the MCO’s. EOHHS continues to work on improving the TPL process specifically cleaning up the TPL data in the MMIS and eligibility system today. Future system enhancements include a direct TPL vendor and new TPL module which should improve TPL accuracy. Anticipated Completion Date: July 31, 2028 Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov
2025-062a: EOHHS recently determined that the MCOs were unknowingly assigning the incorrect Organization Type Code to multiple provider types since EOHHS adopted the 837 standard in SFY 2014. This created unacceptably high encounter denial rates that led EOHHS to relax certain edits in the years tha...
2025-062a: EOHHS recently determined that the MCOs were unknowingly assigning the incorrect Organization Type Code to multiple provider types since EOHHS adopted the 837 standard in SFY 2014. This created unacceptably high encounter denial rates that led EOHHS to relax certain edits in the years that followed. An MMIS project is currently underway that will help ensure the plans are assigning the correct codes to their providers. Once the MCO's are submitting the correct codes, EOHHS will be able to begin the process of re-enabling the edits in the 2nd half of SFY 2027, which will improve controls over encounter claims data submissions. 2025-062b: Medicaid has deployed several control measures to improve the identification and processing of individuals determined to be deceased and living out State. In January 2026, the State operationalized a new interface with the National Change of Address (NCOA) database. The RI Bridges system verifies addresses of Medicaid recipients on a weekly (those with returned mail) and monthly (entire Medicaid population) basis. Automated rules ensure individuals with an out of State address received from NCOA are provided an opportunity to verify their residency. Failure to respond to the verification results in termination of eligibility. Effective December 2025, the RI Bridges system receives quarterly matches from the SSA Death Master File (DMF). The DMF is automatically sent to the State as part of the quarterly PARIS data matching process. The State has deployed temporary system measures to process the file and automatically terminate Medicaid eligibility for individuals flagged as deceased on the DMF. As per section 71104 of the Working Families Tax Cut (WFTC) legislation, signed by the President on 7/4/25, the State will be deploying a long-term system enhancement to, “at least a quarterly basis, check the DMF to identify if enrolled individuals are deceased. If an individual is identified as deceased on the DMF, then the state must treat this information as factual, disenroll the individual, and discontinue any payments for items or services furnished after the death of the individual.” This enhancement is scheduled for the March 2027 release. Anticipated Completion Dates: 2025-062a: Q4 SFY 2027 2025-062b: March 2027 Contact Persons: Rob Tingle, Chief of Program Analytics, Executive Office of Health and Human Services robert.tingle@ohhs.ri.gov Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov
EOHHS understands that the audit findings primarily resulted from three items: 1. Lack of management oversight of the AlloCAP system’s functionality and its effect on financial reporting. 2. The use of incorrect FMAPs on sister agencies’ quarterly administrative claiming reports submitted to Medicai...
EOHHS understands that the audit findings primarily resulted from three items: 1. Lack of management oversight of the AlloCAP system’s functionality and its effect on financial reporting. 2. The use of incorrect FMAPs on sister agencies’ quarterly administrative claiming reports submitted to Medicaid Finance, and Medicaid’s subsequent lack of review of these reports. 3. No segregation of duties in the Assistant Director Financial and Contract Management position within the EOHHS Central Management finance team. Several actions have been taken to enhance oversight of the AlloCAP system functionality and improve the overall cost allocation process, including hiring an Administrator, Financial Management position. This position has been cross trained and is completing the quarterly AlloCAP activities with review completed by the Assistant Director Financial and Contract Management position. Management’s additional correction action plans for each of these are below. 1. Finance will request a SOC I Type II report from its AlloCAP vendor. The report(s) will be shared with CFOs at all agencies using the AlloCAP system for Medicaid allocations for their review. 2. Finance has already implemented controls to rectify this finding. The items below were implemented during SFY 2026. a. Additional training for sister agencies on the administrative claiming reporting process. Trainings were held on February 4th and April 15th, 2026, and included the importance of the correct FMAP and a list of FMAPs by CMS-64 line item. b. Office hours with Medicaid administrative claiming agencies prior to the submission of quarterly expenditure reports. This allows agencies to ask questions and troubleshoot possible issues prior to report submission. c. Medicaid Finance review of all agency-submitted quarterly expenditure reports. This includes checking that: i. the reported federal amounts tie to the quarterly draw down amount. If there is a variance, the variance must be explained and documented for future reconciliation; ii. FMAPs are used and align with CMS-64 line item FMAPs; iii. The reported federal amounts do not exceed CMS-64 line item budgets (when applicable). d. Training additional Medicaid Finance staff on the review of agency submitted reports and data entry to separate staff duties and allow for double-checking of staff work. Finance will continue to refine improvements and implement processes to ensure reporting accuracy, including drafting relevant SOPs. Additionally, Medicaid Finance retained a contractor that has worked with other states to review the CMS-64 claiming process to suggest further areas of improvement and automation. 3. EOHHS will continue to explore options for improving controls over AlloCAP system functionality and cost allocation work. 4. Finance staff across EOHHS and Medicaid teams will detail additional controls and recommendations for implementation. Anticipated Completion Date: September 1, 2026 Contact Persons: Dezeree Hodish, Associate Director, Financial Management, Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov Victoria Pavao, Assistant Director, Financial and Contract Management, Executive Office of Health and Human Services victoria.pavao@ohhs.ri.gov
EOHHS understands that this finding stems from two items. 1. Current limitations of the MMIS and the volume of manual transactions, including retroactive capitation adjustments and corrective journal entries related to CHIP funding 2. Lack of internal controls regarding CHIP draw downs and reporting...
EOHHS understands that this finding stems from two items. 1. Current limitations of the MMIS and the volume of manual transactions, including retroactive capitation adjustments and corrective journal entries related to CHIP funding 2. Lack of internal controls regarding CHIP draw downs and reporting. Management’s correction action plans for each item are below. 1. EOHHS will improve SOPs to include additional review of source data, collation of source data, and review of formula calculations for manual adjustment activities. These steps will be built into analyst training, and measures have been taken to include training and the creation/improvements of internal SOPs before the upcoming SFY 2026 closing activities occur. EOHHS will include within its forthcoming procurement of specific MMIS modules requirements to reduce the number of manual calculations and related entries. 2. Medicaid finance has and will take the following actions. a. Staff training. i. In May 2026, Medicaid Finance sent two employees to internal control training, which was sponsored by the Office of the Auditor General (OAG) ii. In July 2027, these two employees will train all Medicaid finance staff members on the importance of risk and internal controls using material from the OAG sponsored training. b. SOP tracker and dedicated work time i. Medicaid finance created an inventory of all finance-related SOPs to track assignments to ensure timely completion of high priority SOPs. ii. The Associate Director (Financial Management) has weekly worktime dedicated to the completion of high priority SOPs. iii. Each fiscal close, one staff member has been assigned to work with analysts to draft six SOPs (two from each finance unit—fee for service, managed care, and federal reporting) to continue to document all year end closing procedures. c. Post FFY-quarter end reconciliations i. Beginning in FFY 2026, the Associate Director (Financial Management) completes a post-quarter reconciliation of Medicaid draw down accounts (benefits, administrative claiming, and CHIP). ii. Staff email the Associate Director (Financial Management) after each federal draw down and include verification of the PMS draw down amount and account. iii. The Associate Director (Financial Management) enters this into a tracking sheet to ensure sufficient federal funds remain in each account during the quarter. Should additional funds be needed, Medicaid finance submits a supplemental budget request to CMS to prevent the shifting of funds between federal accounts benefits, administrative claiming, and CHIP accounts. iv. Shortly after the end of each FFY year quarter close, the Associate Director (Financial Management) completes the following: 1. Receives staff-run reports form the PMS system showing all draw downs in the previous quarter. 2. Checks that Medicaid Finance internal trackers (high level and detail trackers) accurately capture correct federal accounts and amounts. If variances, research is completed to reconcile to PMS. v. Associate Director (Financial Management) ensures that all CMS adjustments, such as Parts A, B, and D adjustments and TPL/AOR adjustments are included in the high-level fund tracker to match and verify CMS’ quarterly account balances. d. EOHHS acknowledges that many of the new checks and reviews implemented have not been formally codified. It will work to codify controls to document these reviews and checks. Anticipated Completion Date: Additional SOP and internal control development is ongoing and the date of procurement/implementation of the MMIS Finance module is still be determined. Contact Persons: Storm Lawrence, Chief of Strategic Planning, Monitoring & Evaluation, Executive Office of Health and Human Services storm.lawrence@ohhs.ri.gov Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov
Management concurs with the findings related to controls over child care eligibility determinations and provider payments. Management notes that the number and scope of findings identified in the current audit have been substantially reduced compared to prior Single Audits, reflecting continued prog...
Management concurs with the findings related to controls over child care eligibility determinations and provider payments. Management notes that the number and scope of findings identified in the current audit have been substantially reduced compared to prior Single Audits, reflecting continued progress in strengthening internal controls. The Office of Child Care remains committed to enhancing eligibility determination processes and related internal controls, including ensuring that required eligibility documentation is consistently maintained in the electronic case record. Corrective actions to address the remaining findings, along with the anticipated completion dates, are outlined below. [See Corrective Action Plans for table.] In addition to the corrective actions outlined above, the Department is strengthening supervisory oversight through implementation of routine pre-authorization quality reviews and standardized supervisory monitoring practices. Supervisors will utilize these tools as part of ongoing quality assurance activities to verify that required eligibility documentation is complete prior to authorization, identify recurring error trends, and provide targeted coaching, training, and process improvements to strengthen program integrity and reduce future eligibility errors. Management agrees with the recommendation to evaluate modifications to the existing eligibility system to support eligibility determinations under the CCAP Child Care Staff program. The Department previously assessed the feasibility of modifying RIBridges to accommodate eligibility determinations for the CCAP Child Care Educators and Child Care Staff pilot program. At that time, implementation was not feasible due to competing system development priorities, limited vendor development capacity, and the pilot status of the program. Since the period covered by the audit, the Department has implemented a requirement that participants in the pilot program also apply for the traditional CCAP program. This change has strengthened documentation requirements and helped mitigate risks associated with incomplete eligibility documentation. While these interim measures have improved program administration, the Department recognizes that administering eligibility determinations outside of the primary eligibility system is not a sustainable long-term approach. Accordingly, the Department is reassessing the future administration of the pilot program and evaluating options to incorporate eligibility determinations into RIBridges or, alternatively, to develop the functionality within RISES and integrate it with RIBridges. The Department will determine the most appropriate path forward based on program needs, system capabilities, and available resources to ensure a sustainable and well-controlled eligibility process. Additionally, the Department has strengthened controls over provider payments for the CCAP Child Care Staff pilot program since the audit period. Prior to each payment, the CCAP program team reviews the copayment workbook to identify and resolve discrepancies between pilot program payments and traditional CCAP benefits. In addition, the CCAP Finance team performs a formal review of each payment workbook before payments are processed. The vendor supporting the pilot has also enhanced its payment file process by implementing an additional level of financial review by the project team prior to submission and incorporating safeguards to identify attendance records that may have been previously paid, reducing the risk of duplicate payments. The Department has established procedures to recover identified overpayments, including both one-time recoveries through withholding from future pilot payments, where appropriate, and a formal recoupment process for providers who are no longer participating in the pilot program. These enhanced controls are intended to strengthen payment accuracy and support effective stewardship of program funds. Anticipated Completion Dates: See table above Contact Person: Nicole Chiello, Associate Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov
RIDOH agrees with this repeat finding and recommendations. RIDOH staff often do not pay attention to the Budgeted Allocation column on their time sheets, focusing only on their reporting of time and effort, which leads to inaccurate cumulative Budgeted Allocations on Variance Reports leading to inac...
RIDOH agrees with this repeat finding and recommendations. RIDOH staff often do not pay attention to the Budgeted Allocation column on their time sheets, focusing only on their reporting of time and effort, which leads to inaccurate cumulative Budgeted Allocations on Variance Reports leading to inaccurate variances for correction. The RIDOH reconciliation methodology includes a step to compare reported time and effort to financial system payroll reports (the Variance Correction tab in each reconciliation adjustment calculation spreadsheet). This ensures that all adjustments are accurately processed to the appropriate grants even if they do not appear to agree with the variances in individual Variance Reports. 2025-043a: RIDOH abolished all “umbrella” or general Programs/Activities from Time Sheet Workbooks as of SFY2027 Qtr1. All grant activities now are reported with Appropriation numbers, and grouped activities were removed, except for Medicaid Match account pairs and consecutive federal awards for the same purpose which are spent down in sequence (e.g., DWQ State Revolving Fund awards). RIDOH continues to monitor the status of reporting by Project Tags in Workday, which will provide automatic reconciliation per time and effort reported. Currently, reporting by Project Tags results in inaccurate charging of leave time. When that issue has been resolved, RIDOH will switch to Workday Project Tag reporting and will discontinue using Time Sheet Workbooks. 2025-043b: RIDOH will review SFY2026 Time Sheet Workbooks and revise them to show the correct budgeted allocations, providing the basis for the variance adjustments. Any revisions will be documented. Time and effort reported will not be changed. For SFY2027, RIDOH Grants Management began providing payroll reports formatted by the Time Sheet Workbook Programs/Activities for Division Finance Liaisons to update and share with Division staff, to support correct recording of Budgeted Allocations in Time Sheet Workbooks. RIDOH Grants Management will continue to do this quarterly, ensuring accurate variance calculations on quarterly Variance Reports. 2025-043c: RIDOH will review the SFY2025 payroll reconciliations in question and make corrections as needed. Anticipated Completion Dates: 2025-043a: Enhanced reporting completed. Transition to Workday Project Tag reporting by June 30, 2027 2025-043b: Ongoing 2025-043c: December 31, 2026 Contact Persons: Carla Lundquist, Deputy CFO / Federal Grants Manager, Department of Health carla.lundquist@health.ri.gov Shannon Healy, Assistant Federal Grants Manager, Department of Health shannon.healy@health.ri.gov
We agree with the recommendations. We have resubmitted the FY24 SWCAP to include these costs. We will work with our SWCAP consulting partner to review prior submissions to ensure grant management services are assessed as billed costs and include the costs going forward. Anticipated Completion Date: ...
We agree with the recommendations. We have resubmitted the FY24 SWCAP to include these costs. We will work with our SWCAP consulting partner to review prior submissions to ensure grant management services are assessed as billed costs and include the costs going forward. Anticipated Completion Date: To Be Determined Contact Person: Steve Thompson, Associate Controller, Office of Accounts & Control, Department of Administration steve.thompson@doa.ri.gov
Finding 1224916 (2025-002)
Material Weakness 2025
Corrective Action: What we've already been doing to correct the issue LifeWire has strengthened oversight within Services by consolidating the Services and Rapid Rehousing programs under a single Director, creating clearer accountability for expenditure documentation. The expanded multi-tier approva...
Corrective Action: What we've already been doing to correct the issue LifeWire has strengthened oversight within Services by consolidating the Services and Rapid Rehousing programs under a single Director, creating clearer accountability for expenditure documentation. The expanded multi-tier approval workflow (Advocate → Manager → Director → Finance) now includes a documentation completeness check at each stage, requiring that underlying support for all charges be attached and verified before a transaction advances toward payment. LifeWire has updated its policies and procedures to explicitly require that underlying documentation supporting the nature and amount of each expenditure be retained at the time the charge is generated from the program services department, consistent with 2 CFR §200.403(g). This will include clear guidance on what constitutes sufficient documentation (e.g., invoices, receipts, lease agreements, or other source documents) and the requirement that payment confirmation alone is not sufficient. What else we are putting in place LifeWire has implemented training for all Services staff on federal documentation standards, reinforcing that charges to federal programs must be supported by documentation that evidences both the nature and the amount of the expense. The Services Director is responsible for delivering and maintaining this training on an ongoing basis. All staff will be required to formally acknowledge completion of the training and their understanding of the updated requirements. Responsible Staff: Olivia Montgomery •Advocates and program staff (generating and attaching underlying documentation at pointof charge) •Services Managers (first level review for documentation completeness) •Services Director (program oversight and secondary review) •Executive Director (internal audit oversight; reviews Director of Services approvals andmonitors compliance) •Finance Director / Finance Department (final documentation review, approval, and paymentoversight) Anticipated Completion Date: Policy and procedure updates and staff training will be completed, with full implementation and demonstrated compliance expected by Q3 2026.
Finding 2025-002: Account Reconciliations Type of Finding: Material Weakness in Internal Control Over Financial Reporting and Internal Control Over Compliance Corrective Action Narrative: Spectrum Generations will strengthen the balance sheet reconciliation process and supervisory review controls ac...
Finding 2025-002: Account Reconciliations Type of Finding: Material Weakness in Internal Control Over Financial Reporting and Internal Control Over Compliance Corrective Action Narrative: Spectrum Generations will strengthen the balance sheet reconciliation process and supervisory review controls across significant accounts. Planned Corrective Actions: Controller will prepare monthly reconciliations for all significant balance sheet accounts, including cash, AR, prepaid expenses, refundable advances, deferred revenue, notes payable and other material accounts. Each reconciliation will include the general ledger balance, supporting detail, reconciling items, preparer name, and date prepared. CFO will perform and document secondary review, including date of review and follow-up on unresolved items. A standardized reconciliation template and balance sheet close checklist will be used agency-wide. Responsible Officials: Controller and CFO Expected Outcome: Formal monthly reconciliations and documented supervisory review will improve financial reporting accuracy and strengthen compliance oversight.
Finding 2025-001: Significant Deficiency and Noncompliance: Cut-off Errors in Preparing the SEFA Finding: The City’s reported expenditures on the fiscal year 2025 SEFA that were incurred in other fiscal years. For two grants that were closed out and finalized during fiscal year 2025, the City includ...
Finding 2025-001: Significant Deficiency and Noncompliance: Cut-off Errors in Preparing the SEFA Finding: The City’s reported expenditures on the fiscal year 2025 SEFA that were incurred in other fiscal years. For two grants that were closed out and finalized during fiscal year 2025, the City included certain expenditures incurred prior to January 1, 2025, on its 2025 SEFA, representing adjustment of amounts previously reported on the 2023 and 2024 SEFA to account for the finalized grant numbers. The adjustment amounts on the 2025 SEFA for these two grants do represent any actual expenditures incurred in 2025. Therefore, they were not reported on the SEFA in a manner consistent with the fiscal year in which they were recognized as expenditures in the financial statements. This resulted in a net effect of $32,815 of allowable costs reported on the fiscal year 2025 SEFA which were incurred in previous fiscal years. Corrective Actions Taken or Planned: The City has reviewed the circumstances noted in Finding 2025‑001 regarding the reporting of expenditures on the fiscal year 2025 SEFA for two federal airport grants that had already been closed and finalized. These grants required no additional programmatic or financial activity in fiscal year 2025, and the amounts appearing on the 2025 SEFA represented adjustments of expenditures originally recognized and reported in prior fiscal years. Because the grants are fully closed, no further corrective actions are required related to these specific awards beyond the correction already noted in the audit finding. To strengthen controls and ensure accurate reporting periods for all future federal airport grants, the City will implement a dual review process for annual grant expenditure reporting. Both the Airport Manager, MSO Management Analyst and the Finance Grant Accountant will independently review and validate the recording period for all federally funded airport grant expenditures prior to SEFA preparation. This additional verification step will help ensure proper cut off, alignment with the period of recognition in the financial statements, and continued compliance with federal reporting requirements. Contact Person: Shaun Cookson, Rachelle Mathews Anticipated Completion Date: To be completed by December 31st, 2026
ACDJFS will strengthen its internal controls and documentation practices related to the allocation of direct expenses and the completion of Random Moment Sampling (RMS) observations, particularly for programs serving both eligible and non eligible participants. 1. Strengthening Cost Allocation Contr...
ACDJFS will strengthen its internal controls and documentation practices related to the allocation of direct expenses and the completion of Random Moment Sampling (RMS) observations, particularly for programs serving both eligible and non eligible participants. 1. Strengthening Cost Allocation Controls ACDJFS will revise and reinforce its cost allocation procedures to ensure all direct expenses are properly assigned, consistently treated, and supported by clear documentation. Updated procedures will include supervisory review checkpoints and periodic reconciliation to ensure costs are charged in proportion to the benefit received by each program. 2. RMS Compliance and Documentation Standards ACDJFS provides a dedicated RMS Coordinator to maintain clear RMS compliance and documentation standards to ensure activities are coded accurately, consistently, and in accordance with state and federal requirements. Staff are expected to provide complete and accurate RMS responses that clearly describe the activity performed, its purpose, and the population served. Attention will be given to activities that support both eligible and non-eligible populations to ensure proper classification and allocation of costs. Allocation errors will be corrected promptly and documented. Incorrect RMS responses will be corrected and retrained immediately. All RMS responses are currently being reviewed. Supporting documentation must be maintained and readily available to substantiate RMS activities and demonstrate compliance during monitoring, audit, or review processes. Supervisors and management will routinely review RMS documentation and coding practices to ensure consistency, identify areas requiring clarification, and maintain the integrity of the agency's cost allocation methodology. The coding of direct expenses are reviewed prior to the processing month end to ensure that they are coded correctly. These standards help ensure RMS results accurately reflect agency operations and support the appropriate claiming of administrative costs. 3. Staff Training and Capacity Building ACDJFS will conduct targeted training for program and fiscal staff to ensure a consistent understanding of cost allocation principles, RMS documentation requirements, and compliance standards for programs serving mixed-eligibility populations. Annual refresher training will be incorporated into ongoing professional development efforts to reinforce expectations, maintain compliance, and support accurate coding practices. The RMS Coordinator will work closely with agency leadership and the Ohio Department of Job and Family Services (ODJFS) to monitor policy updates, guidance, and best practices related to Random Moment Sampling. The coordinator will obtain and disseminate updated information as quickly as possible to ensure staff receive timely communication, training, and technical assistance when changes occur. In addition, the RMS Coordinator will provide weekly reviews and updates to agency management, creating multiple levels of oversight and accountability. This ongoing review process allows leadership to identify trends, address potential concerns early, verify compliance, and ensure consistent application of RMS requirements across all programs. Through training, communication, and regular management review, ACDJFS strengthens internal controls and promotes the accuracy and integrity of its RMS activities. 4. Monitoring and Continuous Improvement ACDJFS leadership will conduct quarterly monitoring of allocation patterns, RMS samples, and documentation quality. Findings will be used to make timely corrections and guide additional staff training. Monitoring results will be retained and used to support continuous improvement. 5. Implementation Timeline All corrective actions, including updated procedures, training, and monitoring mechanisms—will be implemented within 90 days and maintained on an ongoing basis. Annual RMS training was completed in July 2025. ODJFS provided RMS training to all staff in December of 2025. ODJFS will provide annual RMS training scheduled for September 2, 2026. ODJFS will provide RMS Coordinator training on August 6, 2026. RMS training for Management/Fiscal is scheduled for July 7, 2026. Written documentation of fiscal procedures and policies is being reviewed and will be implemented by September 1, 2026.
Corrective Action: The City will implement and enforce procedures requiring purchase orders or equivalent authorization documentation to be prepared, approved, and retained prior to incurring federally funded expenditures. The City will also implement review procedures to ensure supporting documenta...
Corrective Action: The City will implement and enforce procedures requiring purchase orders or equivalent authorization documentation to be prepared, approved, and retained prior to incurring federally funded expenditures. The City will also implement review procedures to ensure supporting documentation is complete and maintained in grant expenditure files. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Crissy Cantu, Purchasing Manager. Timeline: In Progress. Estimated October 2026.
2025-001 Internal Controls over Allowable Cost – Disaster Assistance Grants Point of Contact: Rachael Wilkinson, Director, APOHSEP Management’s response and corrective action plans are as follows: 1. Management acknowledges the recommendation and has taken steps to enhance oversight of the Federal E...
2025-001 Internal Controls over Allowable Cost – Disaster Assistance Grants Point of Contact: Rachael Wilkinson, Director, APOHSEP Management’s response and corrective action plans are as follows: 1. Management acknowledges the recommendation and has taken steps to enhance oversight of the Federal Emergency Management Agency (FEMA) reimbursement requests, including those prepared by third-party consultants. Ascension Parish Government is implementing a formalized review process by the Ascension Parish Office of Homeland Security and Emergency Preparedness (APOHSEP) prior to submission to ensure that all expenditures are accurate, properly supported, and classified in accordance with FEMA requirements. 2. This process will include reconciling reimbursement requests with underlying payroll records, equipment logs, and other supporting documentation, as applicable. Management will continue to monitor FEMA submissions to ensure compliance with applicable federal guidelines and strengthen documentation of review procedures. 3. Additionally, Ascension Parish Government will amend the project worksheet to address the identified errors
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient ...
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient to support compensation costs charged to the Community Development Financial Institutions Program in accordance with 2 CFR § 200.430. The Organization's methodology relied on management-established allocation percentages based on employee responsibilities and anticipated level of effort supporting CDFI Fund activities. While management believes the costs charged to the award were incurred in support of eligible program activities, the Organization recognizes that documentation supporting the allocation methodology did not meet the standards required under Uniform Guidance. Planned Corrective Action: Beginning July 1, 2026, the Organization will implement formal time and effort reporting procedures for all personnel whose compensation is charged, in whole or in part, to federal awards. Specifically, the Organization will: 1.The CFO will establish a cost allocation plan which includes a methodology to support salary, wage, and fringe benefit charges, and other applicable costs, to the federal award and to support allocation among cost objectives. 2. The CFO will implement a documented process for personnel activity reporting and/or periodic certifications (or other equivalent documentation) that reasonably reflects actual work performed and supports the allocation of compensation costs to eligible activities. 3. CFO will reconfigure the current workforce management system to ensure projects, departments, and contextual details are logged at the source. 4. The COO will review existing timesheet submission and review policy to ensure compliance with federal requirements. The policy will require supervisory review and approval of personnel activity documentation/ certifications consistent with the payroll cadence and retain documentation in the grant file and/or payroll file. The CFO will review and enforce compliance with timesheet submission requirements. 5. The CFO will implement a dynamic allocations module within Sage Intacct to facilitate automated allocation of time and fringe benefits to federal and other programs. 6. The CFO will ensure that the systems established perform periodic reconciliation and after-thefact review of payroll and fringe benefit allocations. The CFO will make timely adjustments when actual activity differs from budget estimates or planned allocations. 7. The CFO, COO, and other personnel working on federal programs will receive training on the documentation standards in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 8. The CFO and COO will provide training to program and finance personnel on the documentation standards. in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 9. The CFO will, as part of the monthly close process, review compensation charged to federal awards to ensure all costs are appropriate and supported prior to requesting reimbursement. Management believes these actions will strengthen internal controls over compensation costs charged to federal awards and ensure compliance with Uniform Guidance requirements going forward. Responsible Official: Julia Gazizova, Chief Financial Officer Anticipated Completion Date: September 30, 2026.
Finding #2025-004: Written Uniform Guidance Policies Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: The System is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
Finding #2025-004: Written Uniform Guidance Policies Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: The System is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
Managements Corrective Action Plan Year Ending – December 31, 2025 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2025. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2025-001 – Allowable Cost Principles – Payro...
Managements Corrective Action Plan Year Ending – December 31, 2025 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2025. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2025-001 – Allowable Cost Principles – Payroll Evidence of Review Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2026 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky will implement a process improvement plan in 2026 that addresses the finding: • For our 2025 Single Audit, we discovered a system limitation in Dayforce preventing approval of timecards beyond the automatic cut-off time. • In partnership with the Human Resources department, staff will establish an “after the fact” approval process to ensure that all timecards are reviewed and approved by management. o The current system will continue to push through timecards to make the defined payroll cut-off time. o A manual process will be established to review and approve missed timecards after payroll is processed. ▪ Managers are to review and approve timecards, even though the timecards have been processed. ▪ A log will be maintained acknowledging missed approvals, logging hours, areas of work, and manager approval o If any errors or changes need to be made, those will be reflected within the next payroll cycle.
The Foundation, through its outsourced bookkeeping firm, acknowledges the audit observation regarding the duplicate reimbursement of lender expenditures. Management believes this was an isolated administrative error rather than the result of a deficiency in the Foundation's internal control environm...
The Foundation, through its outsourced bookkeeping firm, acknowledges the audit observation regarding the duplicate reimbursement of lender expenditures. Management believes this was an isolated administrative error rather than the result of a deficiency in the Foundation's internal control environment. The Foundation maintains controls designed to ensure that expenditures charged to federal awards are reviewed for allowability, properly supported, and approved before submission for reimbursement. In this instance, a subsequent reimbursement from the lender was not identified through the Foundation's normal monitoring process. Management contacted the grantor and resolved the matter by applying other allowable expenditures to the federal award, thereby eliminating any duplicate recovery of federal funds. To further strengthen existing controls, the Foundation has enhanced its procedures to specifically track expenditures submitted for reimbursement under federal programs and monitor any subsequent refunds, credits, rebates, or reimbursements received from vendors or other third parties related to those expenditures. In addition, management will document a post-submission review process to identify vendor credits or recoveries received after reimbursement requests have been submitted and determine whether any adjustment to future reimbursement requests or repayment to the granting agency is required.
Contact Person Mark Kinzler, General Manager Corrective Action Plan All mileage charged to federal awards will be capped at the allowable federal rate to ensure any internal mileage rates exceeding this cap will be covered by non-federal or unrestricted funds. Completion Date Immediate
Contact Person Mark Kinzler, General Manager Corrective Action Plan All mileage charged to federal awards will be capped at the allowable federal rate to ensure any internal mileage rates exceeding this cap will be covered by non-federal or unrestricted funds. Completion Date Immediate
The Airport has incorporated the addition of electronic approvals for Airport Improvement Plan invoices within its existing procurement policy.
The Airport has incorporated the addition of electronic approvals for Airport Improvement Plan invoices within its existing procurement policy.
The Center for Advanced Defense Studies (C4ADS) acknowledges the finding related to disbursement approvals and the instance where required pre-disbursement authorization was not documented in the system. Existing C4ADS policy requires the approval of the budget manager before finance team approval o...
The Center for Advanced Defense Studies (C4ADS) acknowledges the finding related to disbursement approvals and the instance where required pre-disbursement authorization was not documented in the system. Existing C4ADS policy requires the approval of the budget manager before finance team approval on all credit card transactions — this sequence ensures that someone with operational authority verifies necessity and project relevance before charges are recorded. The accounting manager, as the administrator of the credit card online portal, has the ability to override/approve out of sequence with approval from the Senior Director of Operations. Due to staff turnover, the accounting manager inadvertently approved a charge out of cycle. Divvy does not permit retroactive correction of approval order and the accounting manager failed to appropriately document the event. As a result of this finding, C4ADS has implemented the following corrective actions: ● Strengthen Approval Controls: C4ADS added an additional review step where the Director of Finance and the Senior Director of Operations review all credit card charges to ensure all charges have two approvers. In cases where the charge has one approver, the Director of Finance confirms with the Senior Director of Operations that the final coding is appropriate prior month ending billing and month end reporting. ● Enhance Documentation and Monitoring: To demonstrate review, the Director of Finance communicates any anomalies to the Senior Director of Operations via Monday.com, C4ADS’ online ticket and tracking system. The Senior Director of Operations approval, or rejection, is logged in that system. ● Staff Training and Reinforcement: Additional training has been provided to the accounting department related to the approval override system and the appropriate documentation. These measures have been implemented and incorporated into ongoing financial processes to ensure all disbursements are properly authorized and documented.
Finding No.: 2025-003 Condition: During our testing of expenditures submitted for reimbursement under the Special Education Grant, we noted that expenditures included in reimbursement requests were difficult to reconcile to supporting documentation and the District's accounting records. Specifically...
Finding No.: 2025-003 Condition: During our testing of expenditures submitted for reimbursement under the Special Education Grant, we noted that expenditures included in reimbursement requests were difficult to reconcile to supporting documentation and the District's accounting records. Specifically, amounts recorded within the general ledger for certain purchased services and supplies and materials expenditures were incomplete and could not independently support the amounts claimed for reimbursement. District personnel were required to provide additional grant tracking schedules and other supporting records to reconcile the expenditures reported for reimbursement. Plan: Management agrees with the finding and will strengthen grant tracking and reconciliation procedures to ensure expenditures submitted for reimbursement are fully supported, accurately recorded in the general ledger, and readily traceable to the underlying documentation. Anticipated Date of Completion: 6/30/2027 Name of Contact Person: Scott, Assistant Superintendent for Business Services/CSBO Management Response: N/A
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Supplemental Nutrition Assistance Program Cluster & Medical Assistance Assistance Listing Numbers: 10.561 and 93.778 Federal Award Identification Numbers and Years: 252MN101S2514 – 2025 & 2505MN5ADM – 2025 Passed Thro...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Supplemental Nutrition Assistance Program Cluster & Medical Assistance Assistance Listing Numbers: 10.561 and 93.778 Federal Award Identification Numbers and Years: 252MN101S2514 – 2025 & 2505MN5ADM – 2025 Passed Through Entity: Minnesota Department of Human Services Pass Through Number: H55250010 & H58260061 & H55255048 Compliance Requirement: Allowable Activities Award Period: 2025 Recommendation: We recommend that the County review its procedures and control to ensure all RMS listings sent to the State properly exclude those necessary individuals no longer working in the programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will increase coordination with human resources to obtain data on employee turnover as timely as possible and also ensure that the listings are reviewed prior to submission going forward. Name of the contact person responsible for corrective action: Tiffinie Miller, Deputy Director of Employment & Economic Assistance Planned completion date for corrective action plan: December 31, 2026
The Administration of HONOR acknowledges the condition identified in the 2025 Financial Audit concerning the lack of allocation documentation. The following response outlines the steps the HONOR Administration, and Management will take to address these issues and prevent recurrence. During the 2025 ...
The Administration of HONOR acknowledges the condition identified in the 2025 Financial Audit concerning the lack of allocation documentation. The following response outlines the steps the HONOR Administration, and Management will take to address these issues and prevent recurrence. During the 2025 audit process, RBT identified the following condition: “Allocation of allowable costs were not properly documented.” HONOR Chief Financial Officer, along with the Finance Director, reviewed the condition and implemented the following corrective measure: -Ensure source documents are documented with G/L code, cost center and allocation method, if one is used. Documentation will be reviewed for completeness by the Staff Accountant. This will add an additional layer of documentation review prior to month end close. HONOR’s Chief Financial Officer along with the finance team take this audit finding seriously and are committed to strengthening internal controls to prevent future incidents. The steps outlined above will help us maintain compliance and ensure the proper use of resources. HONOR thanks RBT for their due diligence in bringing this matter to our attention.
Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully t...
Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal control process should include a formal way to document the review and approval of Fire Safety salary costs charged to the grant to provide evidence that internal controls are effectively designed and implemented and functioning in a timely manner throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The City has authorized a full-time grants specialist position within the Finance Department to oversee the administration of grants separate from the programming department. The City will strengthen internal controls over grant compliance by implementing formal policies and procedures for allowable costs, documentation, and review. All grant expenditures will be reviewed and approved by Finance prior to submission, with supporting documentation maintained for eligibility determinations. Name(s) of the contact person(s) responsible for corrective action: Rebecca Holden Planned completion date for corrective action plan: 6/30/2026
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