Corrective Action Plans

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Finding No.: 2024-006S Condition: Expenditures submitted for reimbursement did not match the functions in the approved budget. Plan: Management plans to implement procedures to ensure review of budget to actual expenditures. Anticipated Date of Completion: 6/30/2026 Name of Contact Person: Kreg Wesl...
Finding No.: 2024-006S Condition: Expenditures submitted for reimbursement did not match the functions in the approved budget. Plan: Management plans to implement procedures to ensure review of budget to actual expenditures. Anticipated Date of Completion: 6/30/2026 Name of Contact Person: Kreg Wesley, Executive Director of Finance and Operations
Finding No.: 2024-004S Condition: Some of the expenditures submitted for reimbursement were incorrect due to the District using purchase orders to prepare the expenditure reports, not amounts invoiced and paid, as well as reports not being reviewed properly. Plan: Management plans to implement proce...
Finding No.: 2024-004S Condition: Some of the expenditures submitted for reimbursement were incorrect due to the District using purchase orders to prepare the expenditure reports, not amounts invoiced and paid, as well as reports not being reviewed properly. Plan: Management plans to implement procedures to ensure that expenditure reports are prepared based on invoices paid and there is careful review of reports. Anticipated Date of Completion: 6/30/2026 Name of Contact Person: Kreg Wesley, Executive Director of Finance and Operations
View Audit 355704 Questioned Costs: $1
The School District should always reconcile its reimbursement requests with documented workpapers. The School Business Administrator will prepare and retain documentation for each and every reimbursement request, etc. School Business Administrator. 2024-2025 fiscal year.
The School District should always reconcile its reimbursement requests with documented workpapers. The School Business Administrator will prepare and retain documentation for each and every reimbursement request, etc. School Business Administrator. 2024-2025 fiscal year.
Condition During our testing, the College was unable to provide evidence of these Direct Loan reconciliations being performed monthly. Corrective Action(s): Community Christian College will include cash management for Direct Loans into our reconciliation process: Monthly meetings will be held each m...
Condition During our testing, the College was unable to provide evidence of these Direct Loan reconciliations being performed monthly. Corrective Action(s): Community Christian College will include cash management for Direct Loans into our reconciliation process: Monthly meetings will be held each month between the Financial Aid Department and the Accounting Department. Monthly reconciliation will begin May 2025.
Item: 2024-004 Assistance Listing Number: 64.024 Program: VA Homeless Providers Grant and Per Diem Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is require...
Item: 2024-004 Assistance Listing Number: 64.024 Program: VA Homeless Providers Grant and Per Diem Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit monthly requests for reimbursement. Controls should be in place to ensure review and approval of these monthly reports prior to submission to the granting agency. Condition: Of the nine reports tested, there was no evidence of management review or approval for one of the reports prior to submission to the granting agency. Name of Contact Person: Ana Pabon, Controller Phone Number: (602) 650-4852 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure reports are reviewed and approved prior to submission to the granting agency. This review and approval will be clearly documented.
Item: 2024-003 Assistance Listing Number: 64.033 Program: VA Supportive Services for Veteran Families Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is requir...
Item: 2024-003 Assistance Listing Number: 64.033 Program: VA Supportive Services for Veteran Families Program Federal Agency: U.S. Department of Veterans Affairs Pass-Through Agencies: n/a Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit monthly requests for reimbursement. Controls should be in place to ensure review and approval of these monthly reports prior to submission to the granting agency. Condition: For four reports tested, there was no evidence of management review or approval of the reports prior to submission to the granting agency. Name of Contact Person: Ana Pabon, Controller Phone Number: (602) 650-4852 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure reports are reviewed and approved prior to submission to the granting agency. This review and approval will be clearly documented.
Item: 2024-002 Assistance Listing Number: 93.566 Program: Refugee and Entrant Assistance - State/Replacement Designee Administered Programs Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Arizona Department of Economic Security Compliance Requirement: Reporting C...
Item: 2024-002 Assistance Listing Number: 93.566 Program: Refugee and Entrant Assistance - State/Replacement Designee Administered Programs Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Arizona Department of Economic Security Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit monthly requests for reimbursement. Controls should be in place to ensure review and approval of these monthly reports prior to submission to the granting agency. Condition: For seven reports tested, there was no evidence of management review or approval of the reports prior to submission to the granting agency. Name of Contact Person: Ana Pabon, Controller Phone Number: (602) 650-4852 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: The Organization will implement additional controls to ensure reports are reviewed and approved prior to submission to the granting agency. This review and approval will be clearly documented.
Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures. Management expects to present the policies to the board for approval at the May 2025 board meeting.
Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures. Management expects to present the policies to the board for approval at the May 2025 board meeting.
Southeastern Indiana REMC is aware there were two invoices submitted in error totaling $55,705. The result of this error was an overstatement of the amount eligible for reimbursement. Southeastern Indiana REMC has invoices eligible for reimbursement that were not submitted which offsets these errors...
Southeastern Indiana REMC is aware there were two invoices submitted in error totaling $55,705. The result of this error was an overstatement of the amount eligible for reimbursement. Southeastern Indiana REMC has invoices eligible for reimbursement that were not submitted which offsets these errors. Southeastern Indiana REMC, given these circumstances, does not believe they have requested total funds in excess of eligible costs.
View Audit 355278 Questioned Costs: $1
Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual wil...
Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual will be responsible for preparing reimbursement requests and subsequently submitting them; 4) provided extensive training to staff involved in the grant reimbursement procedures; 5) implemented a centralized grant tracking sheet to monitor billed amounts by category and date that is verified by two staff members; 6) implemented a quarterly internal audit review by a Board of Directors member with any findings reported to the Board of Directors for oversight.
View Audit 355230 Questioned Costs: $1
Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes tha...
Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.
Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. C...
Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. Conduct training to clarify and reinforce individual roles and responsibilities. Introduce periodic internal reviews to verify compliance with segregation protocols.
Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the G...
Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the Grant monthly reconciliation to Federal and State Funds Administration Office, Compliance officer reviews the reconciliation and Director of Federal Funds Administration determine needed funds to be requested. A new Enterprise Resource Planning (ERP) software it’s under implementation and will address this issue as part of the implementation process.
Update internal financial aid disbursement policies to require annual and mid-year reviews of Pell Grant schedules. Implement a compliance checklist for verifying disbursement amounts.
Update internal financial aid disbursement policies to require annual and mid-year reviews of Pell Grant schedules. Implement a compliance checklist for verifying disbursement amounts.
Finding 558936 (2024-001)
Significant Deficiency 2024
Management concurs with the finding. The specific occurrences will be reviewed to determine the cause. In addition, the procedure to facilitate drawdowns after funds have been disbursed will be reemphasized to ensure compliance with the three-business day disbursement rule from the time of drawdow...
Management concurs with the finding. The specific occurrences will be reviewed to determine the cause. In addition, the procedure to facilitate drawdowns after funds have been disbursed will be reemphasized to ensure compliance with the three-business day disbursement rule from the time of drawdown. The Student Financial Aid Office (SFA) will authorize Title IV awards and notify the Bursar and the Grants Account. The Bursar will facilitate disbursement of the funds to the students’ accounts and notify the Grants Accountant once the disbursement has been processed. The Grants accountant will facilitate the drawdown of funds after the funds have been disbursed. This will mitigate the potential recurrence of funds being drawn down prior to being disbursed to students’ accounts resulting in the potential for noncompliance with the three-day window.
Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Sta...
Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. As stated in the finding’s Cause of Condition, the Department did not fully implement the prior year’s corrective action plan during the audit period and did not have the reporting capabilities to track rate setting reviews for the entire audit period. To strengthen internal controls and documentation, and as part of the implementation of the new rate assessment process, the Department took the following corrective actions: • Published a new report in FamLink to assist rate assessors in identifying: o Six-month reviews that have not been performed timely. o Cases with upcoming rate assessments and due dates for reviews. • Implemented monthly tracking by supervisors to assist with internal controls and compliance. The Department continues to use the Plan, Do, Check, Act (continuous quality improvement process) to improve the accuracy of the new reports and provide additional training to staff as needed to ensure compliance with the requirement of performing six-month reviews of the reimbursement rates. The conditions noted in this finding were previously reported in finding 2023-067. Completion Date: June 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov
Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Statu...
Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action in progress Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. In response to the prior year audit finding, the Department has taken the following actions: • Between April and December 2023: o Filled two vacant contract staff positions dedicated to reviewing child welfare contracts to include family time visit payments. o Developed compliance audit plans for child welfare contracts and began fiscal monitoring of family time visit payments. o Implemented a new process for creating Sprout invoices from family time activity data to include the following:  Utilizing algorithms to identify reimbursements outside of reasonable amounts.  Requiring providers to submit additional documentation or explanation for flagged invoices.  Identifying duplicate billings using a re-run process.  Performing additional review and approval of invoices of the Network Administrator in Eastern Washington prior to release of payment. • Between January and March 2024: o Identified and implemented regional program approvals for Western Washington providers. o Implemented fiscal monitoring controls to ensure payments to providers for travel and family visits are allowable and adequately supported. o Utilized the Plan, Do, Check, Act (continuous quality improvement process) to add additional steps to the process to ensure payments were accurate. In response to the State Auditor’s Office (SAO) recommendations, the Department will: • Reconcile the identified payment exceptions and take appropriate action. • Review the implemented invoice and payment process and update training resources as needed. • Refine the compliance audit plans and update documentation for the contract monitoring process to ensure that SAO can review documentation for monitoring tasks completed. The conditions noted in this finding were previously reported in findings 2023-066, 2022-048, and 2021-040. Completion Date: Estimated July 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov
View Audit 355165 Questioned Costs: $1
Finding: The Department of Health did not have adequate internal controls over cash management and allowable cost requirements for the Epidemiology and Laboratory Capacity for Infectious Diseases program. Questioned Costs: Assistance Listing # 93.323 93.323 COVID-19 Status: Corrective actio...
Finding: The Department of Health did not have adequate internal controls over cash management and allowable cost requirements for the Epidemiology and Laboratory Capacity for Infectious Diseases program. Questioned Costs: Assistance Listing # 93.323 93.323 COVID-19 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees with the auditors’ assessment of inadequate internal controls to ensure automated draw calculations in the Grant Management System are accurate. The Department is working diligently with the Information Technology (IT) division to identify and correct cash draw report calculation errors until they are resolved. The Department has taken steps to ensure adequate internal controls over cash management and allowable cost requirements for the program, but disagrees with the auditors’ assessment of internal control weaknesses in the following areas: • Daily manual reconciliation - During the audit period, the Department identified a concern with the AFRS Data Distribution Services database reporting criteria. With the IT division’s assistance, the Department was able to identify the cause of the report errors and made corrections within the audit period. • Chart of account updates - The Department initially set up the coding structure based on the Office of Financial Management’s 23-25 biennium Expenditure Authority (EA) schedule. In October 2023, an updated EA schedule was released to correct one EA code. The Department addressed the coding error timely and processed a journal voucher to move recorded expenditures to the correct coding. • Cash Management Improvement Act (CMIA) - The Department spends on a first in, first out method and uses the previous year’s coding for all expenditures that occurred in the allowable period. The Department has controls in place to ensure cash draws are performed in line with the CMIA funding techniques and the payroll cycle. The Department will consult with the grantor to determine whether the questioned costs identified in the finding should be repaid. Completion Date: Estimated July 2025 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov
View Audit 355165 Questioned Costs: $1
Finding: The Department of Health did not have adequate internal controls over cash management and reporting requirements for the Immunization Cooperative Agreements program. Questioned Costs: Assistance Listing # 93.268 93.268 COVID-19 Amount $0 Status: Corrective action in progress Cor...
Finding: The Department of Health did not have adequate internal controls over cash management and reporting requirements for the Immunization Cooperative Agreements program. Questioned Costs: Assistance Listing # 93.268 93.268 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department agrees with the auditors’ assessment of inadequate internal controls to ensure automated draw calculations in the Grant Management System are accurate. The Department is working diligently with the Information Technology (IT) division to identify and correct cash draw report calculation errors until they are resolved. The Department has taken steps to ensure adequate internal controls over cash management and allowable cost requirements for the program, but disagrees with the auditors’ assessment of internal control weaknesses in the following areas: · Daily manual reconciliation - During the audit period, the Department identified a concern with the AFRS Data Distribution Services database reporting criteria. With the IT division’s assistance, the Department was able to identify the cause of the report errors and made corrections within the audit period. · Chart of account updates - The Department initially set up the coding structure based on the Office of Financial Management’s 23-25 biennium Expenditure Authority (EA) schedule. In October 2023, an updated EA schedule was released to correct one EA code. The Department addressed the coding error timely and processed a journal voucher to move recorded expenditures to the correct coding. Completion Date: Estimated July 2025 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov
Finding: The Department of Commerce did not have adequate internal controls to ensure payments to subrecipients were allowable, properly supported and met period of performance requirements for the Coronavirus State and Local Fiscal Recovery Funds. Questioned Costs: Assistance Listing # 21.0...
Finding: The Department of Commerce did not have adequate internal controls to ensure payments to subrecipients were allowable, properly supported and met period of performance requirements for the Coronavirus State and Local Fiscal Recovery Funds. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department maintains that there are effective internal controls over programs that are funded by the Coronavirus State and Local Fiscal Recovery Funds. Due to delayed audit planning and scoping, the auditors were unable to perform procedures to ascertain whether the Department established and followed internal controls to ensure compliance with program requirements. The Department plans to ensure sufficient time and resources are available for all future audits by performing the following steps: • Performing outreach to all federal programs to document internal controls for all applicable compliance requirements before the start of the next single audit cycle. • Working with the State Auditor’s Office earlier in the audit cycle to identify the audit scope for selected programs. • Providing support and guidance to programs selected for audit to ensure compliance with all internal controls and compliance requirements. The conditions noted in this finding were previously reported in findings 2023-027, 2023-028, and 2022-019. Completion Date: Estimated August 2025 Agency Contact: Gena Allen, CFE Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov
Finding: The Housing Finance Commission did not have adequate internal controls over earmarking requirements for the Homeowner Assistance Fund program. Questioned Costs: Assistance Listing # 21.026 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Commission h...
Finding: The Housing Finance Commission did not have adequate internal controls over earmarking requirements for the Homeowner Assistance Fund program. Questioned Costs: Assistance Listing # 21.026 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Commission has taken the following corrective actions to strengthen controls over earmarking requirements for the Homeowner Assistance Fund (HAF) program: • Developed a system to track and monitor expenditures in relation to overall program expenditures to ensure earmarking requirements are within allowable parameters. • Selected an increased percentage of approved, denied, and withdrawn HAF applications that have previously been reviewed by the contractor, as part of the Quality Control process, for a secondary review by program staff. • Reviewed a selection of HAF applications independent of the Quality Control process performed by the contractor. • Reviewed a selection of approved HAF applications prior to disbursing funds to confirm eligibility determinations are proper. The conditions noted in this finding were previously reported in finding 2023-023. Completion Date: October 2024 Agency Contact: Lucas Loranger Senior Finance Director 1000 Second Ave, Suite 2700 Seattle, WA 98104-3601 (206) 464-7139 Lucas.Loranger@wshfc.org
Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in Februar...
Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the hospital offline from processing claims. These two events had a negative and material impact on overall operating results as additional accounts receivable allowances for both contractual adjustments and bad debts were necessary at June 30, 2024. The negative impact on overall operations resulted in the Hospital not meeting the required 1.5 debt service coverage ratio and having less than 90 days of cash on hand at June 30, 2024. The Hospital did receive a waiver for from the USDA regarding not meeting these loan covenants for fiscal year 2024. Views of responsible officials and planned corrective actions The implementation of the new electronic health records created a delay in operational workflow processes which required vendor modifications and corrections to the system. This delayed submitting insurance claims for reimbursement continued throughout fiscal year 2024. Operations have now stabilized and the debt service coverage ratio is expected to be in compliance in fiscal year 2025. Hospital management notified its USDA representatives and received a waiver from the required 1.5 debt service coverage ratio and required 90 days of cash on hand for the period ended June 30, 2024. Anticipated completion date Ongoing
2024-003 – 10.558 – Child and Adult Care Food Program –Eligibility Condition Two providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State...
2024-003 – 10.558 – Child and Adult Care Food Program –Eligibility Condition Two providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Comments on the Finding Given the Organization’s limited size, it is not always feasible to fully segregate the duties surrounding the meal claims processes. However, in order to mitigate errors, steps have been taken to implement checks within those processes. Action Taken Whenever possible, an employee other than the Director will prepare the claims. The Director of the Organization will later review the claims for accuracy and compare the claim numbers in both the excel spreadsheet and the Little Organizer program to ensure their correctness.
Finding 558330 (2024-067)
Significant Deficiency 2024
The RIEMA Recovery staff will conduct an additional review of all projects prior to obligation including both small and large projects. This review will include not only that the state required documentation is included but will also review the FEMA final validation report submitted with the projec...
The RIEMA Recovery staff will conduct an additional review of all projects prior to obligation including both small and large projects. This review will include not only that the state required documentation is included but will also review the FEMA final validation report submitted with the project. We acknowledge the errors which were reported by the State audit review of project number 694201 for federal disaster declaration DR-4505-RI. The agency will contact the Office of Housing and Community Development of the finding and they will be required to reimburse FEMA the unallowable costs. Anticipated Completion Date: RIEMA is implementing this immediately for all project reviews. Contact Person: Lawrence Macedo, Recovery Branch Chief, Rhode Island Emergency Management Agency lawrence.macedo@ema.ri.gov
View Audit 355126 Questioned Costs: $1
Finding 558328 (2024-066)
Significant Deficiency 2024
This audit finding refers to retroactive Medicaid billing from BHDDH for dates of service in 2022 and 2023 once the IMD status was removed from ESH. That provider type currently does not require the Medicare information to be submitted to EOHHS for processing. They bill with a type of bill and if ...
This audit finding refers to retroactive Medicaid billing from BHDDH for dates of service in 2022 and 2023 once the IMD status was removed from ESH. That provider type currently does not require the Medicare information to be submitted to EOHHS for processing. They bill with a type of bill and if there is eligibility on file for Eleanor Slater, the claim is paid. EOHHS will pursue a project to correct this finding. Project PH0630 - OI Edit for ESH was created and is being worked on by Gainwell and the State. The Project Charter states that the state must have controls in place to ensure that claims from the State Hospital, including Eleanor Slater Hospital (ESH) are reimbursed by Medicaid as the payer of last resort. Meetings, requirements gathering, and business designs are ongoing. The Business Design is anticipated to be completed by end of April 2025. Anticipated Completion Date: To Be Determined Contact Person: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov
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