Corrective Action Plans

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Finding 2024-004, Documentation of Case Note Review (Assistance Listing 16.575) Persons Responsible Katrina Schermerhorn, Assistant Executive Director, Children, Youth & Family Services Comment: Per 2 CFR § 200.303(a) (Internal Controls). All recipient and subrecipient must establish, document, an...
Finding 2024-004, Documentation of Case Note Review (Assistance Listing 16.575) Persons Responsible Katrina Schermerhorn, Assistant Executive Director, Children, Youth & Family Services Comment: Per 2 CFR § 200.303(a) (Internal Controls). All recipient and subrecipient must establish, document, and maintain effective internal control over the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Response: Intake forms and Case numbers- In accordance with the requirements outlined by OVS, client names must be excluded from all documentation. Instead, client identification will be represented solely by client numbers. To maintain the integrity and accuracy of client information, an internal CVASSP tracking log designated for internal use only will be maintained, containing both client names and their corresponding numbers. The program coordinator will conduct monthly reviews of this log to ensure the information remains accurate and up-to-date. Audit Forms- Client folders undergo rigorous monitoring to maintain high standards of documentation. Each week, the program supervisor conducts a thorough review of all new cases to ensure that all required documentation is accurately completed. Additionally, the program coordinator performs quarterly audits of a random selection of files to assess compliance with the standards set forth by OVS and WJCS. Following established recommendations, a review form will be added to each case record upon completion of the review process. This form will include the date of the review and the signature of the reviewer, providing clear and transparent documentation of compliance efforts. This systematic approach not only enhances accountability but also fosters continuous improvement in case management practices. Estimated Completion Date: 4/1/2025
Finding 2024-002, Timesheet – Timekeeping (Assistance Listing 16.575 and 93.696) Persons Responsible: Irene Math, Chief Financial Officer, Jessica Schneibolk Controller Comment: Per 2 CFR § 200.430 requires that the distribution of salary and wages charged to federal awards be based on actual em...
Finding 2024-002, Timesheet – Timekeeping (Assistance Listing 16.575 and 93.696) Persons Responsible: Irene Math, Chief Financial Officer, Jessica Schneibolk Controller Comment: Per 2 CFR § 200.430 requires that the distribution of salary and wages charged to federal awards be based on actual employee activity as reflected in personnel activity reports (timesheets), prepared after-the-fact, and includes the total activity for which employees were compensated. Response: In January 2025, WJCS implemented an automated time and attendance system for staff to track time which integrates with the payroll and financial systems to ensure appropriate allocations to Federal awards. Prior to implementation of the new system weekly manual timesheets were used to track staff time and attendance on Federal contracts. However, these manual timesheets were not integrated into a standard agency-wide payroll processing system. The new system enhancements to payroll tracking will allow WJCS to completely and accurately allocate payroll costs to grants with fewer mechanical steps which increase the risk of miscalculations. Estimated Completion Date: The agency-wide time and attendance system was implemented in January 2025.
Finding 2024-001, Expense Allocations - Financial Management (Assistance Listing 16.575) Persons Responsible: Irene Math, Chief Financial Officer, Jessica Schneibolk, Controller Comment: Per 2 CFR § 200.302(a) (Financial Management), all recipient and subrecipient financial management systems mus...
Finding 2024-001, Expense Allocations - Financial Management (Assistance Listing 16.575) Persons Responsible: Irene Math, Chief Financial Officer, Jessica Schneibolk, Controller Comment: Per 2 CFR § 200.302(a) (Financial Management), all recipient and subrecipient financial management systems must be sufficient to track expenditures and establish that funds have been used in accordance with federal statutes, regulations, and the terms and conditions of the federal award. Response: WJCS acknowledges the audit finding regarding the misallocation of occupancy expense. We are committed to strengthening our internal controls by implementing a more structured review process for expense allocations and will provide staff training on accurate cost classification. In addition, we will formalize documentation procedures to support updated automated expense allocations. Estimated Completion Date: The additional review procedures will be implemented by March 31, 2025, and will work to update financial system expense allocations by June 1, 2025
2024-004 - Special Tests – Internal Control and Compliance over Housing Quality Standards Inspections (Material Weakness) Condition: During the Fail Inspection Testing, we found five (5) instances out of nine (9) in which the City did not conduct the Housing Quality Standards (HQS) failed inspecti...
2024-004 - Special Tests – Internal Control and Compliance over Housing Quality Standards Inspections (Material Weakness) Condition: During the Fail Inspection Testing, we found five (5) instances out of nine (9) in which the City did not conduct the Housing Quality Standards (HQS) failed inspection follow-up in a timely manner. Specifically: • For two (2) samples, the reinspection was not performed within 30 days of the failed inspection, and the deficiencies were not confirmed to be resolved within the required timeframe. • For one (1) sample, the inspection checklist indicated a failed inspection, while the inspector erroneously documented and processed it as a passed inspection, meaning o reinspection was performed. • For one (1) sample, the reinspection was not performed, and no documentation was found to verify the follow-up inspection. We also noted one (1) additional instance out of forty (40) samples from Eligibility Cross Testing where the failed inspection did not have any record of a follow-up reinspection. Management concurs. Corrective Actions: Staff will continue to utilize consulting services to complete the necessary HQS inspections during the staff turnover. The City will also strengthen the internal controls for inspections to complete them timely and within compliance. Name of Responsible Person: Ron Garcia, Director of Community Development Ryan Mulligan, Housing Manager
Planned Corrective Action: The two employees are no longer with America’s Finest Charter School (AFCS). However, AFCS will ensure that all Title I employees responsible for reviewing the Semiannual Certification Form will certify it after the pay period. We will continue to provide training for all ...
Planned Corrective Action: The two employees are no longer with America’s Finest Charter School (AFCS). However, AFCS will ensure that all Title I employees responsible for reviewing the Semiannual Certification Form will certify it after the pay period. We will continue to provide training for all employees funded by federal programs and for the HR Manager regarding the requirements for federal time accounting under 2 CFR §200.430. We will also review payroll records to ensure that payroll is accurately charged to the correct programs on a semimonthly basis.
View Audit 349389 Questioned Costs: $1
2024-001 Special Tests and Provisions Corrective action planned: Management has selected a General Ledger account, (associated to a separate Bank Account) identified and named specifically as the USDA Debt Reserve Account.Additionally, Financial Policies will be revised to include language related t...
2024-001 Special Tests and Provisions Corrective action planned: Management has selected a General Ledger account, (associated to a separate Bank Account) identified and named specifically as the USDA Debt Reserve Account.Additionally, Financial Policies will be revised to include language related to compliance of loan and debt covenants, to be reviewed and approved by the Board of Directors. Anticipated completion date: February 2025 Contact person responsible for corrective action: Dawn Weber, Interim CEO
Identifying Number: 2024-005: U.S. Department of Education: Education Stabilization Fund: Institutional Portion – 84.425F Finding: There was no review of quarterly or annual HEERF reports prior to their submission. Corrective Action Taken or Planned: The School will train finance office staff in pre...
Identifying Number: 2024-005: U.S. Department of Education: Education Stabilization Fund: Institutional Portion – 84.425F Finding: There was no review of quarterly or annual HEERF reports prior to their submission. Corrective Action Taken or Planned: The School will train finance office staff in preparation and filing of grant reports. This will allow various staff members to review reports prior to submission. Contact person: Mike Stephens, Director of Accounting Status of finding – The above corrective actions will be implemented beginning April 1, 2025.
– 84.425F Finding: Two errors were noted related to period of performance: 1) the lost revenue calculation was completed in October 2023, which was after the June 30, 2023 period of performance date; and 2) the District also spent money on expenses for the program in November 2023 and January 2024, ...
– 84.425F Finding: Two errors were noted related to period of performance: 1) the lost revenue calculation was completed in October 2023, which was after the June 30, 2023 period of performance date; and 2) the District also spent money on expenses for the program in November 2023 and January 2024, which was after the 120-day liquidation period. Corrective Action Taken or Planned: The School will create and maintain a funding schedule according to the grant agreements. The schedule will be reviewed by various finance staff members for timing of grant reimbursements and deadlines. Contact person: Mike Stephens, Director of Accounting Status of finding – The above corrective actions will be implemented beginning April 1, 2025.
View Audit 349380 Questioned Costs: $1
Identifying Number: 2024-006: U.S. Department of Education: Federal Direct Student Loans – 84.268 Finding: During testing over credit balances, it was noted that: 1) one student did not receive the refund on a timely basis; and 2) two students had amounts applied to a prior-year balance over $200. C...
Identifying Number: 2024-006: U.S. Department of Education: Federal Direct Student Loans – 84.268 Finding: During testing over credit balances, it was noted that: 1) one student did not receive the refund on a timely basis; and 2) two students had amounts applied to a prior-year balance over $200. Corrective Action Taken or Planned: All scheduled disbursements will be reviewed to ensure they are provided on a timely basis and are applied correctly to prior award years. Business Office procedures and processing will be reviewed to ensure that credit balances are processed within the regulatory timeframe. Contact person: Megan Fischer, Vice President for Enrollment Management Status of finding – The above corrective actions will be implemented beginning April 1, 2025.
Finding Number: 2024‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Kevin Davis, Superintendent & Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: This finding related to fede...
Finding Number: 2024‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Kevin Davis, Superintendent & Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: This finding related to federal grants, specifically ESSER Funds was due to changing requirements in the program, the newness of the ESSER grants, and lack of training for our grants manager  as  they  were  also  new  to  the  position.  Additional  grants  training  will  be  conducted  for  this  individual and be completed by July 15, 2025. As our ESSER grants have been expended and completion reports finalized by Grants Management, with no issues or errors found, this should not be an issue in the future. Supervision will be monitored more closely by the Superintendent to ensure proper standards are met.
Management concurs. The City will ensure responsible personnel will have a clear understanding of the reporting guidance. The City will implement policies and procedures to monitor and review all reports prepared and submitted by the Grants Department or its designee.
Management concurs. The City will ensure responsible personnel will have a clear understanding of the reporting guidance. The City will implement policies and procedures to monitor and review all reports prepared and submitted by the Grants Department or its designee.
Finding 538553 (2024-076)
Significant Deficiency 2024
Department: Defense, Veterans and Emergency Management Title: Internal control over the submission of DG – PA program Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Maine Emergency Managemen...
Department: Defense, Veterans and Emergency Management Title: Internal control over the submission of DG – PA program Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Maine Emergency Management Agency (MEMA) and Department of Defense, Veterans and Emergency Management will collaborate on a SEFA reporting process that allows for comprehensive review of SEFA details by MEMA and/or Security and Employment Service Center (SESC) subject matter experts prior to submission to OSC. MEMA will distribute copies of the corrected reporting SOP to subject matter experts within MEMA/DVEM and SESC. MEMA/SESC subject matter experts will perform a comprehensive review of SEFA details for FY2025 reporting. Completion Date: May 1, 2025, May 15, 2025, and June 15, 2025, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507
Finding 538551 (2024-075)
Significant Deficiency 2024
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Maine Emergency Management Agency (MEMA) Management Analyst participated in tr...
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Maine Emergency Management Agency (MEMA) Management Analyst participated in training on use of Public Assistance Federal grant management system, the Payment Management System. MEMA received ongoing feedback from Federal reviewers of submitted SF-425 reports. MEMA will revise the existing SOP for Federal Financial Reporting. MEMA will incorporate detailed review tabs to SF-425 Workbooks. MEMA staff involved in preparation and review of SF-425 reports will participate in further training on the process. Completion Date: June 11, 2025, first item, July 31, 2025, second item, April 30, 2025, third and fourth items, and June 30, 2025, fifth item Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507
Finding 538549 (2024-074)
Significant Deficiency 2024
Department: Defense, Veterans and Emergency Management Administrative and Financial Services Title: Internal control over DG – PA program cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Departments collaboratively developed cash m...
Department: Defense, Veterans and Emergency Management Administrative and Financial Services Title: Internal control over DG – PA program cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Departments collaboratively developed cash management procedures to address prior year finding 2023-097. The Departments implemented a new cash management process, including weekly reconciliation of draw requests The Departments modified the Treasury-State Agreement with the Office of the State Treasurer to list a Weekly Drawdown - Actual & Estimate funding technique for FY2025. Completion Date: December 13, 2023, December 18, 2023, and June 25, 2024, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507
Finding 538539 (2024-071)
Significant Deficiency 2024
Department: Health and Human Services Title: Internal control over Medicaid paid medical claims needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will require the vendor to create a procedure to be used to prepare this report which will ...
Department: Health and Human Services Title: Internal control over Medicaid paid medical claims needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will require the vendor to create a procedure to be used to prepare this report which will be tested and validated by the vendor and the Office of MaineCare Services. Completion Date: June 1, 2025 Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093
Finding 538535 (2024-070)
Significant Deficiency 2024
Department: Health and Human Services Title: Internal control over Medicaid drug rebates needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: PRIMS (Pharmacy Rebate Information Management System), provided to the State of ...
Department: Health and Human Services Title: Internal control over Medicaid drug rebates needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: PRIMS (Pharmacy Rebate Information Management System), provided to the State of Maine by a third-party vendor, is a proven system in production in many locations and PRIMS has passed a wide variety of Federal and State audits. The drug rebate program is complex and there are numerous steps in the process which have already been demonstrated and/or provided to the Office of State Auditor. The controls described to the State Auditor previously (Pre-invoicing controls, pharmacy claims controls and medical claims controls) address all three of the Auditors’ Recommendations. Completion Date: N/A Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093
Finding 538531 (2024-069)
Significant Deficiency 2024
Department: Health and Human Services Title: Internal control over Medicaid cost of care assessments and deductions needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Office of MaineCare Services will request an update to the Retroactive Cost of Car...
Department: Health and Human Services Title: Internal control over Medicaid cost of care assessments and deductions needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Office of MaineCare Services will request an update to the Retroactive Cost of Care report to correct the logic that resulted in a missed cost of care change. Completion Date: June 1, 2025 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481
Finding 538527 (2024-068)
Significant Deficiency 2024
Department: Health and Human Services Title: Internal control over Medicare Part B premium payments needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The MaineCare Program management team will work with the Data Team to explore opportunities to improve...
Department: Health and Human Services Title: Internal control over Medicare Part B premium payments needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The MaineCare Program management team will work with the Data Team to explore opportunities to improve the report to reduce duplication of effort and improve overall efficiency and effectiveness of the review. The MaineCare Program management team will review relevant guidance material, clarify expectations and adjust standard operating procedures for further efficiency and oversight improvements. Completion Date: June 30, 2025 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481
Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department is working to hire staff for the Medicaid Audit unit. The Deputy Director will assign ...
Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department is working to hire staff for the Medicaid Audit unit. The Deputy Director will assign Nursing Facility audits to auditors who have been working on COVID fund audits. The Department will hold monthly meetings with the Director, Deputy Director and Senior auditors to discuss strategies for completing the Nursing Facility audits timely. Completion Date: Ongoing, July 1, 2025 and February 1, 2025 respectively Agency Contact: Herb Downs, Director, Division of Audit, DHHS, 207-287-2778
Department: Health and Human Services Title: Internal control over the Foster Care – Title IV-E and Adoption Assistance – Title IV-E eligibility and benefit determination process needs improvement Questioned Costs: Known: ALN 93.658 $4,647 ALN 93.659 $9,367 Likely: Undeterminable Statu...
Department: Health and Human Services Title: Internal control over the Foster Care – Title IV-E and Adoption Assistance – Title IV-E eligibility and benefit determination process needs improvement Questioned Costs: Known: ALN 93.658 $4,647 ALN 93.659 $9,367 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Title IV-E Program Manager will continue to educate and train the FRS on the proper completion of the Title IV-E initial determination checklists for their FRS files, including the importance of signing off on those checklists for the initial determinations that they have completed. The Title IV-E Program Manager will conduct quarterly quality assurance (QA) reviews in the District that this issue was found, randomly pulling 10 cases to ensure compliance. When FRS staff conduct QA reviews, they will continue to be advised to monitor if signatures are present on the Title IV-E initial determination checklist. Reviewing if a checklist is signed is an existing question within our internal QA review document. The Department will establish a work group to identify the challenges of managing overpayments made to foster parents and to develop a process to minimize this problem. The Department will finalize and receive approval of the protocol/process form managing overpayments. The Department will implement the new overpayments management procedures. Completion Date: March 26, 2025, March 31, 2025, July 1, 2025, September 1, 2025, and November 1, 2025 respectively Agency Contact: Robert Blanchard, Associate Director, OCFS, DHHS, 207-624-7955
View Audit 349360 Questioned Costs: $1
Finding 538508 (2024-060)
Significant Deficiency 2024
Department: Health and Human Services Title: Internal control over CCDF provider health and safety requirements needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Office of Child and Family Services (OCFS) will launch a new data management system (B...
Department: Health and Human Services Title: Internal control over CCDF provider health and safety requirements needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Office of Child and Family Services (OCFS) will launch a new data management system (Baxter) that includes mobile technology (eliminating paper inspections), has extensive reporting, data, tracking technology and system alerts to inform Licensing Specialists and Supervisors of inspection due dates. Enhanced technology will mitigate the risk associated w/ current manual procedures. OCFS will include an agenda item on the next Child Care Licensing Staff meeting regarding annual inspection completion. OCFS will update Standard Operating Procedures to reflect changes in workflow and processes because of the new data management system. Completion Date: May 19, 2025, April 1, 2025, and June 1, 2025 Agency Contact: Janet Whitten, OCFS, CLIS Program Manager, DHHS, 207-441-2259
Department: Health and Human Services Administrative and Financial Services Title: Internal control over CCDF financial reporting needs improvement Questioned Costs: Known: ALN 93.575 $3.7 million Likely: ALN 93.575 $3.7 million Status: Corrective action in progress Corrective Action: The DHHS Finan...
Department: Health and Human Services Administrative and Financial Services Title: Internal control over CCDF financial reporting needs improvement Questioned Costs: Known: ALN 93.575 $3.7 million Likely: ALN 93.575 $3.7 million Status: Corrective action in progress Corrective Action: The DHHS Financial Service Center will enhance policies and procedures for the CCDF grant by modifying the FSR Reviewer Checklist and add an additional layer of FSR reviewer The DHHS Financial Service Center will collaborate with the Office of Child and Family Services to make reporting line determinations. Completion Date: April 30, 2025, and September 1, 2025, respectively Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626
View Audit 349360 Questioned Costs: $1
Finding 538504 (2024-058)
Significant Deficiency 2024
Department: Health and Human Services Title: Internal control over TANF work verification plan procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The TANF Program Manager will review and update ACF 199/209 system processes within OFI to enhan...
Department: Health and Human Services Title: Internal control over TANF work verification plan procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The TANF Program Manager will review and update ACF 199/209 system processes within OFI to enhance existing procedures to ensure that the information reported on the ACF-199 and ACF-209 reports is accurate and complete prior to submission to the Federal government. This will include modifying existing Standard Operating Procedures as necessary. The TANF Senior Program Manager will enhance existing procedures and follow-up processes of the ACRT reviews to ensure that the reviews include information regarding the date the review was conducted and the dates on which any outstanding issues are resolved. Completion Date: June 30, 2025 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207-592-1481
Finding 538503 (2024-057)
Significant Deficiency 2024
Department: Health and Human Services Title: Internal control over TANF performance reporting procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will review and update ACF 199/209 system processes within Office for Family Indep...
Department: Health and Human Services Title: Internal control over TANF performance reporting procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will review and update ACF 199/209 system processes within Office for Family Independence to enhance existing procedures to ensure that the information reported on the ACF-199 and ACF-209 reports is accurate and complete prior to submission to the Federal government. This will include modifying the existing Standard Operating Procedure as necessary. Completion Date: June 30, 2025 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481
Finding 538501 (2024-055)
Significant Deficiency 2024
Department: Health and Human Services Title: Internal control over TANF program subrecipient cash management needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Department i...
Department: Health and Human Services Title: Internal control over TANF program subrecipient cash management needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Department is in compliance with the requirement for minimizing the time between payments to our subrecipients and the disbursement of funds. Payments are made as close as administratively feasible. The Compliance Supplement suggested audit procedures for Cash Management for pass-through entities refers to 200.305(b)(1). That same paragraph states that the timing and amount of advance payments must be as close as is administratively feasible. Completion Date: N/A Agency Contact: Anthony Madden, Deputy Director of Audit, DHHS, 207-287-2834
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