Corrective Action Plans

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The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
Finding 2026-004: Utility Allowances Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-007 Criteria: The Authority must maintain an up-to-date utility allowance schedule. The Authority must review utility rate data for each utility cate...
Finding 2026-004: Utility Allowances Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-007 Criteria: The Authority must maintain an up-to-date utility allowance schedule. The Authority must review utility rate data for each utility category each year and must adjust its utility allowance schedule if there has been a rate change of 10 percent or more for a utility category or fuel type since the last time the utility allowance schedule was revised (24 CFR section 982.517). Condition: The Authority had not updated utility rates since the April 1, 2021 effective date schedules. The Authority had obtained new utility rates during the fiscal year but the new schedules were not implemented. Cause: It was a finding in the prior year that the Authority did not update the utility allowances. The Authority contacted a company to perform the analysis but the Authority felt it was too expensive and then failed to calculate the rates itself. The Authority then contacted another company but the process has not yet been completed. Effect or Potential Effect: The Authority did not comply with the requirements of 24 CFR §982.517. Recommendation: The Authority should review the requirements of 24 CFR §982.517 and establish a system of where the utility allowance is reviewed and documented during each fiscal year. View of the Responsible Officials of the Auditee: The auditee's management agrees with the finding.
Finding 2026-003: HQS Quality Control Inspections Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-006 Criteria: 24 CFR §982.405 states the PHA must conduct supervisory qualify control HQS inspections. Condition: The Authority performe...
Finding 2026-003: HQS Quality Control Inspections Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-006 Criteria: 24 CFR §982.405 states the PHA must conduct supervisory qualify control HQS inspections. Condition: The Authority performed quality control inspections during the year; however, the Authority was not maintaining a log of inspections and had to search emails to find them. Further, the quality control inspections were not a random selection but selected by the original inspector. The Authority was not maintaining a log of all inspections for the quality control inspector to select from. Four of the 8 quality control inspections were done more than 90 days after the initial inspection. Cause: The Authority did not have procedures in place to randomly select inspections to perform quality control inspections on. Further, the Authority did not have a log of inspections and quality control inspections completed. Effect or Potential Effect: The Authority did not comply with the requirements of 24 CFR §982.405. Because inspections were not randomly selected, were not always performed within required timeframes, and were not adequately documented, the Authority did not have assurance that HQS inspections were being conducted consistently and in accordance with HUD requirements. Recommendation: The Authority should review the requirements of 24 CFR §982.405 and establish a system of where HQS inspections have a quality control sampling during each fiscal year. View of the Responsible Officials of the Auditee: The auditee's management agrees with the finding.
Finding 2026-002: Compliance, Inadequate Compliance Monitoring, Regulatory Oversight, and Governance Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2025-004 Criteria: Management is responsible for establishing and maintaining...
Finding 2026-002: Compliance, Inadequate Compliance Monitoring, Regulatory Oversight, and Governance Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2025-004 Criteria: Management is responsible for establishing and maintaining effective internal controls over compliance that provide reasonable assurance the Housing Choice Voucher Program is administered in accordance with Federal statutes, regulations, and HUD requirements. Effective controls should include adequate monitoring of compliance requirements, timely implementation of regulatory changes, maintenance of current policies and procedures, and oversight sufficient to compensate for staffing limitations. HUD program requirements and regulatory changes should be reviewed and incorporated into the Authority's Administrative Plan in a timely manner. Similar control expectations are reflected in HCV compliance guidance addressing policy maintenance, Board oversight, monitoring of regulatory changes, and compensating controls where segregation of duties is limited. Condition: The Authority operates only the Housing Choice Voucher Program and employs a single individual responsible for substantially all program administration and compliance responsibilities. Because staffing levels do not permit traditional segregation of duties, the Authority should have established compensating monitoring and oversight controls. However, our audit identified significant weaknesses in the Authority's internal control structure over compliance. Specifically, we noted: • Compliance responsibilities were concentrated in one individual without independent review or documented monitoring procedures. • The Administrative Plan had not been updated to incorporate applicable HOTMA requirements. • Board minutes indicated the Authority was relying upon HUD Notices H-2025-03 and H-2025-07 when evaluating HOTMA implementation. These notices do not apply to the Housing Choice Voucher Program and the Authority was not utilizing the correct guidance in HUD PIH Notices. • The Authority had not established procedures to identify, evaluate, and implement applicable HUD PIH notices and other regulatory updates affecting the Voucher program. • Audit testing identified deficiencies in multiple compliance areas, indicating that compliance monitoring controls were not operating effectively. The existence of compliance deficiencies across multiple program areas demonstrates that the Authority's controls were not reasonably designed or operating effectively to ensure compliance with Federal program requirements. Similar conditions have been identified in other HCV compliance control assessments, including lack of monitoring of regulatory changes, inadequate Board oversight, and insufficient compensating controls where staffing is limited. Cause: The Authority has not established an effective system of internal control over compliance. Management and the Board of Commissioners did not implement sufficient compensating controls to address the risks associated with a single-employee operating structure. In addition, procedures were not established to ensure that changes in HUD regulations, notices, and program requirements were identified, evaluated, and incorporated into Authority policies and operational practices on a timely basis. Effect: The lack of effective compliance oversight increases the likelihood that material noncompliance with Federal program requirements could occur and not be prevented, detected, or corrected timely. Failure to maintain current policies and implement regulatory changes increases the risk of noncompliance in areas including tenant eligibility, rent calculations, utility allowances, inspections, reporting, and other program requirements. The deficiencies identified during the audit demonstrate that the Authority's control environment does not provide reasonable assurance of compliance with Housing Choice Voucher Program requirements. Recommendation: We recommend the Authority: 1. Establish formal procedures for monitoring compliance with Housing Choice Voucher Program requirements. 2. Update the Administrative Plan to incorporate all applicable HOTMA requirements and other current HUD guidance. 3. Develop a process for reviewing HUD PIH notices, regulatory updates, and other program guidance as issued. 4. Implement documented supervisory or independent compliance reviews to compensate for the lack of segregation of duties. 5. Provide periodic compliance reports to the Board of Commissioners and document Board oversight of corrective actions. 6. Establish written procedures to ensure significant regulatory changes are timely evaluated, adopted, and implemented. Views of Responsible Officials The Authority agrees with the finding.
Views of Responsible Officials and Planned Corrective Actions – University personnel reviewed the four instances identified for untimely NSLDS reporting and determined that neither case resulted from a failed or rejected submission to the National Student Clearinghouse (NSC) or NSLDS. Rather, the ti...
Views of Responsible Officials and Planned Corrective Actions – University personnel reviewed the four instances identified for untimely NSLDS reporting and determined that neither case resulted from a failed or rejected submission to the National Student Clearinghouse (NSC) or NSLDS. Rather, the timing difference resulted from the enrollment status effective date used for NSC reporting, which did not align with the reporting roster submission cycle. The University reports enrollment information to NSLDS through the National Student Clearinghouse on a regular monthly basis and confirmed through review of NSC acknowledgment and error reports that no transmission errors occurred. To reduce the risk of similar timing differences in the future, the University is working on process improvements in coordination with Banner support, including ensuring backdated drops and withdrawals are processed prior to initial NSC transmissions each term, reviewing the timing of enrollment reporting submissions to improve data capture, strengthening procedures for monitoring post-census backdated status changes, continuing timely review of NSC error reports, reviewing enrollment status calculations for nonstandard coursework, and implementing pre-submission validation procedures to confirm all required status calculation and extract processes have been completed prior to NSC file transmission.
Finding 2026-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2027 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-e...
Finding 2026-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2027 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2026, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training cont...
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training controls over the application of the sliding fee discount schedules. The Director of Patient Services (or designee) will perform monthly audits of 25 randomly selected patients accounts that received a sliding fee discount to verify that the correct discount schedule was applied and that the patient responsibility was calculated accurately. In addition, for any future changes to the sliding fee discount schedule, management will implement a transition review process that includes: • Verification that the updated fee schedule is accurately loaded into the billing system prior to the effective date and old fee schedules are inactivated. • Additional training for billing staff before implementation of any revised sliding fee schedule. • Continued monthly audits of sliding fee discounted patient accounts. • Quarterly reporting of audit results to Chief Financial Officer, to identify recurring issues and ensure corrective actions taken are effective. Anticipated completion date: July 31, 2026
In Finding 2026-002, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended March 31, 2026. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s ...
In Finding 2026-002, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended March 31, 2026. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2026-002, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee policy.
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a p...
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2026 Estimated Completion Date: June 2026 Finding #2026-001 – Statement of Condition Patients did not receive the proper sliding fee ad...
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2026 Estimated Completion Date: June 2026 Finding #2026-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding, and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Coordination with Revenue Cycle Management has occurred to ensure awareness across teams. Office Managers review all new sliding fee applications on a monthly basis to ensure accuracy, and the Billing Manager conducts quarterly audits of sliding fee claims to ensure adjustments are entered correctly by the billing department. The Organization also continues to provide staff training for all individuals involved in the sliding fee application process. Management has instructed all outsourced billers not to modify sliding fee adjustments; any required changes must be handled by in-house billing staff. Additionally, sliding fee adjustments auto posted in error will be removed. Management is also working with IT to restrict system access for outsourced users to prevent unauthorized adjustments. Additionally, IT will implement a scheduled monthly audit report to identify improper adjustments and monitor user activity.
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discounts to certain patients who visited the Organization during the year ended March 31, 2026. In addition, sliding fee applications were not maintained for all patients who received sliding fee disco...
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discounts to certain patients who visited the Organization during the year ended March 31, 2026. In addition, sliding fee applications were not maintained for all patients who received sliding fee discounts. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2026-001, proper training will be given to employees and sliding fee applications and discounts will be reviewed by a supervisor on a monthly basis to ensure compliance with the sliding fee policy. The Organization will also establish procedures to ensure that sliding fee applications are maintained in accordance with the Organization’s policies.
Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications on a timely basis. Corrective Action Taken: 1. Immediate Review and C...
Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications on a timely basis. Corrective Action Taken: 1. Immediate Review and Correction Upon determination of the finding, we conducted a full review of the affected patient account. 2. Staff Training All Outreach and Eligibility staff have received refresher training on the proper application of the sliding fee scale, including income verification processes and documentation standards. This training now occurs as part of onboarding and annually thereafter. 3. Policy and Procedure Review We reviewed our internal policies and procedures to ensure clear guidance on income documentation requirements, allowable income sources, and how to properly apply the sliding scale. 4. Double-Verification Process A second-level review has been instituted for all new patient applications and renewals involving sliding fee scale determinations. This ensures that income is correctly assessed, and the appropriate fee level is applied before any charges are finalized. 5. Audit and Monitoring A quarterly internal audit process has been implemented to review a random sample of sliding fee scale determinations for accuracy. Findings from these audits will be tracked, and any trends will be addressed through targeted training or process changes. The corrective actions implemented in the prior year were maintained consistently throughout the current audit period. Based on our evaluation, the processes put in place were operating effectively as designed. The issue identified this year stemmed from front office personnel having access to modify SFS assignments after they had already been appropriately verified and assigned. This access created the opportunity for adjustments outside of the established control process. While the prior corrective actions were effective, we have identified the need for an additional control enhancement. Accordingly, an immediate control has been implemented (see item 6 below) to further restrict access and prevent unauthorized modifications. 6. EMR Restriction As a result of the additional finding identified in 2026, UCHC’s IT Department access to SFS assignments and modifications within the EHR will be restricted exclusively to the Eligibility Team. No other personnel will be permitted to make changes to SFS assignments. All requests for adjustments must be submitted to the Eligibility Team, which will be responsible for thoroughly reviewing and validating each request prior to implementing any changes.
Management agrees with the finding and will put processes and controls in place to verify timely deposits in the future. The required deposit of $4,477 was made in July 2025 to the residual receipts account. The corrective response has already been put into place for this fiscal year.
Management agrees with the finding and will put processes and controls in place to verify timely deposits in the future. The required deposit of $4,477 was made in July 2025 to the residual receipts account. The corrective response has already been put into place for this fiscal year.
Supportive Housing for Persons with Disabilities CFDA No. 14.181 U.S. Department of Housing and Urban Development (“HUD”) Criteria or Specific Requirement – Special Tests and Provisions: (24 CFR section 891.400(e)) Condition – The Organization is required to establish a separate project fund interes...
Supportive Housing for Persons with Disabilities CFDA No. 14.181 U.S. Department of Housing and Urban Development (“HUD”) Criteria or Specific Requirement – Special Tests and Provisions: (24 CFR section 891.400(e)) Condition – The Organization is required to establish a separate project fund interest bearing account in a federally insured depository. During the fiscal year the project fund was not in an interest-bearing account. Questioned Costs - None Context – During the fiscal year the project fund was not included in a interest bearing account. Effect – The Organization did not properly comply with the special test and provisions requirements. Cause – The Organization’s internal controls did not properly identify the project fund was not maintained in an interest-bearing account. Identification as a repeat finding – Not a repeat finding. Recommendation – The Organization should move the project fund into an interest-bearing account. Views of Responsible Officials and Planned Corrective Actions – During the 2027 fiscal year management will move the project fund to an interest-bearing account and implement procedures to periodically review the project fund and other HUD accounts for compliance with HUD requirements. This corrective action plan will be monitored by Nathan Mordica, Controller and Michael Jones, Director of Accounting, and is anticipated to be completed by the end of fiscal year 2027, or March 31, 2027.
Supportive Housing for Persons with Disabilities CFDA No. 14.181 U.S. Department of Housing and Urban Development (“HUD”) Criteria or Specific Requirement – Special Tests and Provisions: (24 CFR section 891.400(e)) Condition – The Organization is required to establish a separate project fund interes...
Supportive Housing for Persons with Disabilities CFDA No. 14.181 U.S. Department of Housing and Urban Development (“HUD”) Criteria or Specific Requirement – Special Tests and Provisions: (24 CFR section 891.400(e)) Condition – The Organization is required to establish a separate project fund interest bearing account in a federally insured depository. During the fiscal year the project fund was not in an interest-bearing account. Questioned Costs - None Context – During the fiscal year the project fund was not included in a interest bearing account. Effect – The Organization did not properly comply with the special test and provisions requirements. Cause – The Organization’s internal controls did not properly identify the project fund was not maintained in an interest-bearing account. Identification as a repeat finding – Not a repeat finding. Recommendation – The Organization should move the project fund into an interest-bearing account. Views of Responsible Officials and Planned Corrective Actions – During the 2027 fiscal year management will move the project fund to an interest-bearing account and implement procedures to periodically review the project fund and other HUD accounts for compliance with HUD requirements. This corrective action plan will be monitored by Nathan Mordica, Controller and Michael Jones, Director of Accounting, and is anticipated to be completed by the end of fiscal year 2027, or March 31, 2027.
Supportive Housing for Persons with Disabilities CFDA No. 14.181 U.S. Department of Housing and Urban Development (“HUD”) Criteria or Specific Requirement – Special Tests and Provisions: (24 CFR section 891.400(e)) Condition – The Organization is required to establish a separate project fund interes...
Supportive Housing for Persons with Disabilities CFDA No. 14.181 U.S. Department of Housing and Urban Development (“HUD”) Criteria or Specific Requirement – Special Tests and Provisions: (24 CFR section 891.400(e)) Condition – The Organization is required to establish a separate project fund interest bearing account in a federally insured depository. During the fiscal year the project fund was not in an interest-bearing account. Questioned Costs - None Context – During the fiscal year the project fund was not included in a interest bearing account. Effect – The Organization did not properly comply with the special test and provisions requirements. Cause – The Organization’s internal controls did not properly identify the project fund was not maintained in an interest-bearing account. Identification as a repeat finding – Not a repeat finding. Recommendation – The Organization should move the project fund into an interest-bearing account. Views of Responsible Officials and Planned Corrective Actions – During the 2027 fiscal year management will move the project fund to an interest-bearing account and implement procedures to periodically review the project fund and other HUD accounts for compliance with HUD requirements. This corrective action plan will be monitored by Nathan Mordica, Controller and Michael Jones, Director of Accounting, and is anticipated to be completed by the end of fiscal year 2027, or March 31, 2027.
Inadequate Support for Benefit Accuracy Measurement Reviews - UI - DLI - The Montana Department of Labor and Industry began retaining copies of the on-demand report generated from the Sun System upon learning of the concern. This process continued until October 2024, when staff confirmed that the ne...
Inadequate Support for Benefit Accuracy Measurement Reviews - UI - DLI - The Montana Department of Labor and Industry began retaining copies of the on-demand report generated from the Sun System upon learning of the concern. This process continued until October 2024, when staff confirmed that the newly developed view in the Montana Unemployment System Enhancement (MUSE) system was functioning as intended. The MUSE system now includes a real-time interface that compares its data with the Sun System, providing staff with immediate information to monitor the volume of items selected for workload sampling. Responsible Party - Robin Graham, Central Services Division Administrator, Montana Department of Labor and Industry Target Implementation Date - 12/31/2026
Inadequate Access and Privilege Controls - TANF - LIHEAP - CHIP - Medicaid - DPHHS - The Montana Department of Public Health and Human Services completed the development of its accounts matrix for the CHIMES eligibility system in October 2025 and implemented an enhanced process for conducting and do...
Inadequate Access and Privilege Controls - TANF - LIHEAP - CHIP - Medicaid - DPHHS - The Montana Department of Public Health and Human Services completed the development of its accounts matrix for the CHIMES eligibility system in October 2025 and implemented an enhanced process for conducting and documenting access reviews, including verification of user permissions. These improvements have been fully incorporated into routine operations, and the department has implemented all aspects of the audit recommendations. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 10/24/2025
Noncompliant Certified Payrolls - HPC - MDT - The Montana Department of Transportation partially concurs that there are late certified payrolls. To verify whether a certified payroll is warranted, contractor records—such as payroll cycle dates and corresponding Daily Work Report entries—must be revi...
Noncompliant Certified Payrolls - HPC - MDT - The Montana Department of Transportation partially concurs that there are late certified payrolls. To verify whether a certified payroll is warranted, contractor records—such as payroll cycle dates and corresponding Daily Work Report entries—must be reviewed. Comparing datasets can help identify items needing further examination, but an analytical review alone cannot determine whether a certified payroll is late. Each contractor follows its own payroll cycle, and federal requirements must be applied to the circumstances of each contractor. This concern was raised multiple times, and while some issues were addressed, the additional review needed to confirm the accuracy of the identified noncompliance remains unresolved. In communication with the department, the auditor stated that “we will never arrive at an exact number we can all agree on due to gaps in Daily Work Report data and an uncertain measurement metric.” This acknowledgment calls into question the reliability of the projected late payment rate and indicates the need for additional procedures to validate the assumptions and methodology used in the analytical review. The department manually recalculated the contractor identified as having the highest number of late submissions. This review resulted in a rate 47.53 percent lower than the auditor’s calculation; however, the auditor did not revise the analysis. This recalculation reflects only one contractor, and reviewing the remaining contractors would likely further reduce the overall percentage. The department will continue strengthening internal controls on overdue payrolls. The original payroll withholding specification lacked a standard calculation method, which led to inconsistent practices among project managers. The Contract Administration Section developed a standardized deduction table based on the awarded contract amount to ensure consistent application statewide. Specification language was also revised for clarity. Additionally, the Contract Administration Section developed a monthly overdue payroll report that will be sent to project managers around the fifteenth of each month. This report will help identify and address overdue payrolls before the monthly estimate cycle ends. The department will continue monitoring overdue payrolls, ensuring proper withholding on estimates, and providing guidance and additional training to project staff. A guide has also been provided to help staff document communication with contractors and apply correct withholding. Responsible Party - Kimberly Doherty, Accounting Systems Supervisor, Montana Department of Transportation Dustin Rouse, Chief Engineer, Montana Department of Transportation Target Implementation Date - 12/31/2026
Inadequate User Access Reviews - HPC - MDT - The Montana Department of Transportation has implemented a security review for AASTHOWare to ensure compliance in 2026. Responsible Party - Kimberly Doherty, Accounting Systems Supervisor, Montana Department of Transportation Dustin Rouse, Chief Engineer,...
Inadequate User Access Reviews - HPC - MDT - The Montana Department of Transportation has implemented a security review for AASTHOWare to ensure compliance in 2026. Responsible Party - Kimberly Doherty, Accounting Systems Supervisor, Montana Department of Transportation Dustin Rouse, Chief Engineer, Montana Department of Transportation Target Implementation Date - 12/31/2026
Inadequate Supporting Documentation - Disaster Grants - DMA - The Montana Department of Military Affairs, Disaster and Emergency Services Division partially concurs. The Division validated the reviewed project costs through its internal review and through additional Federal Emergency Management Agen...
Inadequate Supporting Documentation - Disaster Grants - DMA - The Montana Department of Military Affairs, Disaster and Emergency Services Division partially concurs. The Division validated the reviewed project costs through its internal review and through additional Federal Emergency Management Agency (FEMA) processes, including the Validate As You Go procedure, and determined the costs to be allowable. The division acknowledges the cited federal compliance criteria and recognizes the opportunity to strengthen the consistency, accessibility, and retention of project documentation. To enhance existing processes, the division has implemented a standardized project file structure that clearly identifies the location of supporting documentation and ensures official grant files are complete rather than relying solely on documentation stored within federal systems. This process is being applied to the disasters that occurred in December 2025 and were federally declared in April 2026. The division will continue to evaluate and refine its documentation practices while maintaining appropriate controls, reviews, validations, payments, and closeout procedures for federally funded projects. Responsible Party - Janae Brower, Chief Financial Officer, Montana Department of Military Affairs Target Implementation Date - 10/31/2026
Inadequate Provider Eligibility Controls - CHIP - DPHHS - The Montana Department of Public Health and Human Services does not concur. The department’s existing screening and enrollment controls satisfy the requirements of 42 CFR 455.410 and 455.412, and the federal grantor agency has already reviewe...
Inadequate Provider Eligibility Controls - CHIP - DPHHS - The Montana Department of Public Health and Human Services does not concur. The department’s existing screening and enrollment controls satisfy the requirements of 42 CFR 455.410 and 455.412, and the federal grantor agency has already reviewed and formally closed this finding based on those controls, as described below. The department implemented enhanced internal controls in fiscal year 2025 in direct response to prior single audit recommendations. Under these controls, the department receives and reviews a comprehensive quarterly screening report from its contractor and requires documented follow‑up when necessary. The federal grantor agency reviewed the department’s enhanced procedures, the contractor’s screening methodology, and the validation results, and closed the single audit finding, confirming the controls were adequate. In January 2025, the contractor provided a validation in which active National Provider Identifiers (NPIs) were compared against the Montana Medicaid file and the Provider Enrollment, Chain and Ownership System (PECOS). The validation confirmed a 96‑percent match rate requiring no further screening or enrollment actions, leaving only 4 percent of providers for the contractor to screen and enroll under federal requirements. Upon later audit inquiry, the department again consulted the federal agency. While reiterating regulatory expectations, the federal agency clarified that “the form and manner” of oversight activities remain within the state agency’s discretion. Given this explicit federal affirmation, together with the agency’s prior closure of the finding, the department maintains that its controls are fully compliant and effective and respectfully disagrees with the audit finding. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - N/A
Inadequate Internal Controls Over Certified Payrolls - AIP - DOA - The Montana Department of Administration partially concurs with the finding. While the department oversees construction activities, it has consistently informed agencies that they retain responsibility for grant administration and fe...
Inadequate Internal Controls Over Certified Payrolls - AIP - DOA - The Montana Department of Administration partially concurs with the finding. While the department oversees construction activities, it has consistently informed agencies that they retain responsibility for grant administration and federal reporting for grants awarded directly to them. Each agency is responsible for notifying the Department of all applicable grant requirements, guidance, and restrictions. In this instance, the department understood that the Montana Department of Transportation approved invoices reflecting the federal and non-federal funding split only after receiving the contractor’s Statement of Compliance for all pay periods included in the invoicing period. Due to limited time to respond to the audit finding, the department was unable to confirm with its contracted engineering firm the specific dates the certified payrolls were received and verified. To strengthen future compliance, the department will include language in project memoranda of understanding assigning responsibility for federal wage-rate compliance and record keeping to the agency that received the federal grant. The department will also implement internal controls requiring agencies to confirm that certified payroll requirements have been verified before payments are processed. Responsible Party - Russell Katherman, Administrator of Architecture and Engineering , Montana Long Range Building, Montana Department of Administration Target Implementation Date - 12/31/2026
Noncompliant Return of Uncashed Title IV Funds - SFA - MSU - The Montana State University - Bozeman concurs with the finding. A process has now been implemented for Higher Education Act loans in addition to Parent Loans for Undergraduate Students. This process has been formally documented, and the U...
Noncompliant Return of Uncashed Title IV Funds - SFA - MSU - The Montana State University - Bozeman concurs with the finding. A process has now been implemented for Higher Education Act loans in addition to Parent Loans for Undergraduate Students. This process has been formally documented, and the University will continue to provide cross-training on these procedures. Responsible Party - Ryan Christensen, Director of Student Accounts, Montana State University - Bozeman Target Implementation Date - 8/31/2026
Noncompliant Incentive Compensation Controls - SFA - MSU - The Montana State University - Bozeman concurs with the finding. Since approximately 2023, language has been included on the lump-sum bonus form that prohibits any bonus for classified staff related to the recruitment or admission of student...
Noncompliant Incentive Compensation Controls - SFA - MSU - The Montana State University - Bozeman concurs with the finding. Since approximately 2023, language has been included on the lump-sum bonus form that prohibits any bonus for classified staff related to the recruitment or admission of students. Any bonus request submitted to the Office of the Commissioner of Higher Education for contract employees is reviewed and approved by the University's Compensation Advisory Council, which also reviewed these federal regulations. In December 2024, the Montana University System Staff Compensation Plan was updated to explicitly exclude such payments. Responsible Party - Jeannette Grey Gilbert, Chief Human Resources Officer, Montana State University - Bozeman Target Implementation Date - 12/31/2024
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