Corrective Action Plans

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A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s T...
A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s TPL data is not good enough to reject encounter claims from the MCO’s. EOHHS continues to work on improving the TPL process specifically cleaning up the TPL data in the MMIS and eligibility system today. Future system enhancements include a direct TPL vendor and new TPL module which should improve TPL accuracy. Anticipated Completion Date: July 31, 2028 Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov
EOHHS is in agreement with these findings and is in the process of working with Gainwell and its managed care partners to address these discrepancies. The providers that were not properly subjected to EOHHS’s enrollment processes were out of network providers within one of the managed care plans’ na...
EOHHS is in agreement with these findings and is in the process of working with Gainwell and its managed care partners to address these discrepancies. The providers that were not properly subjected to EOHHS’s enrollment processes were out of network providers within one of the managed care plans’ national network provider management system. These providers have been incorrectly included in provider network data as this managed care plan is in the process of end-dating these providers, which will resolve this discrepancy. EOHHS has reorganized Provider Enrollment oversight functions under the Office of Program Integrity (OPI) in alignment with federal standards, and as such will continue to audit and monitor enrollment files to ensure compliance with state and federal requirements. OPI is formalizing a process to swiftly terminate providers who have lost their licensure, as well as randomly auditing enrollment files to ensure proper licensure. Additionally, EOHHS will begin collecting DCYF licensure data as required. Anticipated Completion Date: December 31, 2026 Contact Persons: Nicholas James, Implementation Director of Policy and Programs, Executive Office of Health and Human Services nicholas.james@ohhs.ri.gov Rob Tingle, Chief of Program Analytics, Executive Office of Health and Human Services robert.tingle@ohhs.ri.gov
EOHHS understands that the audit findings primarily resulted from three items: 1. Lack of management oversight of the AlloCAP system’s functionality and its effect on financial reporting. 2. The use of incorrect FMAPs on sister agencies’ quarterly administrative claiming reports submitted to Medicai...
EOHHS understands that the audit findings primarily resulted from three items: 1. Lack of management oversight of the AlloCAP system’s functionality and its effect on financial reporting. 2. The use of incorrect FMAPs on sister agencies’ quarterly administrative claiming reports submitted to Medicaid Finance, and Medicaid’s subsequent lack of review of these reports. 3. No segregation of duties in the Assistant Director Financial and Contract Management position within the EOHHS Central Management finance team. Several actions have been taken to enhance oversight of the AlloCAP system functionality and improve the overall cost allocation process, including hiring an Administrator, Financial Management position. This position has been cross trained and is completing the quarterly AlloCAP activities with review completed by the Assistant Director Financial and Contract Management position. Management’s additional correction action plans for each of these are below. 1. Finance will request a SOC I Type II report from its AlloCAP vendor. The report(s) will be shared with CFOs at all agencies using the AlloCAP system for Medicaid allocations for their review. 2. Finance has already implemented controls to rectify this finding. The items below were implemented during SFY 2026. a. Additional training for sister agencies on the administrative claiming reporting process. Trainings were held on February 4th and April 15th, 2026, and included the importance of the correct FMAP and a list of FMAPs by CMS-64 line item. b. Office hours with Medicaid administrative claiming agencies prior to the submission of quarterly expenditure reports. This allows agencies to ask questions and troubleshoot possible issues prior to report submission. c. Medicaid Finance review of all agency-submitted quarterly expenditure reports. This includes checking that: i. the reported federal amounts tie to the quarterly draw down amount. If there is a variance, the variance must be explained and documented for future reconciliation; ii. FMAPs are used and align with CMS-64 line item FMAPs; iii. The reported federal amounts do not exceed CMS-64 line item budgets (when applicable). d. Training additional Medicaid Finance staff on the review of agency submitted reports and data entry to separate staff duties and allow for double-checking of staff work. Finance will continue to refine improvements and implement processes to ensure reporting accuracy, including drafting relevant SOPs. Additionally, Medicaid Finance retained a contractor that has worked with other states to review the CMS-64 claiming process to suggest further areas of improvement and automation. 3. EOHHS will continue to explore options for improving controls over AlloCAP system functionality and cost allocation work. 4. Finance staff across EOHHS and Medicaid teams will detail additional controls and recommendations for implementation. Anticipated Completion Date: September 1, 2026 Contact Persons: Dezeree Hodish, Associate Director, Financial Management, Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov Victoria Pavao, Assistant Director, Financial and Contract Management, Executive Office of Health and Human Services victoria.pavao@ohhs.ri.gov
2025-032a: MMIS system access is controlled via an electronic system called GainwellNow. An MMIS access request form must be completed by the requestor, signed by that individual and their supervisor, and then sent to the Systems Group staff members who are responsible for approving or denying acces...
2025-032a: MMIS system access is controlled via an electronic system called GainwellNow. An MMIS access request form must be completed by the requestor, signed by that individual and their supervisor, and then sent to the Systems Group staff members who are responsible for approving or denying access requests. The Systems Group will sign the request form and approve the request within GainwellNow and the requestor will be granted access. The GainwellNow system also generates and sends email notifications to the Systems Group Administrators notifying them of a pending access request if the requestor enters it into GainwellNow directly. From there, the same approval/denial process occurs. If an individual has not logged into MMIS for 30 days, then they require a password reset in order to regain access. Those password reset requests create system generated emails that are sent to the Systems Group Admins for approval or denial. After 60 days of inactivity, the individual is locked out and cannot access the MMIS without requesting and obtaining approval of the password reset. If someone leaves state employment, then the Systems Group Admins submit an access deletion request into GainwellNow, deleting the account completely. Gainwell Technologies also sends monthly access reports to the Systems Group for review and confirmation that account deletion requests were completed as submitted. Additionally, Gainwell sends monthly “New or Deleted Users” reports to the Systems group for review. For IT security, the Systems Group receives and reviews the following reports: · RI-CDM-ASQC-Security-Report · RI-CSHARP-ASQC-Security-Report · RI-Java-ASQC-Security Report · RI-XIX-DR Exercise Scope · RI-XIX-DR Executive Summary Report 2025-032b: The Arc-Ampe (formerly called MARS-E) third party assessment is underway. Security scanning and testing is complete, and security controls have been evaluated. Final report is due by 6/30/2026. Remediation of legitimate vulnerabilities is underway and defects are tracked on the RIBridges POAM. 2025-032c: EOHHS/Medicaid will work collaboratively with ETSS and their vendors to proactively assess critical risk areas planned for the review year. 2025-032d: For RIBridges, SOC engagements occur every other year. A third-party Attestation of the Arc-Ampe controls occurs annually. The state can evaluate the results of this year’s upcoming SOC audit to determine if an increased frequency of the SOC is needed. Anticipated Completion Dates: 2025-032a: EOHHS believes this item to be complete and will defer to OAG for resolution of this finding. 2025-032b: High findings – 30 days, moderate findings – 90 days, low findings – 365 days. July 31, 2027. 2025-032c: Ongoing 2025-032d: December 31, 2026 Contact Persons: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov Deb Merrill, Security Officer, ETSS, Department of Administration deb.merrill@doit.ri.gov Brian Tichenor, Medicaid Systems Manager, Executive Office of Health and Human Services brian.tichenor@ohhs.ri.gov
DCYF will continue to work with Public Consulting Group to ensure that eligibility quality control reviews are performed in a timely manner. Anticipated Completion Date: Ongoing Contact Person: Kimberly Reynolds, Associate Director of Financial Management, Department of Children, Youth and Families ...
DCYF will continue to work with Public Consulting Group to ensure that eligibility quality control reviews are performed in a timely manner. Anticipated Completion Date: Ongoing Contact Person: Kimberly Reynolds, Associate Director of Financial Management, Department of Children, Youth and Families kim.reynolds@dcyf.ri.gov
Management agrees with the finding regarding health and safety requirements for timely unannounced monitoring visits. While several providers identified in the audit did receive a monitoring visit within 60 days of the annual due date, the Licensing Department experienced delays in completing some m...
Management agrees with the finding regarding health and safety requirements for timely unannounced monitoring visits. While several providers identified in the audit did receive a monitoring visit within 60 days of the annual due date, the Licensing Department experienced delays in completing some monitoring visits due to staff shortages and employee leave. To address the backlog and prioritize oversight activities, The Department has implemented a team-based prioritization approach rather than individual caseload management. This approach allows the unit to prioritize providers with the greatest need for monitoring and ensure that available resources are directed toward the highest-risk areas. The Department is actively working to increase staffing capacity within the unit. The Department is currently onboarding four new staff members to address existing vacancies and has recently received two additional FTE positions to further support monitoring activities. The unit continues to manage the impact of two staff members being out on extended medical leave with undetermined return dates; however, despite these staffing challenges, the unit has completed 423 monitoring visits since January 1, 2026. The Department will continue to monitor progress toward eliminating the backlog, strengthening system processes, and ensuring timely completion and documentation of required unannounced monitoring visits. DHS has also implemented enhanced monitoring capabilities within RISES. The system now generates automated notifications to the Licensing Department at established intervals before monitoring visits are due for both child care centers and family child care programs. These automated reminders strengthen monitoring workflows, improve oversight of upcoming monitoring requirements, and support the timely completion of unannounced visits. In addition, RISES has strengthened the Department's ability to consistently track provider compliance, document corrective actions, and identify providers requiring increased oversight. These enhanced monitoring tools have improved accountability by providing greater visibility into provider compliance and enabling licensing staff to more effectively prioritize regulatory activities based on risk. Management does not concur with the findings related to corrective action plans and inspections but has implemented various enhancements to support streamlined processes in these areas since the audit time period. As discussed during the audit, several factors affect the timing and applicability of required inspections and do not necessarily indicate provider noncompliance. For example, radon testing may only be conducted during specific times of the year. Providers may make timely efforts to schedule testing but be unable to obtain an inspection due to limited inspector availability or because the request falls outside the allowable testing window. In these circumstances, DHS does not consider the provider to be out of compliance. Similarly, fire inspections must be completed by the State Fire Marshal's Office. In recent years, staffing challenges have affected the ability to complete inspections within standard timeframes, despite providers' efforts to obtain them. When a provider has a history of compliant fire inspections, the Licensing Department accepts documentation demonstrating the provider's attempt to schedule the required inspection and may proceed with license renewal while awaiting the inspection. Additionally, lead inspections are not required for facilities constructed after the applicable regulatory date and are not required for school-age programs. During the audit process, DHS identified several providers flagged for inspection concerns that appeared to fall into one or both of these exempt categories. To strengthen compliance monitoring, RISES now generates automated notifications beginning 90 days before inspection expiration dates. DHS has already observed improved provider responsiveness in renewing required inspections and will continue to use RISES to proactively monitor inspection status and work with providers to maintain current inspection documentation. Regarding corrective action plans, under the previous licensing system, providers submitted corrective action plans and supporting documentation directly to the assigned licensor. This is typically through email. As a result, documentation was often maintained outside of the licensing system and may not have been consistently reflected in the inspection record. If the corrective action or follow-up information was not documented within the system or the inspection status was not updated, the report could continue to appear as pending, even when the provider had submitted the required information. To address this limitation, DHS intentionally designed the RISES system to centralize the corrective action process. Following an inspection, the report is issued to the provider through RISES, where the provider is required to submit a corrective action plan directly within the system. The corrective action plan is then routed to DHS for review and approval, creating a documented workflow and improving the consistency and completeness of recordkeeping. If a provider does not submit a corrective action plan, DHS is able to identify the outstanding item within RISES and determine whether a follow-up inspection is warranted to verify that the noncompliance has been addressed. Currently, DHS prioritizes follow-up for high-risk noncompliance, including issues related to facilities, background checks, staff-to-child ratios and supervision, and infant and toddler care. Anticipated Completion Date: This corrective action has since been completed through the implementation of the 2026 requirement that all regulated providers utilize RISES. Contact Person: Nicole Chiello, Associate Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov
Management concurs with the findings related to controls over child care eligibility determinations and provider payments. Management notes that the number and scope of findings identified in the current audit have been substantially reduced compared to prior Single Audits, reflecting continued prog...
Management concurs with the findings related to controls over child care eligibility determinations and provider payments. Management notes that the number and scope of findings identified in the current audit have been substantially reduced compared to prior Single Audits, reflecting continued progress in strengthening internal controls. The Office of Child Care remains committed to enhancing eligibility determination processes and related internal controls, including ensuring that required eligibility documentation is consistently maintained in the electronic case record. Corrective actions to address the remaining findings, along with the anticipated completion dates, are outlined below. [See Corrective Action Plans for table.] In addition to the corrective actions outlined above, the Department is strengthening supervisory oversight through implementation of routine pre-authorization quality reviews and standardized supervisory monitoring practices. Supervisors will utilize these tools as part of ongoing quality assurance activities to verify that required eligibility documentation is complete prior to authorization, identify recurring error trends, and provide targeted coaching, training, and process improvements to strengthen program integrity and reduce future eligibility errors. Management agrees with the recommendation to evaluate modifications to the existing eligibility system to support eligibility determinations under the CCAP Child Care Staff program. The Department previously assessed the feasibility of modifying RIBridges to accommodate eligibility determinations for the CCAP Child Care Educators and Child Care Staff pilot program. At that time, implementation was not feasible due to competing system development priorities, limited vendor development capacity, and the pilot status of the program. Since the period covered by the audit, the Department has implemented a requirement that participants in the pilot program also apply for the traditional CCAP program. This change has strengthened documentation requirements and helped mitigate risks associated with incomplete eligibility documentation. While these interim measures have improved program administration, the Department recognizes that administering eligibility determinations outside of the primary eligibility system is not a sustainable long-term approach. Accordingly, the Department is reassessing the future administration of the pilot program and evaluating options to incorporate eligibility determinations into RIBridges or, alternatively, to develop the functionality within RISES and integrate it with RIBridges. The Department will determine the most appropriate path forward based on program needs, system capabilities, and available resources to ensure a sustainable and well-controlled eligibility process. Additionally, the Department has strengthened controls over provider payments for the CCAP Child Care Staff pilot program since the audit period. Prior to each payment, the CCAP program team reviews the copayment workbook to identify and resolve discrepancies between pilot program payments and traditional CCAP benefits. In addition, the CCAP Finance team performs a formal review of each payment workbook before payments are processed. The vendor supporting the pilot has also enhanced its payment file process by implementing an additional level of financial review by the project team prior to submission and incorporating safeguards to identify attendance records that may have been previously paid, reducing the risk of duplicate payments. The Department has established procedures to recover identified overpayments, including both one-time recoveries through withholding from future pilot payments, where appropriate, and a formal recoupment process for providers who are no longer participating in the pilot program. These enhanced controls are intended to strengthen payment accuracy and support effective stewardship of program funds. Anticipated Completion Dates: See table above Contact Person: Nicole Chiello, Associate Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov
During the audit period, responsibility for FFATA reporting transitioned among multiple staff due to staffing changes, which contributed to untimely reporting. To strengthen internal controls and ensure continuity of operations, DHS will cross-train multiple employees on FFATA reporting requirements...
During the audit period, responsibility for FFATA reporting transitioned among multiple staff due to staffing changes, which contributed to untimely reporting. To strengthen internal controls and ensure continuity of operations, DHS will cross-train multiple employees on FFATA reporting requirements and reporting procedures. In addition, DHS will establish a standardized reporting calendar, designate primary and backup staff responsible for FFATA submissions, and implement a supervisory review process to verify that all required subaward reports are submitted timely and in accordance with federal reporting requirements. These actions are intended to strengthen monitoring controls, reduce the risk of reporting delays, and ensure ongoing compliance with FFATA reporting requirements. Anticipated Completion Date: July 31, 2026 Contact Person: Ben Quattrucci, Assistant Director, Financial Contract Management, Department of Human Services benjamin.a.quattrucci@dhs.ri.gov
The Department updated Policy (218-RICR-20-002) to reflect 45 CFR 205.55, including procedures for using IEVS interfaces and incorporating the resulting information into eligibility determinations. The updated policy will be sent to OMB 7/1/26. Additionally, the updated policy will be discussed at m...
The Department updated Policy (218-RICR-20-002) to reflect 45 CFR 205.55, including procedures for using IEVS interfaces and incorporating the resulting information into eligibility determinations. The updated policy will be sent to OMB 7/1/26. Additionally, the updated policy will be discussed at meetings (Office Hours, Training consultations, and Quarterlies). System interfaces will run on a quarterly basis consistent with the language in 45 CFR §205.55 regarding all applicants. This process is being tracked and prioritized in BRR-141767 which is the ticket number used to communicate with the vendor. In addition, DHS is strengthening operational controls to ensure required IEVS interfaces are executed, reviewed, and acted upon within required federal timeframes. Supervisors will monitor outstanding interface matches and timeliness of case actions as part of routine quality assurance activities to ensure interface information is appropriately evaluated, documented within the electronic case record, and incorporated into eligibility determinations. These actions will be supported by the Department's broader supervisory quality assurance and pre-authorization review initiatives to improve verification accuracy, ensure timely processing of electronic data matches, and reduce future eligibility errors. The Department also notes that a portion of the untimely processing identified during the audit occurred during the RIBridges cybersecurity incident, when staff were operating under documented Business Continuity Plan (BCP) procedures to restore critical operations and address processing backlogs. While these circumstances contributed to delays during the audit period, the Department recognizes the need to strengthen routine controls and has implemented the corrective actions described above. Information security enhancements are further addressed in response to Finding 2025-032. Anticipated Completion Date: Ongoing – The process of posting updated policy and then the public comment period historically takes about 6 months. Disseminating information to staff regarding the policy updates will begin July 2026 and continue until saturation. Contact Person: Donna Rook, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov
Any missing or incomplete policy and procedure items identified during the audit process are currently in the process of being included in a revised draft of the Corporation’s federal grants policy manual. The Corporation expects a revised and all-encompassing version of the manual to be finalized a...
Any missing or incomplete policy and procedure items identified during the audit process are currently in the process of being included in a revised draft of the Corporation’s federal grants policy manual. The Corporation expects a revised and all-encompassing version of the manual to be finalized and filed by the end of March 2026. Anticipated Completion Date: March 31, 2026 Contact Person: Justin Medeiros, Senior Controller / CFO, Rhode Island Commerce Corporation justin.medeiros@commerceri.com
Management agrees with this finding and will improve the documentation of subrecipient audit report reviews to include notation of whether any findings in the single audit report pertained to the CPF subaward require a management decision in accordance with Uniform Guidance and whether any other fin...
Management agrees with this finding and will improve the documentation of subrecipient audit report reviews to include notation of whether any findings in the single audit report pertained to the CPF subaward require a management decision in accordance with Uniform Guidance and whether any other findings reported could indirectly impact the administration of the subaward. Management will add the following fields to the Pandemic Recovery Office’s reviewing document titled “PRO Fin Risk Template -DOA-PRO-LTCTR4”: 1. Does the Single Audit report include any findings pertaining to the CPF subaward? (YES/NO) 2. Are there any other findings reported that could indirectly impact the administration of the subaward? (YES/NO) Anticipated Completion Date: Immediately but no later than August 31, 2026. Contact Persons: Paul Dion, Director, Pandemic Recovery Office, Department of Administration paul.l.dion@doa.ri.gov Sagree Sharma, Capital Projects Fund Administrator, Pandemic Recovery Office, Department of Administration sagree.sharma@doa.ri.gov
Management agrees with the finding that subrecipient monitoring procedures were insufficient to ensure subrecipient audit reports are obtained and reviewed. Monitoring procedures were not in place to ensure adequate documentation was obtained regarding the use of payment advances. The Pandemic Recov...
Management agrees with the finding that subrecipient monitoring procedures were insufficient to ensure subrecipient audit reports are obtained and reviewed. Monitoring procedures were not in place to ensure adequate documentation was obtained regarding the use of payment advances. The Pandemic Recovery Office has communicated with the Executive Office of Housing on the best practices to be employed to ensure that effective subrecipient monitoring takes place. To that end the Executive Office of Housing has implemented policies and procedures to: • Ensure the timely review of subrecipient audit reports and the issuance of management decisions in accordance with the Uniform Guidance. In particular, the Executive of Housing (EOH) now requires that subrecipients submit their Single Audit Report or financial audit report when submitting for annual funding. At that time, these reports are reviewed by EOH, and action is taken as needed regarding management decisions. • Develop and implement internal controls to ensure that adequate documentation of monitoring procedures and support for subrecipient expenditures is obtained. EOH executes periodic site visits of subrecipients at which time expenditures are reviewed and documentation for said expenditures is obtained (i.e., invoices, demonstration of services performed, etc.). • Strengthen and improve subrecipient monitoring procedures to ensure compliance with the terms and conditions of the grant award. PRO will communicate to EOH the need to provide the proper reconciliation documentation for payment advances made to subrecipients and acquire supporting documentation for reimbursement of subrecipient expenditures. • Enhance controls to ensure all award identifying information required by 2 CFR §200.332(b)(1) is accurately included in the subaward. PRO will reiterate to EOH the need for subrecipients to have an accurate Unique Entity Identification (UEI) number, issued by SAM.gov, to receive funding under the State Fiscal Recovery Fund and/or the Emergency Rental Assistance programs. Further, EOH will review all subawards to ensure that every subaward includes the Federal Award Identification Number, Assistance Listing Number, and program title. Anticipated Completion Date: September 30, 2026 Contact Persons: Paul Dion, Director, Pandemic Recovery Office, Department of Administration paul.l.dion@doa.ri.gov Brianna Ruggiero, Chief of Staff, Pandemic Recovery Office, Department of Administration brianna.ruggiero@doa.ri.gov
2025-034a: We appreciate the work performed by OAG and understand the importance of the SAR. While the noted exception, was an isolated incident, our internal control was lacking. We do have compensating controls in place to identify potential noncompliance with the registration requirement, this is...
2025-034a: We appreciate the work performed by OAG and understand the importance of the SAR. While the noted exception, was an isolated incident, our internal control was lacking. We do have compensating controls in place to identify potential noncompliance with the registration requirement, this isolated transaction did not appear on the daily error report. ETSS is investigating how this occurred and will ensure that similar exception do not occur in the future. We will also use your recommendation as an opportunity to review and modify any control deficiencies related to the current legacy limitations. For example, not having a field on the AS400 to capture the dependent SS#, after initial application is filed. 2025-034b: DLT’s 2024 Systems Modernization Strategic Plan outlines long-term efforts to enhance system integration, automation, and data monitoring capabilities. RI DLT Modernization Strategic Plan - 2024.pdf. The Department is actively evaluating the feasibility of financing this effort. 2025-034c: UI Administration will consult with DLT legal office to update applicable regulations. Anticipated Completion Dates: 2025-034a: October 31, 2026 2025-034b: Ongoing 2025-034c: October 31, 2026 Contact Person: Sarah Fresch, Deputy Director, COO, Department of Labor and Training sarah.fresch@dlt.ri.gov Philip D’Ambra, Deputy Director (Income Support) UI Director, Department of Labor and Training Philip.l.dambra@dlt.ri.gov
FINDINGS 2025-003 Contact person responsible for Corrective Action: Christi McElhaney, City Clerk Treasurer Contact phone number: 260-356-1400 x2016 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The City continues to implement controls when contrac...
FINDINGS 2025-003 Contact person responsible for Corrective Action: Christi McElhaney, City Clerk Treasurer Contact phone number: 260-356-1400 x2016 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The City continues to implement controls when contracted consultants are assisting with projects, to ensure grant reports are properly reviewed and approved by a designated City employee before being submitted. Anticipated completion date: July 31, 2026
FINDINGS 2025-002 Contact person responsible for Corrective Action: Christi McElhaney, City Clerk Treasurer Contact phone number: 260-356-1400 x2016 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The City continues to develop and implement controls ...
FINDINGS 2025-002 Contact person responsible for Corrective Action: Christi McElhaney, City Clerk Treasurer Contact phone number: 260-356-1400 x2016 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The City continues to develop and implement controls that will ensure that all vendors used for Federal Grants will be checked for suspended and debarment within the SAM.gov website and/or include in the contract with the vendor. Anticipated completion date: July 31, 2026
Finding 2025-002 Subject: Drinking Water State Revolving Fund (DWSRF) - Suspension and Debarment Federal Agency: U.S. Department of Environmental Protection Agency Federal Program: Drinking Water State Revolving Fund (DWSRF) Assistance Listing Number: 66.468 Federal Award Number: DW24414504 Pass-Thr...
Finding 2025-002 Subject: Drinking Water State Revolving Fund (DWSRF) - Suspension and Debarment Federal Agency: U.S. Department of Environmental Protection Agency Federal Program: Drinking Water State Revolving Fund (DWSRF) Assistance Listing Number: 66.468 Federal Award Number: DW24414504 Pass-Through Entity: Indiana Finance Authority Compliance Requirements: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: David B. Benson Contact Phone Number and email Address: 219-662-3235 (office) dbenson@crownpoint.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: In 2026 the City will continue to institute the control of requiring each Drinking Water State Revolving Fund (DWSRF) payment being reviewed and confirming the vendor has neither been suspended or debarred by one of three methods. These methods include certification through the contract, checking on SAM EPLS or a signed certification from the vendor. Anticipated Completion Date: 12/31/2026
Finding 2025-001 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Number and Year:...
Finding 2025-001 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Number and Year: CY2024 Compliance Requirement: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: David B. Benson Contact Phone Number and email Address: 219-662-3235 (office) dbenson@crownpoint.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: In 2026 the City will continue to institute the control of requiring each CSLRFR payment being reviewed and confirming the vendor has neither been suspended or debarred by one of three methods. These methods include certification through the contract, checking on SAM EPLS or a signed certification from the vendor. Anticipated Completion Date: 12/31/2026
Finding 1224916 (2025-002)
Material Weakness 2025
Corrective Action: What we've already been doing to correct the issue LifeWire has strengthened oversight within Services by consolidating the Services and Rapid Rehousing programs under a single Director, creating clearer accountability for expenditure documentation. The expanded multi-tier approva...
Corrective Action: What we've already been doing to correct the issue LifeWire has strengthened oversight within Services by consolidating the Services and Rapid Rehousing programs under a single Director, creating clearer accountability for expenditure documentation. The expanded multi-tier approval workflow (Advocate → Manager → Director → Finance) now includes a documentation completeness check at each stage, requiring that underlying support for all charges be attached and verified before a transaction advances toward payment. LifeWire has updated its policies and procedures to explicitly require that underlying documentation supporting the nature and amount of each expenditure be retained at the time the charge is generated from the program services department, consistent with 2 CFR §200.403(g). This will include clear guidance on what constitutes sufficient documentation (e.g., invoices, receipts, lease agreements, or other source documents) and the requirement that payment confirmation alone is not sufficient. What else we are putting in place LifeWire has implemented training for all Services staff on federal documentation standards, reinforcing that charges to federal programs must be supported by documentation that evidences both the nature and the amount of the expense. The Services Director is responsible for delivering and maintaining this training on an ongoing basis. All staff will be required to formally acknowledge completion of the training and their understanding of the updated requirements. Responsible Staff: Olivia Montgomery •Advocates and program staff (generating and attaching underlying documentation at pointof charge) •Services Managers (first level review for documentation completeness) •Services Director (program oversight and secondary review) •Executive Director (internal audit oversight; reviews Director of Services approvals andmonitors compliance) •Finance Director / Finance Department (final documentation review, approval, and paymentoversight) Anticipated Completion Date: Policy and procedure updates and staff training will be completed, with full implementation and demonstrated compliance expected by Q3 2026.
Finding 1224913 (2025-001)
Material Weakness 2025
Finding Number 2025-001 – Special Tests and Provisions (Rent Reasonableness) Corrective Action: What we've already been doing to correct the issue LifeWire has strengthened oversight within Services by consolidating the Services and Rapid Rehousing programs under a single Director, creating clearer ...
Finding Number 2025-001 – Special Tests and Provisions (Rent Reasonableness) Corrective Action: What we've already been doing to correct the issue LifeWire has strengthened oversight within Services by consolidating the Services and Rapid Rehousing programs under a single Director, creating clearer accountability and consistency in implementation. Additionally, we have expanded our approval workflow to include multiple levels of review: Advocate → Manager → Director → Finance. This structured, multi-tiered review process increases oversight and enhances our ability to identify and address issues related to rent reasonableness documentation prior to payment. As part of this enhanced workflow, we require that internal audit practices occur at each level of approval, ensuring that rent reasonableness and comparable unit analysis documentation is reviewed for completeness, accuracy, and timeliness — and that review and approval occur prior to tenant move-in — before advancing to the next stage. At each level, reviewers will audit a minimum of 5% of files or 5 files per month, whichever is greater. What else we are putting in place LifeWire will continue to provide comprehensive training for all Services staff, including advocates, managers, and directors, focused on rent reasonableness requirements and the timing of comparable unit analysis completion and review. The Services Director is responsible for delivering and overseeing this training. This training will address the specific requirements outlined in 24 CFR §578.49 and §578.51 and reinforce expectations that documentation is completed, reviewed, andapproved prior to tenant move-in. All staff will be required to formally acknowledge completion ofthe training and their understanding of the updated requirements. Responsible Staff: Olivia Montgomery •Advocates (initial preparation of rent reasonableness and comparable unit analysisdocumentation) •Services Managers (first-level supervisory review and approval prior to move-in) •Services Director (program oversight and secondary review) •Executive Director (internal audit of Services Director approvals) •Finance Director / Finance Department (final review, approval, and payment oversight) Anticipated Completion Date: Enhancements are currently in progress, with full implementation and demonstrated compliance expected by Q3 2026.
Finding 2025-004: Inadequate Financial Reporting Expertise Resulting in Incorrect Submission of Required Federal Reports Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Corrective Action Narrative: Spectrum Generations will strengthen federal compliance repo...
Finding 2025-004: Inadequate Financial Reporting Expertise Resulting in Incorrect Submission of Required Federal Reports Type of Finding: Significant Deficiency in Internal Control and Nonmaterial Noncompliance Corrective Action Narrative: Spectrum Generations will strengthen federal compliance reporting procedures so required reports are prepared accurately, reviewed before submission, and supported by documentation. Planned Corrective Actions: Written procedures will be developed for recurring federal compliance reports. Submission checklists will be created and retained with each filing. All federal reports will receive documented Controller review before submission. Supporting schedules and source documentation will be maintained for all reported amounts. Responsible Officials: Controller, CFO and Program Management Expected Outcome: Federal compliance reporting will be more consistent, accurate, documented and independently reviewed before submission.
Finding 2025-003: Late Submission of Data Collection Form Type of Finding: Federal Single Audit Reporting Finding Corrective Action Narrative: This finding appears to result from audit completion delays associated with unresolved MaineCare Fee-for-Service AR balances. The underlying reconciliation i...
Finding 2025-003: Late Submission of Data Collection Form Type of Finding: Federal Single Audit Reporting Finding Corrective Action Narrative: This finding appears to result from audit completion delays associated with unresolved MaineCare Fee-for-Service AR balances. The underlying reconciliation issues are addressed through the corrective actions for Findings 2025-001 and 2025-002. Planned Corrective Actions: Management will establish an annual audit preparation calendar. Key balance sheet reconciliations will be completed and reviewed before audit fieldwork begins. Controller and CFO will monitor Single Audit reporting deadlines quarterly. Federal filing deadlines will be incorporated into the agency finance and compliance calendar. Responsible Officials: Controller and CFO Expected Outcome: Improved audit readiness and deadline monitoring will support timely future federal reporting package submissions.
Finding Summary: Material noncompliance was noted in reporting as reported amounts did not agree to underlying supporting documentation. Responsible Individuals: Kim Clay, Corporate Controller and Paul DiTomasso, Site`2 Controller Corrective Action Plan: Management will review and improve internal c...
Finding Summary: Material noncompliance was noted in reporting as reported amounts did not agree to underlying supporting documentation. Responsible Individuals: Kim Clay, Corporate Controller and Paul DiTomasso, Site`2 Controller Corrective Action Plan: Management will review and improve internal controls over reporting to ensure that reported amounts agree to underlying supporting documentation. Anticipated Completion Date: June 30, 2026
FINDING 2025-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Internal Controls Contact Person Responsible for Corrective Action: Melinda Amstutz (Office Manager) Contact Phone Number and Email Address: (260) 657-1552 Views of Responsible Officials: We concur with ...
FINDING 2025-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Internal Controls Contact Person Responsible for Corrective Action: Melinda Amstutz (Office Manager) Contact Phone Number and Email Address: (260) 657-1552 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When preparing the Monthly Project Spending Reports, Melinda Amstutz, office manager will be signing the report and initial as the preparer and dating it. Then another employee or Board member will review the report and initial the review box. Anticipated Completion Date: The projected date of completion of major tasks for the planned corrective actions described above will be completed on July 15, 2026.
Finding 2025-004: Material Weakness and Noncompliance: Special Tests and Provisions (Revenue Diversion) Finding: The City’s Airport Improvement Program has special tests and provisions requirements applicable to revenue diversion requirements of the grant. The City did not have processes and control...
Finding 2025-004: Material Weakness and Noncompliance: Special Tests and Provisions (Revenue Diversion) Finding: The City’s Airport Improvement Program has special tests and provisions requirements applicable to revenue diversion requirements of the grant. The City did not have processes and controls in place to ensure compliance with federal requirements related to the prevention of revenue diversion, along with other regulatory matters identified by the FAA. The City did not also have sufficient processes and controls in place for monitoring the execution and performance of agreements and lessees and FBO. Corrective Actions Taken or Planned: The City has and continues to perform a legal and management review of the FAA’s concerns associated with the Airport Improvement Program requirements. After consultation with the City’s legal counsel, our analysis shows that corrections are necessary and revenue diversion may not have occurred, or not to the extent originally asserted. This ongoing matter will be addressed with additional consultation with the FAA and City airport managers. The issues identified pertain to compliance with grant assurance obligations, specifically the need for strengthened processes to ensure ongoing adherence to federal program requirements. The City’s review is ongoing with assistance from counsel specializing in airport operations and federal regulatory compliance. As this work advances, the City will collaborate closely with the Airport Manager and Executive Leadership to design, formalize, and implement the necessary internal controls to ensure compliance with FAA grant assurances. This could include and is not limited to procedures for: 1. Monitoring and documenting compliance with grant assurance requirements; 2. Strengthening oversight of agreements, leases, and FBO operations; 3. Establishing systematic controls for revenue diversion monitoring and periodic testing; 4. Ensuring timely reporting and documentation to detect and prevent noncompliance. Contact Person: Melissa Sieben, Toni Wheeler, Rachelle Mathews Anticipated Completion Date: December 31, 2026
Finding No. 2025-001 – Suspension and Debarment In April 2024, GMHA began requiring the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants for Invitation for Bids and Request for Proposals. To ensure the suspension and debarment verif...
Finding No. 2025-001 – Suspension and Debarment In April 2024, GMHA began requiring the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants for Invitation for Bids and Request for Proposals. To ensure the suspension and debarment verifications are performed for all federal expenditures, the Accounting Department and Materials Management Department will ensure invoices that are later converted to federal funding contain the certificate. Name of Contact Person(s) Responsible for Corrective Action: Amacris Legaspi, General Accounting Supervisor Audrey Paulino, Hospital Materials Management Assistant Administrator, Acting Anticipated Completion Date: Completed.
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