Corrective Action Plans

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Action taken in response to finding: The organization has implemented a procedure to review and approve required reports prior to submission.
Action taken in response to finding: The organization has implemented a procedure to review and approve required reports prior to submission.
Action taken in response to finding: The organization has worked with appropriate staff to provide further clarification on sliding fee intake and approval process.
Action taken in response to finding: The organization has worked with appropriate staff to provide further clarification on sliding fee intake and approval process.
Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies...
Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies and procedures for the review and approval of journal entries, adjustments to expenditures, and account reconciliations, to ensure expenditures reported to granting agencies are complete, accurate, allowable, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment -Once we were made aware of this finding through the audit, we began thinking of the most efficient way to document the Board’s knowledge and approvals of journal entries, including adjustments to expenditures and account reconciliations. Root Cause -HOPE is currently revising all policies and procedures. This was HOPE’s first federal single audit, so once we heard of the finding we prioritized revisions of fiscal policies and procedures to address the finding. Action Taken- The first board meeting after learning of this finding will be held on July 27th, 2026. Beginning with that meeting, the Board’s approval of the statement of activity detail, consisting of all charges and journal entries entered into HOPE’s accounting system since the date of the last Board meeting, will be approved via motion and seconded and noted as such in the Board meeting minutes. Most journal entries made during the month are currently entered into the system by HOPE’s CPA. The remaining journal entries are entered by HOPE’s Executive Director. To ensure that the Board is aware of the adjustments made in the system, all journal entries made since the last Board meeting will be approved via a motion and a second as a separate agenda item to ensure that the Board is reviewing these items particularly. All approvals will be noted in the Board meeting minutes. The list of journal entries viewed during the meeting will be initialed by a Board member and kept on file as documentation of internal controls.
Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was app...
Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was applied Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Billing Team Planned Corrective Action: The Organization revised its sliding fee discount policies, implemented centralized documentation tracking, and enhanced staff training related to eligibility determination and documentation requirements. Monitoring procedures, including periodic supervisory review, were established to ensure compliance. Anticipated Completion Date: Implemented and in progress. Due to the timing of the prior year’s audit completion, the Organization did not have time to complete a full monitoring cycle prior to audit testing.
Finding: 2025-002 Condition Found: The FAC filing for the fiscal year ended March 31, 2025, was submitted late. Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Board of Directors Planned Corrective Action: Management agrees with the finding. Due to the timin...
Finding: 2025-002 Condition Found: The FAC filing for the fiscal year ended March 31, 2025, was submitted late. Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Board of Directors Planned Corrective Action: Management agrees with the finding. Due to the timing of prior year audit completion and associated late filing, the Organization did not have sufficient time within the current audit period to fully implement and demonstrate the effectiveness of corrective actions related to audit timeliness. As a result, this finding has reoccurred. The Organization has strengthened oversight by formalizing a compliance calendar, assigning clear ownership of Single Audit and Federal Audit Clearinghouse deadlines, and incorporating milestone tracking into finance operations and executive oversight processes. In addition, continued fractional CFO support provides enhanced accountability and monitoring of financial reporting timelines. These actions build upon prior year corrective efforts and are designed to ensure timely and compliant filings going forward. Anticipated Completion Date: FY2026 filing cycle.
SF-425 Reporting Planned Corrective Action: American Bird Conservancy will prepare, review and maintain documented comparison of general ledger details to the SF-425 reports prepared. Person Responsible for Corrective Action Plan: Angela Modrick, Vice President of Finance Anticipated Date of Complet...
SF-425 Reporting Planned Corrective Action: American Bird Conservancy will prepare, review and maintain documented comparison of general ledger details to the SF-425 reports prepared. Person Responsible for Corrective Action Plan: Angela Modrick, Vice President of Finance Anticipated Date of Completion: Implemented
FINDING 2025-001 Internal Control over Compliance and Compliance with Reporting (Significant Deficiency and Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will strengthen its procedures for collecting, maintaining, retaining, and reviewi...
FINDING 2025-001 Internal Control over Compliance and Compliance with Reporting (Significant Deficiency and Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will strengthen its procedures for collecting, maintaining, retaining, and reviewing supporting documentation for performance metrics reported to the U.S. Department of Education. Going forward, every reported metric will be supported by source documentation that is retained, readily accessible, and available for review upon request. The University will implement the following corrective actions: • Develop and document procedures identifying the source documentation required to support each reported performance metric. • Establish a centralized electronic repository for performance-metric documentation. Staff submitting a metric write-up will be required to submit the associated raw data file with it, so the source documentation is captured at the point of submission rather than reconstructed later. • Implement a review process requiring verification of supporting documentation prior to submission of reports. • Provide training to personnel responsible for collecting, compiling, and reporting performance metrics regarding documentation and record-retention requirements. • Periodically review supporting documentation to ensure compliance with Department of Education reporting requirements and federal record-retention standards. Together, these actions will address the documentation gap identified in the finding and establish a sustainable process to support future reporting cycles. Individual(s) Responsible for Corrective Action Plan: Caroline Kobek Pezzarossi, Dean of Curriculum, Outreach, Resources and Effectiveness Khadijat Rashid, Provost Estimated Completion Date: September 30, 2026
Federal Award Finding 2025-005 - Material Weakness, Material Non-Compliance - Special Tests and Provisions, Surplus Cash and Distributions to Owners or Affiliates Finding: During the fiscal year ended December 31, 2025, project management did not prepare or document a surplus cash calculation in acc...
Federal Award Finding 2025-005 - Material Weakness, Material Non-Compliance - Special Tests and Provisions, Surplus Cash and Distributions to Owners or Affiliates Finding: During the fiscal year ended December 31, 2025, project management did not prepare or document a surplus cash calculation in accordance with HUD requirements, nor did management implement controls to review, approve, or retain documentation supporting the required calculation. Recommendation: Management should establish and implement formal policies and procedures to ensure that surplus cash is independently calculated in accordance with HUD requirements and the applicable HUD Regulatory Agreement. Such procedures should include preparation of a documented surplus cash calculation at each required reporting period using HUD-prescribed criteria; Independent review and approval of the surplus cash calculation by appropriate management personnel or, where applicable, the court-appointed receiver; and retention of supporting documentation sufficient to demonstrate compliance with HUD restrictions on the use and distribution of project funds. Management should coordinate with the court-appointed receiver and HUD to ensure that surplus cash determinations are performed consistently and in compliance with program requirements going forward. Action Taken: Management acknowledges the finding related to the absence of an independently prepared and documented surplus cash calculation. During the fiscal year ended December 31, 2025, the Organization operated in an environment of financial distress, limited staffing resources, and evolving oversight responsibilities, which contributed to informal and undocumented procedures related to surplus cash determinations. As disclosed in the financial statements, the Organization became subject to a court-appointed receivership. Following the appointment of the receiver, responsibility for financial oversight, including compliance with HUD cash flow and surplus cash requirements, has transitioned to the receiver in coordination with HUD. The receiver and management are evaluating HUD requirements related to surplus cash calculation. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: Not started
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: S2505MN5ADM - 2025 Award Period: 2025 Type of Finding: • Material Weakness in Internal Control over Compliance Recomme...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: S2505MN5ADM - 2025 Award Period: 2025 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: CLA recommend that the County implement sufficient internal control procedures to ensure properly documented review of all reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement the recommendation immediately. Name of the contact person responsible for corrective action plan: Loraine Rupp, Sherburne County Auditor-Treasurer Planned completion date for corrective action plan: Already corrected
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: S2505MN5ADM - 2025 Award Period: 2025 Type of Finding: • Significant Deficiency in Internal Control over Compliance • ...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: S2505MN5ADM - 2025 Award Period: 2025 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Recommendation: CLA recommend that the County implement sufficient internal control procedures to ensure LCTS payments are made within 30 days of receipt. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement the recommendation immediately. Name of the contact person responsible for corrective action plan: Loraine Rupp, Sherburne County Auditor-Treasurer Planned completion date for corrective action plan: Already corrected
Management has strengthened internal controls over payroll processing and timecard approvals. Effective January 1, 2026, prior to processing each payroll, the Organization downloads a complete file of timesheet hours by employee, hour type, and cost center and compares the data against the contractu...
Management has strengthened internal controls over payroll processing and timecard approvals. Effective January 1, 2026, prior to processing each payroll, the Organization downloads a complete file of timesheet hours by employee, hour type, and cost center and compares the data against the contractual allocation plan. Any exception or deviation identified through this review is routed to the responsible supervisor for resolution before payroll is processed. Supervisors are responsible for correcting and approving timecard errors or documenting confirmation that the timesheet accurately reflects the work performed. This process is designed to ensure that timecards are reviewed, approved, and retained in support of payroll costs charged to federal awards. Management will continue to evaluate this control and implement enhancements as needed as part of its ongoing commitment to continuous quality improvement.
Corrective Action Plan (CAP) Disagreement with Audit Finding: None Actions Planned in Response to Finding: The City is aware of the limited segregation of duties and will continue to review internal controls and make changes when they can be made. Official Responsible for Ensuring CAP: Amy Mell, Cit...
Corrective Action Plan (CAP) Disagreement with Audit Finding: None Actions Planned in Response to Finding: The City is aware of the limited segregation of duties and will continue to review internal controls and make changes when they can be made. Official Responsible for Ensuring CAP: Amy Mell, City Administrator Planned Completion Date for CAP: December 31, 2026 Plan to Monitor Completion of CAP: City Council
Corrective Action Plan (CAP) Disagreement with Audit Finding: None Actions Planned in Response to Finding: The City is aware of the lack of expertise to ensure all disclosures required by GAAP are included in the financial statements, however, the City will review the notes for accuracy and compare ...
Corrective Action Plan (CAP) Disagreement with Audit Finding: None Actions Planned in Response to Finding: The City is aware of the lack of expertise to ensure all disclosures required by GAAP are included in the financial statements, however, the City will review the notes for accuracy and compare balances in the financial report to the general ledger and other City reports prior to issuance of the financial statements. Official Responsible for Ensuring CAP: Amy Mell, City Administrator Planned Completion Date for CAP: December 31, 2026 Plan to Monitor Completion of CAP: City Council
Corrective Action Plan (CAP) Disagreement with Audit Finding: None Actions Planned in Response to Finding: The City will continue to review and approve adjusting journal entries as proposed by the auditor, as well as taking responsibility for the audited financial statements. Official Responsible fo...
Corrective Action Plan (CAP) Disagreement with Audit Finding: None Actions Planned in Response to Finding: The City will continue to review and approve adjusting journal entries as proposed by the auditor, as well as taking responsibility for the audited financial statements. Official Responsible for Ensuring CAP: Amy Mell, City Administrator Planned Completion Date for CAP: December 31, 2026 Plan to Monitor Completion of CAP: City Council
Finding 2025-003 a. Name of Contact Person Responsible for Corrective Action: Jeff Jones, Business Manager b. Corrective Action Planned: Additional Training has been provided during professional development sessions to keep in the forefront the importance of preventing conflicts of interest as well ...
Finding 2025-003 a. Name of Contact Person Responsible for Corrective Action: Jeff Jones, Business Manager b. Corrective Action Planned: Additional Training has been provided during professional development sessions to keep in the forefront the importance of preventing conflicts of interest as well as possible nepotism as defined by Miss. Code Ann. § 25-1-53 and Miss. Code Ann. § 25-4-105(1). New hires are required to disclose possible conflicts of interest during the application process. Department heads making recommendations for hire are required to disclose if they are related to the person they are recommending for hire. c. Anticipated Completion Date: Training was provided in February, 2026, after disclosures were added to the employment applications in the human resource software asking the applicant to disclose if they are aware if they are related to anyone currently working in the district. As soon as the violation was identified, the Office of Child Nutrition at the Mississippi Department of Education was notified
1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Administration will add additional internal controls where the benefit exceeds the cost. 3. Official Responsible for Ensuring CAP: Michael Marshall, Board Se...
1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Administration will add additional internal controls where the benefit exceeds the cost. 3. Official Responsible for Ensuring CAP: Michael Marshall, Board Secretary/Treasurer, is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP: The planned completion date for the CAP is June 30, 2026. 5. Plan to Monitor Completion of CAP: The School Board will be monitoring this CAP.
EOHHS is in agreement with these findings and is in the process of working with Gainwell and its managed care partners to address these discrepancies. The providers that were not properly subjected to EOHHS’s enrollment processes were out of network providers within one of the managed care plans’ na...
EOHHS is in agreement with these findings and is in the process of working with Gainwell and its managed care partners to address these discrepancies. The providers that were not properly subjected to EOHHS’s enrollment processes were out of network providers within one of the managed care plans’ national network provider management system. These providers have been incorrectly included in provider network data as this managed care plan is in the process of end-dating these providers, which will resolve this discrepancy. EOHHS has reorganized Provider Enrollment oversight functions under the Office of Program Integrity (OPI) in alignment with federal standards, and as such will continue to audit and monitor enrollment files to ensure compliance with state and federal requirements. OPI is formalizing a process to swiftly terminate providers who have lost their licensure, as well as randomly auditing enrollment files to ensure proper licensure. Additionally, EOHHS will begin collecting DCYF licensure data as required. Anticipated Completion Date: December 31, 2026 Contact Persons: Nicholas James, Implementation Director of Policy and Programs, Executive Office of Health and Human Services nicholas.james@ohhs.ri.gov Rob Tingle, Chief of Program Analytics, Executive Office of Health and Human Services robert.tingle@ohhs.ri.gov
2025-032a: MMIS system access is controlled via an electronic system called GainwellNow. An MMIS access request form must be completed by the requestor, signed by that individual and their supervisor, and then sent to the Systems Group staff members who are responsible for approving or denying acces...
2025-032a: MMIS system access is controlled via an electronic system called GainwellNow. An MMIS access request form must be completed by the requestor, signed by that individual and their supervisor, and then sent to the Systems Group staff members who are responsible for approving or denying access requests. The Systems Group will sign the request form and approve the request within GainwellNow and the requestor will be granted access. The GainwellNow system also generates and sends email notifications to the Systems Group Administrators notifying them of a pending access request if the requestor enters it into GainwellNow directly. From there, the same approval/denial process occurs. If an individual has not logged into MMIS for 30 days, then they require a password reset in order to regain access. Those password reset requests create system generated emails that are sent to the Systems Group Admins for approval or denial. After 60 days of inactivity, the individual is locked out and cannot access the MMIS without requesting and obtaining approval of the password reset. If someone leaves state employment, then the Systems Group Admins submit an access deletion request into GainwellNow, deleting the account completely. Gainwell Technologies also sends monthly access reports to the Systems Group for review and confirmation that account deletion requests were completed as submitted. Additionally, Gainwell sends monthly “New or Deleted Users” reports to the Systems group for review. For IT security, the Systems Group receives and reviews the following reports: · RI-CDM-ASQC-Security-Report · RI-CSHARP-ASQC-Security-Report · RI-Java-ASQC-Security Report · RI-XIX-DR Exercise Scope · RI-XIX-DR Executive Summary Report 2025-032b: The Arc-Ampe (formerly called MARS-E) third party assessment is underway. Security scanning and testing is complete, and security controls have been evaluated. Final report is due by 6/30/2026. Remediation of legitimate vulnerabilities is underway and defects are tracked on the RIBridges POAM. 2025-032c: EOHHS/Medicaid will work collaboratively with ETSS and their vendors to proactively assess critical risk areas planned for the review year. 2025-032d: For RIBridges, SOC engagements occur every other year. A third-party Attestation of the Arc-Ampe controls occurs annually. The state can evaluate the results of this year’s upcoming SOC audit to determine if an increased frequency of the SOC is needed. Anticipated Completion Dates: 2025-032a: EOHHS believes this item to be complete and will defer to OAG for resolution of this finding. 2025-032b: High findings – 30 days, moderate findings – 90 days, low findings – 365 days. July 31, 2027. 2025-032c: Ongoing 2025-032d: December 31, 2026 Contact Persons: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov Deb Merrill, Security Officer, ETSS, Department of Administration deb.merrill@doit.ri.gov Brian Tichenor, Medicaid Systems Manager, Executive Office of Health and Human Services brian.tichenor@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
2025-056a: Management and budget will work with team members to allow for proper separation of responsibilities, as well as, ensure that proper training is provided. 2025-056b: MARVIN will address this issue as the department will not be waiting 45 days after the QE for the RPT54. It is going to be ...
2025-056a: Management and budget will work with team members to allow for proper separation of responsibilities, as well as, ensure that proper training is provided. 2025-056b: MARVIN will address this issue as the department will not be waiting 45 days after the QE for the RPT54. It is going to be more real time. MARVIN is proposed to go live at the end of CY2027 which means that we will have this issue for both 2026 and 2027 fiscal close. Anticipated Completion Date: Ongoing Contact Person: Kimberly Reynolds, Associate Director of Financial Management, Department of Children, Youth and Families kim.reynolds@dcyf.ri.gov
Management agrees with the finding regarding health and safety requirements for timely unannounced monitoring visits. While several providers identified in the audit did receive a monitoring visit within 60 days of the annual due date, the Licensing Department experienced delays in completing some m...
Management agrees with the finding regarding health and safety requirements for timely unannounced monitoring visits. While several providers identified in the audit did receive a monitoring visit within 60 days of the annual due date, the Licensing Department experienced delays in completing some monitoring visits due to staff shortages and employee leave. To address the backlog and prioritize oversight activities, The Department has implemented a team-based prioritization approach rather than individual caseload management. This approach allows the unit to prioritize providers with the greatest need for monitoring and ensure that available resources are directed toward the highest-risk areas. The Department is actively working to increase staffing capacity within the unit. The Department is currently onboarding four new staff members to address existing vacancies and has recently received two additional FTE positions to further support monitoring activities. The unit continues to manage the impact of two staff members being out on extended medical leave with undetermined return dates; however, despite these staffing challenges, the unit has completed 423 monitoring visits since January 1, 2026. The Department will continue to monitor progress toward eliminating the backlog, strengthening system processes, and ensuring timely completion and documentation of required unannounced monitoring visits. DHS has also implemented enhanced monitoring capabilities within RISES. The system now generates automated notifications to the Licensing Department at established intervals before monitoring visits are due for both child care centers and family child care programs. These automated reminders strengthen monitoring workflows, improve oversight of upcoming monitoring requirements, and support the timely completion of unannounced visits. In addition, RISES has strengthened the Department's ability to consistently track provider compliance, document corrective actions, and identify providers requiring increased oversight. These enhanced monitoring tools have improved accountability by providing greater visibility into provider compliance and enabling licensing staff to more effectively prioritize regulatory activities based on risk. Management does not concur with the findings related to corrective action plans and inspections but has implemented various enhancements to support streamlined processes in these areas since the audit time period. As discussed during the audit, several factors affect the timing and applicability of required inspections and do not necessarily indicate provider noncompliance. For example, radon testing may only be conducted during specific times of the year. Providers may make timely efforts to schedule testing but be unable to obtain an inspection due to limited inspector availability or because the request falls outside the allowable testing window. In these circumstances, DHS does not consider the provider to be out of compliance. Similarly, fire inspections must be completed by the State Fire Marshal's Office. In recent years, staffing challenges have affected the ability to complete inspections within standard timeframes, despite providers' efforts to obtain them. When a provider has a history of compliant fire inspections, the Licensing Department accepts documentation demonstrating the provider's attempt to schedule the required inspection and may proceed with license renewal while awaiting the inspection. Additionally, lead inspections are not required for facilities constructed after the applicable regulatory date and are not required for school-age programs. During the audit process, DHS identified several providers flagged for inspection concerns that appeared to fall into one or both of these exempt categories. To strengthen compliance monitoring, RISES now generates automated notifications beginning 90 days before inspection expiration dates. DHS has already observed improved provider responsiveness in renewing required inspections and will continue to use RISES to proactively monitor inspection status and work with providers to maintain current inspection documentation. Regarding corrective action plans, under the previous licensing system, providers submitted corrective action plans and supporting documentation directly to the assigned licensor. This is typically through email. As a result, documentation was often maintained outside of the licensing system and may not have been consistently reflected in the inspection record. If the corrective action or follow-up information was not documented within the system or the inspection status was not updated, the report could continue to appear as pending, even when the provider had submitted the required information. To address this limitation, DHS intentionally designed the RISES system to centralize the corrective action process. Following an inspection, the report is issued to the provider through RISES, where the provider is required to submit a corrective action plan directly within the system. The corrective action plan is then routed to DHS for review and approval, creating a documented workflow and improving the consistency and completeness of recordkeeping. If a provider does not submit a corrective action plan, DHS is able to identify the outstanding item within RISES and determine whether a follow-up inspection is warranted to verify that the noncompliance has been addressed. Currently, DHS prioritizes follow-up for high-risk noncompliance, including issues related to facilities, background checks, staff-to-child ratios and supervision, and infant and toddler care. Anticipated Completion Date: This corrective action has since been completed through the implementation of the 2026 requirement that all regulated providers utilize RISES. Contact Person: Nicole Chiello, Associate Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov
The RI Works unit has completed a comprehensive revision of the State's Work Verification Plan. The revised plan is currently undergoing an internal quality review to ensure consistency, appropriate terminology, removal of legacy references, and alignment with current program operations. Upon comple...
The RI Works unit has completed a comprehensive revision of the State's Work Verification Plan. The revised plan is currently undergoing an internal quality review to ensure consistency, appropriate terminology, removal of legacy references, and alignment with current program operations. Upon completion of this review, the Work Verification Plan will be submitted to the Administration for Children and Families (ACF) for review and approval. To strengthen ongoing compliance with the Work Verification Plan, DHS will implement documented supervisory quality assurance reviews to verify work participation documentation, ensure compliance with established verification procedures, and confirm the accuracy of work participation data reported to ACF. In addition, the Multi-Program Eligibility Review Tool referenced in Finding 2025-046 will be incorporated into the Department's supervisory monitoring process. Supervisors will utilize the tool to conduct routine case reviews to verify eligibility accuracy, work verification documentation, and compliance with federal and State requirements. Review results will be used to identify trends, provide targeted coaching, and strengthen ongoing quality assurance activities. Anticipated Completion Date: October 1, 2026 Contact Person: Donna Rook, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov
The Department has worked with the ACF Data Unit and the system vendor to identify the required coding corrections and implement updates consistent with current ACF reporting guidance. System enhancements are underway to address the identified coding issues. The Department will also implement a docu...
The Department has worked with the ACF Data Unit and the system vendor to identify the required coding corrections and implement updates consistent with current ACF reporting guidance. System enhancements are underway to address the identified coding issues. The Department will also implement a documented quality assurance review process for each quarterly ACF-199 submission. Prior to submission, designated staff will validate report data against RIBridges case information, verify compliance with current ACF reporting guidance, and document supervisory review and approval. DHS has incorporated updated ACF reporting guidance into its reporting procedures and will provide training and technical assistance to staff responsible for preparing and reviewing ACF-199 reports to ensure consistent application of federal reporting requirements. The Department will also obtain documentation on a quality assurance review for the quarterly 199 reports. Anticipated Completion Date: Ongoing Contact Person: Nikolaos Petropoulos, Data Analyst III, Office of Performance Analytics & Continuous Improvement, Department of Human Services nikolaos.petropoulos@dhs.ri.gov
The Department has developed a comprehensive Multi-Program Eligibility Review Tool designed to strengthen supervisory oversight and improve consistency in eligibility determinations across public assistance programs. The tool, currently in final development, will be implemented statewide and utilize...
The Department has developed a comprehensive Multi-Program Eligibility Review Tool designed to strengthen supervisory oversight and improve consistency in eligibility determinations across public assistance programs. The tool, currently in final development, will be implemented statewide and utilized by supervisory staff as part of routine quality assurance and case review activities. The review tool has been expanded to specifically address the documentation deficiencies identified through the audit, including verification of citizenship and identity for all household members, residency documentation, hardship determinations, employment plans, initial applications, recertifications, interim reports, and required case documentation maintained within RIBridges. In addition, the Department has revised the DHS-2H Hardship Request form to clearly document hardship eligibility criteria and require participant attestation for the applicable hardship category, strengthening documentation supporting eligibility determinations. To further strengthen internal controls, the Department will: • implement supervisory case reviews using the Multi-Program Review Tool; • provide staff training on documentation and eligibility requirements; • monitor review results to identify recurring trends and implement corrective coaching where needed; and • incorporate findings into ongoing quality assurance and program monitoring to ensure sustained compliance with eligibility documentation requirements. These actions are intended to strengthen supervisory oversight, improve documentation compliance, and reduce the risk of unsupported eligibility determinations identified in the audit. Anticipated Completion Date: Fall of 2026 Contact Persons: Donna Rook, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov Vania Rebollo, Assistant Administrator Family and Children Service, Department of Human Services Vania.Rebollo@dhs.ri.gov
Initially, the Pandemic Recovery Office used contractors to help with the ERA 2 program data validation function for U.S. Treasury reporting purposes. PRO decided to directly incorporate the ERA 2 data validation process into PRO’s operations using State personnel rather than contractors. At this tr...
Initially, the Pandemic Recovery Office used contractors to help with the ERA 2 program data validation function for U.S. Treasury reporting purposes. PRO decided to directly incorporate the ERA 2 data validation process into PRO’s operations using State personnel rather than contractors. At this transition point, PRO staff became aware that inconsistencies existed in the demographic categorization of ERA 2 participant data. PRO hired a consultant, who along with PRO staff, developed a Power BI model and standardized the logic associated with the assessment of the ERA 2 participant data. Once PRO standardized the data across ERA 2 participants, PRO updated the ERA 2 participant demographic data in the final ERA 2 report to U.S. Treasury to reflect the new data standardization process PRO implemented. The standardization of the ERA 2 participant demographic data corrected the earlier reports submitted to U.S. Treasury. The final ERA 2 report, as is the case with all U.S. Treasury reports, is cumulative as of the date of submission of the report. The final ERA 2 report covered the entire period of performance for the ERA 2 program, the end point of which was September 30, 2026. Anticipated Completion Date: January 26, 2026, the date on which the final ERA 2 report was submitted. Contact Persons: Paul Dion, Director, Pandemic Recovery Office, Department of Administration paul.l.dion@doa.ri.gov Brianna Ruggiero, Chief of Staff, Pandemic Recovery Office, Department of Administration brianna.ruggiero@doa.ri.gov
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