Corrective Action Plans

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Finding 2025‐003 Reimbursement Request Approval Documentation ‐ Significant Deficiency Management Response: The Association acknowledges this finding and agrees that reimbursement request files should contain clearer documentation evidencing the preparation and approval process required under intern...
Finding 2025‐003 Reimbursement Request Approval Documentation ‐ Significant Deficiency Management Response: The Association acknowledges this finding and agrees that reimbursement request files should contain clearer documentation evidencing the preparation and approval process required under internal policy. Although reimbursement requests were prepared and submitted as part of routine grant administration, the supporting documentation did not consistently reflect the full preparation trail and approval record expected for audit purposes. Management has already identified the need to formalize this process and will implement a standardized reimbursement request file structure for all future reimbursement submissions. This process will include documentation showing who prepared the request, the date of preparation, the review and approval path, and the supporting expenditure records associated with the reimbursement period. Where applicable, the Association will incorporate a formal checklist or cover sheet to ensure each request file demonstrates compliance with internal procedures and grant requirements. Management does not believe the issue resulted from intentional noncompliance, but rather from inadequate documentation of a process that had been operationally performed. Even so, management agrees that documentation standards must be improved to reduce risk and strengthen compliance controls over federal reimbursement activity. The Association is committed to implementing this corrective action immediately for all future reimbursement requests to ensure that preparation and approval procedures are clearly evidenced and consistently retained. The draft audit notes that the comparable prior-year federal finding appears to be resolved, and management intends to similarly resolve this finding through standardized documentation and retention procedures. Responsible Official: Director / Business Manager Planned Corrective Action Date: Immediately for all reimbursement requests submitted after audit issuance
Corrective Action Plan 2025-003 Non-Compliance with JOM Annual Report Submission Federal Program Information Funding Agency US Bureau of Indian Education Title: Johnson O’Malley Federal Assistance Listing: 15.130 Pass Through Zuni Tribe Award Year 2022-2027 Responsible Official’s Plan Due to unfores...
Corrective Action Plan 2025-003 Non-Compliance with JOM Annual Report Submission Federal Program Information Funding Agency US Bureau of Indian Education Title: Johnson O’Malley Federal Assistance Listing: 15.130 Pass Through Zuni Tribe Award Year 2022-2027 Responsible Official’s Plan Due to unforeseen circumstances, the Federal Programs Director for Zuni Public Schools retired mid year. Because of the abrupt timing of the retirement, the new Federal Programs Director did not receive an optimal amount of training. Additional training has been received regarding federal fund report compliance. The Johnson O’Mallley report referenced in the finding has been completed and submitted. Specific corrective action plan for funding: It is being completed and will be submitted by the new Federal Programs Director, Ms. Florence Acque. Timeline for completion of corrective action March 31, 2026 Employee Position responsible for meeting the timeline: Florence Acque Federal Programs Director
Department: Redacted Title: Redacted Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with the finding. The Department’s explanation and specific reasons for disagreement have been excluded to protect confidenti...
Department: Redacted Title: Redacted Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with the 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
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department’s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protec...
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with the 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: February 5, 2026, April 10, 2026, May 15, 2026, June 26, 2026, and June 30, 2027 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been pro...
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the 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: May 1, 2026, May 29, 2026, June 12, 2026, September 18, 2026, and September 21, 2026, respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Health and Human Services Title: Internal control over Medicaid utilization control needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. This finding represents a mis...
Department: Health and Human Services Title: Internal control over Medicaid utilization control needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. This finding represents a misunderstanding of the applicable federal regulations and the state entity responsible for compliance. A Utilization Control (UC) program is the responsibility of the State Medicaid Agency as a whole, not the Program Integrity Unit (PIU). Additionally, there are many more federal regulations governing UC programs than cited by the Office of State Auditor (OSA) in the finding and touch on a host of controls that were not reviewed or considered in this audit. Moreover, the OSA appears to be basing findings on interpretations that are unsupported by the regulatory text cited. Second, the OSA confuses PIU's annual review plan (a yearly plan of focused program integrity areas of focus and review) with an agency-wide UC program: these are not the same, nor are they required to be. The Department's current processes for PIU's annual review plan were implemented in response to OSA findings in 2015 relating to an OSA finding that the Department was not fully utilizing available data analytics. In the intervening years, the OSA has not found Program Integrity's annual review plan, or the process of developing the plan, to be deficient. There has been no change in the Department's process or the regulation to justify the OSA's newly found position here. The OSA's criticism of PIU's use of data analytics contradicts a prior OSA findings on data analytics use, is contrary to accepted Department adjustments made in response, and represents a significant departure from federal guidance and industry standards around best practices for leveraging data analytics to prevent and detect improper payments and/or utilization. The PIU's annual review plan supplements post-payment reviews that PIU conducts based upon complaints and referrals. Finally, this finding’s singular focus on PIU's annual review plan fails to account for a myriad of other systems and processes the Department has in place to monitor utilization, including, but not limited to: 1. A contracted vendor (HMS) performing post-payment reviews of hospitals, nursing facilities, and other long-term care facilities; 2. MaineCare's Case Mix unit - performing look back reviews of documentation and services in nursing facilities and other long-term care units; 3. A contracted vendor (Acentra) reviewing authorization requests for behavioral health services and continuing stay reviews of services at designated intervals; 4. A contracted vendor (Maximus) that performs assessments and authorizations for nursing and personal care services; 5. A contracted vendor (Optum) that performs prior authorization reviews for pharmacy services and produces a variety of reports on drug utilization; 6. Fiscal intermediaries performing oversight and administrative support for self-directed services; 7. State staff who review and approve plans of care for Home and Community Based Waiver Services and conduct quality reviews of providers; 8. State staff performing quality assurance reviews of providers of mental and behavioral health services; 9. State staff monitoring and addressing inappropriate emergency department usage by beneficiaries; and 10. State staff with oversight and performing qualitative and quantitative reviews of a variety of programs operated under delivery service reform, including: Accountable Communities, Behavioral Health Homes, Certified Community Behavioral Health Clinics, Community Care Teams, MaineMOM, Opioid Health Homes, and Primary Care Plus. 11. State and contracted vendor (Gainwell) staff reviewing medical necessity and other allowability for medical services requiring prior authorization for initial requests and renewals. 12. A CMS-compliant Electronic Visit Verification (EVV) system, in accordance with Section 12006 of the 21st Century Cures Act, that ensures payment for applicable services is tied to an EVV record demonstrating that the service occurred; data from the system also contributes to post-payment reviews for applicable services. Completion Date: N/A Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093
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: The Department disagrees with this finding. Drug Rebate pre-invoicing and post-i...
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: The Department disagrees with this finding. Drug Rebate pre-invoicing and post-invoicing is completed quarterly. As demonstrated during walkthroughs and during our meetings Maine completes specific tasks to ensure accuracy of the invoicing process. The pre-invoicing and post-invoicing procedures are documented in the Pharmacy Rebate Information Management System (PRIMS) Desk Level Procedure (DLP). The pre-invoicing work is performed by the State that compares drug utilization data to the number of dispensed units invoiced. Upon the completion of the pre-invoicing review approval is provided to the vendor allowing them to continue with the invoicing process. There is no requirement regarding how we select our sample of invoices to review. Based on OSA noting no exceptions to the drug rebate amounts, our system in place to review invoiced drug rebates is functioning as intended. Completion Date: N/A Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093
Department: Health and Human Services Administrative and Financial Services Title: Internal control over Foster Care and Adoption Assistance cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Financial Service Center will update...
Department: Health and Human Services Administrative and Financial Services Title: Internal control over Foster Care and Adoption Assistance cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Financial Service Center will update the IV-E cash on hand analysis to ensure the cash balances are tracked separately by each of the following Title IV-E programs: Foster Care, Adoption Assistance, Prevention Program and Guardianship Assistance. Completion Date: March 31, 2026 Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been pro...
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the 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: May 1, 2026 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Health and Human Services Title: Internal control over CCDF eligibility determinations needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department successfully addressed this issue and all QA functionality and processes are working as exp...
Department: Health and Human Services Title: Internal control over CCDF eligibility determinations needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department successfully addressed this issue and all QA functionality and processes are working as expected as of July 2025 and ongoing. Completion Date: July 1, 2025 Agency Contact: Gina Forbes, Child Care Services Program Manager, DHHS, 207-592-0865
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 include an agenda item at the next Chi...
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 include an agenda item at the next Child Care Licensing Staff meeting, scheduled for 3/17/2026, to discuss all expectations related to timeframes/completion of annual unannounced inspections. The OCFS Child Care Licensing Supervisors will utilize the Baxter dashboard report for "latest correspondence yet to be posted" once weekly to ensure all documents ready for posting to the consumer education website have been posted. Completion Date: March 17, 2026, and April 1, 2026, respectively 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: None Status: Corrective action completed Corrective Action: The DHHS Financial Service Center enhanced policies and procedures for the...
Department: Health and Human Services Administrative and Financial Services Title: Internal control over CCDF financial reporting needs improvement Questioned Costs: None Status: Corrective action completed Corrective Action: The DHHS Financial Service Center enhanced policies and procedures for the CCDF grant by modifying the FSR Reviewer Checklist and adding an additional layer of FSR review. The DHHS Financial Service Center collaborated with OCFS to make reporting line determinations, complete corrective journal entries and submit Federal Financial Reports. Completion Date: April 30, 2025, and September 1, 2025, respectively Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626
Department: Health and Human Services Administrative and Financial Services Judicial Branch Title: Internal control over Child Support Services expenditures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS and the Maine Judicial Branch will u...
Department: Health and Human Services Administrative and Financial Services Judicial Branch Title: Internal control over Child Support Services expenditures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS and the Maine Judicial Branch will update the Cooperative Agreement to strengthen policies, procedures, and oversight in order to ensure that expenditures are based on actual costs. Completion Date: March 31, 2026 Agency Contact: Jerry Joy, Director, Division of Support Enforcement and Recovery, DHHS, 207- 624-6985
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 Department will review and update ACF199/209 system processes within OFI and the ASPIRE Cont...
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 Department will review and update ACF199/209 system processes within OFI and the ASPIRE Contractor to enhance existing procedures to ensure that information reported on the ACF-199/209 is accurate and complete prior to submission to the Federal government. This will include modifying existing SOP as necessary. The Department 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. The Department will review the Work Verification Plan to identify opportunities to improve the processes created to accurately record and report on work participation data. Completion Date: June 30, 2026 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207-592-1481
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 ACF199 system processes within OFI and the ASPIRE Contracto...
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 ACF199 system processes within OFI and the ASPIRE Contractor to enhance existing procedures to ensure that information reported on the ACF-199 is accurate and complete prior to submission to the Federal government. This will include modifying existing SOPs as necessary. The Department will review the Work Verification Plan to identify opportunities to improve the processes created to accurately record and report on work participation data. Completion Date: June 30, 2026 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207-592-1481
Department: Health and Human Services Title: Internal control over Income Eligibility and Verification System procedures needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department has allocated TANF trained Eligibility Specialists to review the quar...
Department: Health and Human Services Title: Internal control over Income Eligibility and Verification System procedures needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department has allocated TANF trained Eligibility Specialists to review the quarterly income discrepancy report effective SFY 2026. Completion Date: July 1, 2025 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207-592-1481
Department: Defense, Veterans and Emergency Management Title: Internal control over National Guard cash management and the related financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will improve policies and procedures...
Department: Defense, Veterans and Emergency Management Title: Internal control over National Guard cash management and the related financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will improve policies and procedures to follow up on outstanding reimbursement requests to facilitate a more timely reimbursements from the Federal government. The Department will improve policies and procedures, including reconciling reimbursement activity to the State’s accounting system. The Department will improve and maintain effective internal control over Federal awards to provide reasonable assurance that the Department is managing awards in compliance with federal statutes, regulations and the terms and conditions of awards. The Department will review, update and document supervisory oversight. Completion Date: June 30, 2026 (first, second and third items), and May 30, 2026 (fourth item) Agency Contact: Diane Dunn, Commissioner, DVEM, 207- 430-5158
Department: Education Title: Internal control over CNC subrecipient audit monitoring needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Fiscal Review and Compliance Consultant: The Policy and Procedure manual will be updated to include regular monthly n...
Department: Education Title: Internal control over CNC subrecipient audit monitoring needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Fiscal Review and Compliance Consultant: The Policy and Procedure manual will be updated to include regular monthly notifications in a system (such as Microsoft Outlook) to update the audit tracking spreadsheet for accuracy. Regionalization and Compliance Coordinator: The Policy and Procedure manual will be updated to add a step to set up regular monthly notifications in a system (such as Microsoft Outlook) for the supervisor to review the audit tracking spreadsheet for accuracy and completion. Completion Date: April 30, 2026 Agency Contact: Nicole Denis, Director of Finance, DOE, 207-530-2161
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been pro...
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the 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: August 30, 2026, and October 1, 2026, respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department’s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protec...
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with the 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: March 16, 2026 (first through fourth items), April 1, 2026 (fifth and sixth items), and June 1, 2026 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been pro...
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the 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, 2026 (first, second and third items), September 1, 2026 (fourth item), July 31, 2026 (fifth item), November 30, 2026 (sixth item), and March 31, 2028 (seventh item) Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 2025-002: Significant Deficiency in Internal Control over Compliance – Allowable Costs Corrective Action Plan: With the implementation of the new UKG Payroll system in January 2026, the timesheet process now systematically reflects the ability for individuals to track time spent on individua...
Finding 2025-002: Significant Deficiency in Internal Control over Compliance – Allowable Costs Corrective Action Plan: With the implementation of the new UKG Payroll system in January 2026, the timesheet process now systematically reflects the ability for individuals to track time spent on individual grants when completing their timesheet. Name of Person Responsible for the Corrective Action Plan: Francene LaPoint, Chief Financial Officer and Brandon Wheatly, University Controller Anticipated Completion Date: January 30, 2026
Student Financial Assistance Cluster – 84.063 – Federal Pell Program Recommendation: We recommend the University should return the overawarded amount of $924 to the US Department of Education and should review and strengthen internal controls over Pell Grant calculations and disbursements to prevent...
Student Financial Assistance Cluster – 84.063 – Federal Pell Program Recommendation: We recommend the University should return the overawarded amount of $924 to the US Department of Education and should review and strengthen internal controls over Pell Grant calculations and disbursements to prevent future over-awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The institution will implement a recurring enrollment report for Pell-eligible students reflecting enrollment term and registered credits as of the date the report is run. The report will be reviewed weekly during summer terms and after census for fall and spring to identify enrollment changes impacting Pell eligibility. Names of the contact persons responsible for corrective action: Lauren Svanda, Director of Financial Aid Planned completion date for corrective action plan: 05/04/2026
Management Response: All staff will be required to complete annual trainings during the same time each year. This has already been implemented for the current fiscal year FY25-26. Tracking of staff trainings will be maintained monthly and filed in staff personnel files by a Human Resources staff.
Management Response: All staff will be required to complete annual trainings during the same time each year. This has already been implemented for the current fiscal year FY25-26. Tracking of staff trainings will be maintained monthly and filed in staff personnel files by a Human Resources staff.
Congressionally Directed Spending – 93.493 Recommendation: We recommend that the University reviews its procedures around review and approval of expenditures to ensure that only valid expenditures are reported. Explanation of disagreement with audit finding: There is no disagreement with the audit f...
Congressionally Directed Spending – 93.493 Recommendation: We recommend that the University reviews its procedures around review and approval of expenditures to ensure that only valid expenditures are reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The identified expenditures were removed from the award and appropriately reclassified in September 2025. In response to this finding, the University of Maine at Augusta (UMA) has increased the frequency of general ledger review for its federal awards from monthly to twice monthly. This review process includes a direct cross-reference between transactions and the approved award budget. This enhanced oversight allows for timely identification and correction of discrepancies. The UMA Finance Department has several initiatives underway which will mitigate the risk of similar mispostings in the future, including the implementation of a formal training program for staff as a preventative control. A monthly reconciliation and transaction level review process which will be completed with principal investigators is also being developed. These additional procedures are expected to be in place by May 2026 and will support a consistent and strong awareness of federal compliance requirements, award administration and University of Maine System policies and procedures. Name(s) of the contact person(s) responsible for corrective action: Mark Mantey, Assistant Director of Finance, University of Maine at Augusta Planned completion date for corrective action plan: May 2026 If the United States Department of Education or other agency has questions regarding this plan, please call Darla Reynolds at 207-262-7743 or darlab@maine.edu.
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