Corrective Action Plans

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Finding 2022-002 Internal Control Deficiency over Allowable Activities Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Sum...
Finding 2022-002 Internal Control Deficiency over Allowable Activities Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Finding: Management did not retain evidence of controls surrounding the compliance with the terms and conditions of the award. Corrective Action Plan: Management will ensure documentation is retained to evidence the controls were performed. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2023
Finding 2022-001 Internal Control Deficiency over Reporting Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Fin...
Finding 2022-001 Internal Control Deficiency over Reporting Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to ensure lost revenues submitted for the Provider Relief Fund were allowable under the terms and conditions of the award, as reported in the HRSA filings. Corrective Action Plan: Management will ensure documentation is retained to evidence the controls were performed. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2023
Finding 28250 (2022-003)
Significant Deficiency 2022
We submitted two reports late resulting in this finding. The first late report, June 2022 Emergency Food and Shelter Program, due July 30th and submitted in August and the October ESFP report due November 30th and submitted in December. The reports were late because the program manager failed to tim...
We submitted two reports late resulting in this finding. The first late report, June 2022 Emergency Food and Shelter Program, due July 30th and submitted in August and the October ESFP report due November 30th and submitted in December. The reports were late because the program manager failed to timely provide the narrative portion to accounting. We will refine our company wide effort for tracking grant reporting timelines.
Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. Management will continue to make extra deposits to resolve the replacement reserve deficiency. Mana...
Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. Management will continue to make extra deposits to resolve the replacement reserve deficiency. Management will ensure that the replacement reserve deposits are made on a timely basis in the future. Completion Date: September 9, 2022
Finding 28235 (2022-063)
Material Weakness 2022
Department: Health and Human Services Title: Internal control over ELC program reporting needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department has implemented Microsoft Project (within the ELC Team) for each Program Area. The Department has de...
Department: Health and Human Services Title: Internal control over ELC program reporting needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department has implemented Microsoft Project (within the ELC Team) for each Program Area. The Department has developed a process to document the completion of each submission. The first quarterly reports due will be submitted to federal CDC using the new documented process Completion Date: January 15, 2023 (first and second items) and February 28, 2023 (third item) Agency Contact: Sara Robinson, Senior Program Manager, DHHS, 207-287-4610
Finding 28223 (2022-062)
Significant Deficiency 2022
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disagre...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete corrective action plan as well as the explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: August 9, 2022 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28220 (2022-059)
Material Weakness 2022
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. Th...
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: June 30, 2023 (first, third and fifth items), June 1, 2023 (second item) and May 15, 2024 (fourth item) Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28167 (2022-055)
Material Weakness 2022
Department: Redacted Title: ________ over the ________ and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information...
Department: Redacted Title: ________ over the ________ and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: April 1, 2023, April 15, 2023 and April 30, 2023 respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28166 (2022-054)
Material Weakness 2022
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complet...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: April 30, 2023 and September 30, 2023 respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28164 (2022-052)
Material Weakness 2022
Department: Education Title: Internal control over ESF expenditures needs improvement Questioned Costs: Known: $620,676 Likely: $6,364,627 Status: Management?s opinion is that corrective action is not required Corrective Action: The Maine Department of Education (MDOE) disagrees with the identified ...
Department: Education Title: Internal control over ESF expenditures needs improvement Questioned Costs: Known: $620,676 Likely: $6,364,627 Status: Management?s opinion is that corrective action is not required Corrective Action: The Maine Department of Education (MDOE) disagrees with the identified questioned costs. The Office of Federal Emergency Relief Programs (OFERP) utilized guidance provided by the U.S. Department of Education (grantor) and conferred in writing with Maine?s assigned U.S. Department of Education program officer throughout the Education Stabilization Fund application review process. The Maine Department of Education?s OFERP provided the auditor with the grantor?s guidance which clearly states that the questioned costs were allowable, reasonable, and necessary to prepare, prevent, and respond to the COVID-19 pandemic. Throughout the application review process, OFERP utilized ESF federal statutory language and the grantor?s published guidance to determine allowability. Once funding applications were approved, SAUs requested reimbursement from the OFERP for the approved costs outlined in the school administrative unit (SAU) application. The OFERP reviewed SAU reimbursement requests and provided payment for approved expenses. The ESF costs outlined in this finding were allowable, reasonable, and necessary to prepare, prevent, and respond to the COVID-19 pandemic. Documentation provided by the grantor supports the determinations made by the Maine Department of Education. Completion Date: N/A Agency Contact: Shelly Chasse-Johndro, Director of OFERP, DOE, 207-458-3180
View Audit 32781 Questioned Costs: $1
Finding 28162 (2022-051)
Material Weakness 2022
Department: Labor Administrative and Financial Services Title: Internal control over CSLFRF expenditures needs improvement Questioned Costs: Known: $51,482,644 Likely: $51,482,644 Status: Management?s opinion is that corrective action is not required Corrective Action: We disagree with this finding....
Department: Labor Administrative and Financial Services Title: Internal control over CSLFRF expenditures needs improvement Questioned Costs: Known: $51,482,644 Likely: $51,482,644 Status: Management?s opinion is that corrective action is not required Corrective Action: We disagree with this finding. Likewise, we are unable to determine why the auditor has identified a questioned cost or includes a recommendation that only allowable costs are funded by CSLFRF. The transfer of $80 million to the Unemployment Trust Fund is completely allowable, with a portion categorized under the Public Health and Economic Impacts use category and a portion under the Revenue Loss - Provision of Government Services use category. All documentation to support the allowability of this transfer was provided to the auditor for review. There were errors in the original calculation of the total amount eligible under the Public Health and Economic Impacts category; however, we provided documentation to support that the total amount was eligible under the Revenue Loss - Provision of Government Services use category. Although we have identified a weakness in internal control over compliance, there was no actual noncompliance. Consequently, there is no cost that is considered unallowable; therefore, there should be no questioned cost. Completion Date: N/A Agency Contact: DOL Contact: Kimberly Smith, Deputy Commissioner, Department of Labor, 207-621-5096 DAFS Contact: Frank Wiltuck, Director of Internal Audit, OSC, 207-626-8420
View Audit 32781 Questioned Costs: $1
Finding 28161 (2022-050)
Material Weakness 2022
Department: Economic and Community Development Title: Internal control over ERA Program reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will require MaineHousing to submit data gathered to prepare reports to DECD for review a...
Department: Economic and Community Development Title: Internal control over ERA Program reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will require MaineHousing to submit data gathered to prepare reports to DECD for review and approval prior to certification and submission. Completion Date: June 30, 2023 Agency Contact: Deborah Johnson, Director, Office of Community Development, DECD, 207-624-9817
Finding 28151 (2022-045)
Material Weakness 2022
Department: Labor Title: Internal control over UI claim payments needs improvement Questioned Costs: Known: $19,278 Likely: $2,700,000 Status: Management?s opinion is that corrective action is not required (first item) Corrective action in progress (remaining items) Corrective Action: The Department...
Department: Labor Title: Internal control over UI claim payments needs improvement Questioned Costs: Known: $19,278 Likely: $2,700,000 Status: Management?s opinion is that corrective action is not required (first item) Corrective action in progress (remaining items) Corrective Action: The Department disagrees with the findings around the PUA program and the timing of the notices to provide Proof of Employment for continued eligibility. USDOL in its guidance acknowledged that it would take time to implement the new requirement from a systems and operational perspective. The Department worked diligently to implement the new requirement (along with other requirements from the CAA) as soon as possible. Furthermore, the PUA program was a one-time program created by the Federal government in response to the COVID-19 pandemic, to provide monetary support to those individuals who traditionally do not qualify for unemployment compensation benefits. All CARES Act programs, including PUA, ended in September, 2021. At this time there is no corrective action we can take, as the program no longer exists in its prior form. At most we may still see PUA eligibility as a result of a pending appeal, or court case. We will follow established processes at that time, which are based on Federal guidance provided. The Department will add a text field to obtain more information on the location of a job fair or the name of an activity when a claimant reports a CareerCenter job fair or other activity as a work search. Information will be provided to businesses through a new report for review. The Department will create a work search issue for fact-finding and possible adjudication when a claimant reports a CareerCenter Job Fair or other activity as a work search more than three times. The Department will review functionality of Vital Statistics Crossmatch to ensure that all data related to date of death for active claimants is received as timely as possible. The Department will add system controls when entering a date of birth, both for claimants and businesses to prevent avoidable data entry errors. Completion Date: June 30, 2023 (second and third items), June 30, 2024 (fourth and fifth items) Agency Contact: Laura Boyett, Director, Bureau of Unemployment Compensation, DOL, 207-621-5156
View Audit 32781 Questioned Costs: $1
Finding 28149 (2022-014)
Material Weakness 2022
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complet...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: June 30, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28148 (2022-047)
Significant Deficiency 2022
Department: Redacted Title: ________ over ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disagree...
Department: Redacted Title: ________ over ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete corrective action plan as well as the explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: July 1, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28117 (2022-020)
Significant Deficiency 2022
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disa...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete corrective action plan as well as the explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: May 1, 2024 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28105 (2022-043)
Significant Deficiency 2022
Department: Education Title: Internal control over CACFP eligibility needs improvement Questioned Costs: Known: $50,275 Likely: Undeterminable Status: Corrective action complete Corrective Action: The Department added to the check list a space for the on-site documentation for the pre-approval site ...
Department: Education Title: Internal control over CACFP eligibility needs improvement Questioned Costs: Known: $50,275 Likely: Undeterminable Status: Corrective action complete Corrective Action: The Department added to the check list a space for the on-site documentation for the pre-approval site visit to be uploaded into CNPWeb. The Department made the pre-site visit mandatory before the start of the program. Completion Date: March 6, 2023 Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880
View Audit 32781 Questioned Costs: $1
Finding 28103 (2022-041)
Material Weakness 2022
Department: Education Title: Internal control over CACFP claim reimbursements needs improvement Questioned Costs: Known: $11,222 Likely: Undeterminable Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. As explained t...
Department: Education Title: Internal control over CACFP claim reimbursements needs improvement Questioned Costs: Known: $11,222 Likely: Undeterminable Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. As explained to OSA by DOE, DHHS, and USDA, Child Care Centers/Providers can enroll and claim over the licensed capacity. The claim edit check that was in place for SY22 for DCH Providers was Total Monthly Attendance x Approved Meal Types due to the fact that providers can enroll over the licensed capacity. Sponsors have been trained: Total Monthly Attendance equals the number of unique kids who attended during the day, are enrolled in CACFP and who ate at least one meal or snack during the day, then add up those daily totals for the month. To use licensed capacity as an edit check, which OSA did to calculate the costs in question, disallows provider reimbursement for eligible meals. CACFP Total Monthly Attendance is a better edit check as it only calculates attendance for enrolled participants. For the provider claims in question the CACFP Team tested them against the Total Monthly Attendance edit check and none suggest an overclaim. The CACFP Team discovered the missing enrollment edit check on 8/24/22 and immediately submitted a ticket to the web designers. This correction required multiple meetings with the web designers and in-depth system testing. The correction to the edit check was completed on 12/23/22. The claim edit checks now in place are: Attendance x Approved Meal Types (same as before) ? AND- Enrollment x Operating Days x Approved Meal Types. Completion Date: N/A Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880
View Audit 32781 Questioned Costs: $1
Department of Health and Human Services Ashe Memorial Hospital, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 through December 31, 2022 The finding from the schedule of findings and questioned costs i...
Department of Health and Human Services Ashe Memorial Hospital, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 through December 31, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2022-001 Provider Relief Funding ? Assistance Listing No. 93.498 Recommendation: We recommend the organization review the lost revenue calculation in future periods to ensure that all hospital revenue is being included in calculation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. While we are not anticipating any future Lost Revenue calculations, we will have this reviewed by our accounting firm if the situation arises. Name of the contact person responsible for corrective action: Charles Wright, CFO Planned completion date for corrective action plan: 9/30/23 If the Department of Health and Human Services has questions regarding this plan, please call Charles Wright, CFO at 336-846-0798.
FINDING 2022-003 ? Significant Deficiency in Internal Controls over Compliance Recommendation: Policies and procedures over federal grant reporting should be modified to ensure reports are submitted in a timely manner. Corrective Action Plan: We have implemented new processes to make sure our third ...
FINDING 2022-003 ? Significant Deficiency in Internal Controls over Compliance Recommendation: Policies and procedures over federal grant reporting should be modified to ensure reports are submitted in a timely manner. Corrective Action Plan: We have implemented new processes to make sure our third party preparers are engaged on time with enough lead-time to prepare the reports. Since the filing of the Period 2 PRF report for Grancell Village, we have filed all other reports timely. Contact Person Responsible for Corrective Action Plan: Mark C de Baca, Corporate Controller Anticipated Completion of Corrective Action Plan: June 30, 2023
Name of contract person: Amanda Bertran, Senior Finance Manager Corrective Action: Currently, the Finance Coordinator reviews the timesheets completed on time each pay period. Then, the Senior Finance Manager reviews the proper grants allocation in the journal entry. The management will strengthen t...
Name of contract person: Amanda Bertran, Senior Finance Manager Corrective Action: Currently, the Finance Coordinator reviews the timesheets completed on time each pay period. Then, the Senior Finance Manager reviews the proper grants allocation in the journal entry. The management will strengthen the controls to review personnel allocations processes to ensure accuracy. The Finance Coordinator will generate payroll reports to review timesheet allocations to grants and complete the effort table accordingly to provide the outside accounting firm for the review and recording. The Senior Finance Manager will review the journal entry posted by the accounting firm to make sure there are no discrepancies between timesheets and payroll grant allocations. Proposed Completion Date: The Organization will implement the above procedure starting January 01, 2023.
View Audit 27895 Questioned Costs: $1
Finding 28049 (2022-083)
Material Weakness 2022
Department: Redacted Title: ________ over ________ 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?s explanation and specific reasons for disagreement have be...
Department: Redacted Title: ________ over ________ 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?s explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: N/A Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28047 (2022-029)
Significant Deficiency 2022
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disa...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete corrective action plan as well as the explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: April 30, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28045 (2022-027)
Significant Deficiency 2022
Department: Health and Human Services Title: Internal control over EBT reconciliation procedures needs improvement Questioned Costs: Known: $80,555 Likely: $80,555 Status: Corrective action is completed regarding controls over EBT reconciliations Corrective action in progress regarding the correctio...
Department: Health and Human Services Title: Internal control over EBT reconciliation procedures needs improvement Questioned Costs: Known: $80,555 Likely: $80,555 Status: Corrective action is completed regarding controls over EBT reconciliations Corrective action in progress regarding the correction of an error Corrective Action: Since May of 2022, the reconciliations in question have been completed each day, per Federal regulations. Additionally, the FY 2022 reconciliations that were due prior to April 2022 were completed retrospectively. The auditor did not note any deviations in the current process; therefore, no additional corrective action is required. There is no current deficiency in the Department's EBT reconciliation processes. While performing reconciliations, the Department detected an $80,555 error where benefits were charged to the incorrect program. Upon the completion of revisions to reports dating as far back as October 2020, the Department will move any incorrectly charged amounts to the correct program to include the $80,555 of questioned costs. Completion Date: May 2022 and April 2023 Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104
View Audit 32781 Questioned Costs: $1
Finding 28043 (2022-025)
Significant Deficiency 2022
Department: Health and Human Services Title: Internal control over automated SNAP eligibility determinations and benefit calculations needs improvement Questioned Costs: Known: $2,952 Likely: $7,686,166 Status: Corrective action in progress Corrective Action: The management of OFI will review the st...
Department: Health and Human Services Title: Internal control over automated SNAP eligibility determinations and benefit calculations needs improvement Questioned Costs: Known: $2,952 Likely: $7,686,166 Status: Corrective action in progress Corrective Action: The management of OFI will review the standard operating procedures to identify opportunities for improvement and distribute to all staff involved. Completion Date: June 1, 2023 Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104
View Audit 32781 Questioned Costs: $1
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