Corrective Action Plans

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Finding 2025-002: Equipment and Real Property Management The single audit report included the following recommendation: EY recommends Amtrak set up a system with certain criteria for identifying sites at a higher risk for noncompliance with safeguard requirements, and creates an action plan for eval...
Finding 2025-002: Equipment and Real Property Management The single audit report included the following recommendation: EY recommends Amtrak set up a system with certain criteria for identifying sites at a higher risk for noncompliance with safeguard requirements, and creates an action plan for evaluating, and remediating potential noncompliance. EY recommends that management consider redesigning one of its key controls to help ensure that the monitoring of the observations is occurring on a preventive basis to help identify any exposure to non-compliance before it occurs and clearly identifies any follow-up steps and actions. For example, there should be established a protocol as well as timeline for when required observations are to take place, additionally, as it is known in advance, which items are coming up for inventory, Amtrak could prepare an annual schedule of inventories, that could be revised quarterly. Management Response/Status of Action Plans: Amtrak acknowledges the recommendation that Amtrak should have a system with certain criteria for identifying sites at a higher risk for noncompliance with safeguard requirements and create an action plan for evaluating and remediating potential noncompliance. As part of this effort, the Enterprise Asset Management and Disposition Team will work with Corporate Security to review and, as appropriate, align existing governance processes to reduce the likelihood of similar noncompliance. Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. Amtrak published an updated Equipment Control Policy and created an eLearning course, as well as implemented several processes, technologies, and reporting that help to proactively monitor and identify equipment that is 90 days or less of needing an inventory. This has improved the compliance rate from less than 70% in FY22 to over 97% in FY25. Amtrak understands that this is a repeat finding and will review with Infrastructure Maintenance and Construction Services, the owner of equipment that was out of compliance to strengthen the practice and reduce the likelihood of noncompliance. The contact for this item is Robert Hoban, Director Asset Management. Amtrak anticipates fully remediating this finding by September 2028.
Finding 2025-001: Review of Compliance Matrices and Narratives – Special Tests and Provisions The single audit report included the following recommendation: EY recommends that Amtrak update the control design with enough precision to ensure that reviews and updates to the compliance matrices are mad...
Finding 2025-001: Review of Compliance Matrices and Narratives – Special Tests and Provisions The single audit report included the following recommendation: EY recommends that Amtrak update the control design with enough precision to ensure that reviews and updates to the compliance matrices are made on a regular cadence to ensure that any updates, amendments or changes are monitored and updated timely. Management Response/Status of Action Plans: Amtrak recognizes the need to improve our controls over the updates of the compliance matrices and will review its control processes. The company specifically notes the need to update its compliance matrices in a regular cadence and after every amendment. Amtrak will develop a process document to create or update compliance matrices that will be used as a guide by compliance matrices preparers and reviewers when one is created or updated. The contact for this item is Lucia Butts, AVP Funding and Grants. Amtrak anticipates fully remediating this finding by September 2026.
Views of Responsible Officials: In March 2026, the Foundation hired a staff accountant that replaced a role that was previously held by a consultant. The Foundation's Board President, in the absence of the vacant Executive Director position, is approving the reports. The reports are being submitted ...
Views of Responsible Officials: In March 2026, the Foundation hired a staff accountant that replaced a role that was previously held by a consultant. The Foundation's Board President, in the absence of the vacant Executive Director position, is approving the reports. The reports are being submitted on a timely basis.
The City acknowledges the finding. The City will continue developing and maintaining written policies and procedures appropriate to its federal award activity and the terms and conditions of applicable federal awards. Policies and procedures will address internal controls, reporting responsibilities...
The City acknowledges the finding. The City will continue developing and maintaining written policies and procedures appropriate to its federal award activity and the terms and conditions of applicable federal awards. Policies and procedures will address internal controls, reporting responsibilities, record retention, allowable costs, procurement standards, conflictof- interest requirements where applicable, and compliance monitoring procedures consistent with Uniform Guidance requirements.
Finding No. 2025-004 Condition – Claims submitted for reimbursement did not reconcile with the District’s internally prepared monthly claim summary report. Plan – The District will ensure that meal counts are thoroughly reviewed prior to submission. Meal counts are entered into the computer by the F...
Finding No. 2025-004 Condition – Claims submitted for reimbursement did not reconcile with the District’s internally prepared monthly claim summary report. Plan – The District will ensure that meal counts are thoroughly reviewed prior to submission. Meal counts are entered into the computer by the FSMC, and has been a place where errors have occurred. The district secretary is responsible for entering the meal counts into the state system. She is verifying the counts from the FSMC, comparing to attendance and invoices, and ensuring correct data goes into IWAS. This was started last spring, when we became aware of FSMC inconsistencies. The current year, FY26, has been much more accurate. Anticipated Date of Completion: current – 9/1/2026 Name of Contact Person: Matt Stines, Superintendent
Condition: The Organization was reimbursed $22,968 under the grant award for amounts incurred subsequent to the performance year of the grant. The control in place to review expenditures was not effective in identifying expenditures that were outside the grant period. Planned Corrective Action: The ...
Condition: The Organization was reimbursed $22,968 under the grant award for amounts incurred subsequent to the performance year of the grant. The control in place to review expenditures was not effective in identifying expenditures that were outside the grant period. Planned Corrective Action: The Organization will implement enhanced review procedures of federal expenditures sought for reimbursement to better align with the underlying accounting treatment. Contact person responsible for corrective action: David Anderson Anticipated Completion Date: September 30, 2026
Community Development Block Grants Cluster Entitlements/Special Purpose – Assistance Listing No. 14.218 Recommendation: It is recommended the County modify its procedure to include: • Improve reconciliation procedures to verify hours per pay period recorded in quarterly spreadsheet agrees to hours r...
Community Development Block Grants Cluster Entitlements/Special Purpose – Assistance Listing No. 14.218 Recommendation: It is recommended the County modify its procedure to include: • Improve reconciliation procedures to verify hours per pay period recorded in quarterly spreadsheet agrees to hours recorded in the KRONOS system. • Record grant wages using the pay rate at the beginning of the quarter if recorded on a quarterly basis or use pay rates for each pay period if recorded on a pay period basis. Explanation of disagreement with audit finding: Management concurs with the auditor’s recommendations. Action taken in response to finding: • Document the audit process in a formalized SOP and cross train all reviewers from SRGA Admin, Budget, and Fiscal. • Create a checklist to accompany each personnel draw to ensure that after rates are verified that SRGA Admin certify that no RPAs or pay adjustments were approved during the pay periods reported and if there were, a second pay rate is entered for that draw and hours are split according to accurate rates/dates. • Document the cure process in the SOP to ensure that any errors found after the fact will be corrected with HUD to remain compliant and to ensure that no funds drawn in error are retained. • Include a date verification process prior to submission of the draw to ensure that staff did not duplicate any dates. This verification will be an audit of the Time Tracking Review completed by Admin staff. Ongoing training and coaching will be administered should duplicate entries be found on final draw reports. • Audit of all personnel draws for both allocations of CDBG-DR grants will be completed using the new SOP and verification tools before the end of FY2026. Name of the contact person responsible for corrective action: Nicole Turner, Director Planned completion date for corrective action plan: The above action plan will be implemented immediately; an audit of all personnel draws will be conducted using new process and checklists by the end of FY2026.
Continuum of Care Assistance Listing No. 14.267 Payroll Disbursements Recommendation: We recommend that LAHSA implement procedures to ensure that timesheet approval is documented timely. Explanation of disagreement with audit finding: There is no disagreement withthe audit finding. Action taken in r...
Continuum of Care Assistance Listing No. 14.267 Payroll Disbursements Recommendation: We recommend that LAHSA implement procedures to ensure that timesheet approval is documented timely. Explanation of disagreement with audit finding: There is no disagreement withthe audit finding. Action taken in response to finding: LAHSA has enhanced its internal controls over timesheet approvals to ensure timely documentation. Timesheet approval status reports are reviewed on a weekly basis during Chief level meetings to monitor compliance. Timesheets not approved within two days of the established deadline are escalated to the respective Chief and Deputy Chief for immediate follow-up. If timesheets remain unapproved after an additional two days, the matter is further escalated to the CEO, for prompt resolution. These procedures establish clear accountability and escalation protocols to ensure timely approval of timesheets Names of the contact persons responsible for corrective action: Gita O'Neill, Keshia Douglas, Christopher Williams, and Paul Rubenstein. Planned completion date for corrective action plan: Implemented
Subject: Corrective Action Plan for FY2025 Audit Action Taken in Response to the Finding The Commission reviewed the two transactions cited in the audit—Adobe Lightroom ($127.07) and Hover ($103.02)—and determined that these small-dollar purchases resulted from unintentional administrative oversight...
Subject: Corrective Action Plan for FY2025 Audit Action Taken in Response to the Finding The Commission reviewed the two transactions cited in the audit—Adobe Lightroom ($127.07) and Hover ($103.02)—and determined that these small-dollar purchases resulted from unintentional administrative oversights rather than systemic issues. To prevent similar issues going forward, the following actions have been taken or are in progress: 1. Clarifying vendor coverage under existing agreements ICPRB maintains a blanket procurement agreement for Adobe products. A detailed review of that agreement confirmed that Adobe Lightroom is not currently covered. Going forward, any Adobe products not explicitly included in an approved blanket agreement will require a separate procurement requisition before purchase. 2. Strengthening controls over procurement thresholds Procedures have been reinforced to ensure that any purchase exceeding the $100 threshold is properly documented before the purchase is made. As part of this effort, a Director of Finance and Administration—who is a CPA—joined the organization effective April 6, 2026, with direct responsibility for overseeing procurement activities and ensuring compliance with applicable policies. 3. Monitoring cumulative spending by vendor In the case of Hover, ICPRB initially incurred a small annual charge of $16.17 for website hosting. Over time, additional sites were added, which caused total spending with the vendor to exceed the $100 threshold by $3.02. New procedures are now in place to monitor cumulative spending with each vendor throughout the year so that procurement requirements are triggered promptly when thresholds are reached. 4. Reinforcing training and communication Finance and administrative staff involved in purchasing and procurement were reminded of key requirements, including: The importance of obtaining proper procurement documentation for applicable purchases. • The need to track cumulative vendor spending to identify when thresholds are exceeded. • The limitations of blanket procurement agreements 5. Conducting periodic compliance reviews The Finance Department will perform regular reviews of vendor expenditures to identify any vendors approaching or exceeding procurement thresholds and will take appropriate action as needed to maintain compliance. Name(s) of the contact person(s) responsible for corrective action: P. Ernest Parker, Jr., Director of Finance and Administration eparker@icprb.org, 301.450.2413 Wendy Wang, Senior Accountant wwang@icprb.org, 301.274.8129 Planned completion date for corrective action plan: June 30, 2026.
Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding Lincoln Public Schools procurement standards do not include the essential elements as outlined in 2 CFR sections 200.303, and 200.318 through 200.326 within Uniform Guidance. Statement of Concurrence or ...
Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding Lincoln Public Schools procurement standards do not include the essential elements as outlined in 2 CFR sections 200.303, and 200.318 through 200.326 within Uniform Guidance. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Management will update Lincoln Public Schools’ procurement policies to include all essential elements to be in compliance with Uniform Guidance.
Finding 1214780 (2025-001)
Material Weakness 2025
Sanford
SD
As it relates to Research milestone billing for the PASC grant, procedures were revised in 2025 after the 2024 Audit. Upon receipt of invoice and payment from PASC, the Research Billing team will review and provide notification to Research Director and Research Manager via email if the invoice and p...
As it relates to Research milestone billing for the PASC grant, procedures were revised in 2025 after the 2024 Audit. Upon receipt of invoice and payment from PASC, the Research Billing team will review and provide notification to Research Director and Research Manager via email if the invoice and payment received matches to what is shown as owed in our systems. The Corrective Action Plan from the 2024 Audit was already put into place however this is a repeat finding due to the timing of the 2024 finding. Responsible Party: Stephanie Swanson, Director of Insurance Anticipated completion date: Already Complete
Corrective Action Plan: NSLDS Reporting Institution: Congregation YMH d/b/a Yeshiva Meor Hatalmud Audit Period: Year Ended August 31, 2025 Finding 2025:001: Noncompliance with NSLDS Enrollment Reporting Requirements Views of Responsible Officials The Organization acknowledges a misunderstanding duri...
Corrective Action Plan: NSLDS Reporting Institution: Congregation YMH d/b/a Yeshiva Meor Hatalmud Audit Period: Year Ended August 31, 2025 Finding 2025:001: Noncompliance with NSLDS Enrollment Reporting Requirements Views of Responsible Officials The Organization acknowledges a misunderstanding during the initial year of the program regarding the necessity of NSLDS reporting when student loans are not present. Upon clarification, management prioritized resolving this reporting requirement. Corrective Action Taken • System Registration: The institution successfully finalized its registration with the National Student Loan Data System (NSLDS). • Technical Resolution: Initial attempts to resolve technical access issues began on March 30, 2026. These issues, tracked under Case #260330-000528, were fully resolved on April 29, 2026. • Reporting Compliance: The Organization completed its initial enrollment reporting at both the Campus and Program levels to the Department of Education on April 29, 2026. • Verification of Proof: Official confirmation of the successful registration and enrollment reporting has been provided to auditors. • Internal Controls: To ensure ongoing compliance with 2 CFR §200.303(a), the Organization established formal procedures. These include monthly monitoring of enrollment changes, maintaining an audit trail of NSLDS communications, and assigning specific reporting responsibilities to the administrative office. Completion Status: Resolved/ Completed Responsible Person: Mr. Frisch, Administrator
Finding 1214631 (2025-001)
Material Weakness 2025
Recommendation: The Federal Funding Accountability and Transparency Act (FFATA) reporting requirement is a general term and condition from the Department of Commerce and should be completed as required and reviewed by someone other than the preparer before submission. Management’s Response: The FFAT...
Recommendation: The Federal Funding Accountability and Transparency Act (FFATA) reporting requirement is a general term and condition from the Department of Commerce and should be completed as required and reviewed by someone other than the preparer before submission. Management’s Response: The FFATA reporting requirement was not a specific award condition on the grant award to the IRL Council from NOAA Fisheries. However, it is a standard general term and condition from the Department of Commerce which is referenced on the grant award. The subawards for the NOAA grant have now been input into SAM.gov. The IRL Council will review the specific FFATA requirements required by the Department of Commerce (different than the EPA requirements) and will make sure that the IRL Council continues to be in compliance. Responsible Party: Daniel Kolodny, Chief Operating Officer Anticipated Completion Date: May 1, 2026
The District will establish a system of internal controls to ensure wage rate requirements are included in construction contracts funded by Federal awards, and certified payroll reports are obtained from contractors to verify compliance with federal prevailing wage requirements.
The District will establish a system of internal controls to ensure wage rate requirements are included in construction contracts funded by Federal awards, and certified payroll reports are obtained from contractors to verify compliance with federal prevailing wage requirements.
Corrective Action: The Finance Director, in coordination with Human Resources, will execute a "Mobility File Standardization Plan." A census of transferred personnel will be conducted to identify missing documents (I-9 forms, tax withholdings, academic certifications, and background checks). A 90-da...
Corrective Action: The Finance Director, in coordination with Human Resources, will execute a "Mobility File Standardization Plan." A census of transferred personnel will be conducted to identify missing documents (I-9 forms, tax withholdings, academic certifications, and background checks). A 90-day term is established to complete the physical and digital archives.
The Department of Finance will work with the Department of Administration to obtain the necessary documentation of the required physical inventory of all grant funded property and equipment, the reconciliation of the physical inventory to property records, and the equipment maintenance logs. Trainin...
The Department of Finance will work with the Department of Administration to obtain the necessary documentation of the required physical inventory of all grant funded property and equipment, the reconciliation of the physical inventory to property records, and the equipment maintenance logs. Training for all employees responsible for these activities will be provided as deemed necessary. Additionally, the Department of Finance will provide a formal memorandum to all of the Borough departments outlining the federal requirements governing the purchase, management, inventory, use and disposition of assets acquired with federal grant funds in accordance with 2 C.F.R. Part 200.
Finding 2025-002 – Reporting (Internal Controls Over Compliance) Impact Aid Applications Significant Deficiency Condition: We did not receive back up documentation to support the Children with Disabilities figures on both the Elementary and High School Impact Aid applications. Questioned Costs: None...
Finding 2025-002 – Reporting (Internal Controls Over Compliance) Impact Aid Applications Significant Deficiency Condition: We did not receive back up documentation to support the Children with Disabilities figures on both the Elementary and High School Impact Aid applications. Questioned Costs: None. Criteria: Uniform Guidance, 2 CFR section 200.303 (Internal Controls), effective internal controls require the entity to establish and implement written policies and procedures. These policies must ensure that disbursements are supported by adequate documentation, demonstrating proper authorization, accuracy, and compliance with applicable laws and regulations. Cause: Lack of retention of documents used to support the figures that were presented in the Elementary and High School Impact Aid applications. Although the review and approval of the Impact Aid applications was noted as being performed, the lack of retention of supporting documentation relating to the applications does not support reperformance. Effect: The School District was not in compliance with Uniform Guidance, which could lead to sanctions by the funding agencies. Recommendation: We recommend the entity strengthen internal controls over the review of the impact aid application and the retention of documents used to complete the Impact Aid applications. Views of Responsible Officials: We concur that data submitted by previous school administration was not verifiable. The District has since taken steps to ensure that all CWD student data is submitted to Impact Aid timely and accurately and date used from the Special Ed Dept at the school via reports submitted to the Office of Public Instruction.
Finding 2025-002 – Reporting (Internal Controls Over Compliance) Impact Aid Applications Significant Deficiency Condition: We did not receive back up documentation to support the Children with Disabilities figures on both the Elementary and High School Impact Aid applications. Questioned Costs: None...
Finding 2025-002 – Reporting (Internal Controls Over Compliance) Impact Aid Applications Significant Deficiency Condition: We did not receive back up documentation to support the Children with Disabilities figures on both the Elementary and High School Impact Aid applications. Questioned Costs: None. Criteria: Uniform Guidance, 2 CFR section 200.303 (Internal Controls), effective internal controls require the entity to establish and implement written policies and procedures. These policies must ensure that disbursements are supported by adequate documentation, demonstrating proper authorization, accuracy, and compliance with applicable laws and regulations. Cause: Lack of retention of documents used to support the figures that were presented in the Elementary and High School Impact Aid applications. Although the review and approval of the Impact Aid applications was noted as being performed, the lack of retention of supporting documentation relating to the applications does not support reperformance. Effect: The School District was not in compliance with Uniform Guidance, which could lead to sanctions by the funding agencies. Recommendation: We recommend the entity strengthen internal controls over the review of the impact aid application and the retention of documents used to complete the Impact Aid applications. Views of Responsible Officials: We concur that data submitted by previous school administration was not verifiable. The District has since taken steps to ensure that all CWD student data is submitted to Impact Aid timely and accurately and date used from the Special Ed Dept at the school via reports submitted to the Office of Public Instruction.
Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding: There i...
Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the review of program reporting and campus reporting, the college will identify the cause for the data error. The college will explore the impact of branch campuses and the potential to shift to a single college reporting model. The following specific steps will be completed. 1. Identify and Analyze the Issues 2. Root Cause Analysis 3. Corrective Measures 4. Automation: Implement automated checks and balances to ensure data integrity before files are processed and sent. Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Cheryl Eldredge, College Associate Dean for Registrar and Master Schedule Planned completion date for corrective action plan: December 31, 2026
2025-036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) 97.036 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. The Department should review and enhance its procedures and internal controls to ensure that ...
2025-036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) 97.036 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. The Department should review and enhance its procedures and internal controls to ensure that all required subawards are reported timely and accurately to SAM.gov no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: MEMA has assigned entering roles and review/approval roles to several employees to ensure our ability to meet MEMA’s FFATA reporting requirements. Grants Units will not forward any contract, amendment, settlement agreement to CFO for signature without confirmation that a properly completed/signed FFATA form has been received from subrecipient. Once contract/amendment/settlement agreement has been signed by CFO, grant program staff will save FFATA form in SharePoint FFATA folder, within the month/year of obligation (signed by MEMA). Grants Unit will have at least one position, and Fiscal will have at least one position assigned to the role of FFATA Data Entry. Assigned FFATA Data entry personnel will review the FFATA SharePoint folders for any recent FFATA forms. This review should be done weekly but no later than every other week. All new FFATA forms will be entered into SAM.gov within ten (10) business days of subcontractor/subrecipient award obligation (date contract/amendment is signed by MEMA’s CFO). Grants Unit will have at least one position, and Fiscal will have at least one position assigned to the role of FFATA Data reviewer/approval. FFATA Data reviewers/approvals will be notified by FFATA Data entry personnel when new FFATA forms have been entered. Reviews/Approval will have ten (10) business days to review the new forms and either approval or reach back to the Data Entry personnel for clarification/adjustments if needed. Name(s) of the contact person(s) responsible for corrective action: Shannon Norton, Chief Fiscal Officer Planned completion date for corrective action plan: End of the Federal Fiscal Year 9/30/2025
2025-035 Opioid STR 93.788 Recommendation: We recommend the Department complete its corrective action plan from the prior year. The Department should verify that its internal controls and procedures are sufficient to ensure subrecipient monitoring is performed in compliance with the requirements of ...
2025-035 Opioid STR 93.788 Recommendation: We recommend the Department complete its corrective action plan from the prior year. The Department should verify that its internal controls and procedures are sufficient to ensure subrecipient monitoring is performed in compliance with the requirements of the federal program and that all required information is included in subaward agreements. Action taken in response to finding: The Department will implement a procedure to verify annually each city and town subrecipient meets the Single Audit threshold, obtain the corresponding audit reports from directly from the Federal Audit Clearinghouse (fac.gov), and document. Additionally, a monitoring checklist and staff training will be updated to reinforce these requirements and ensure ongoing compliance. The Department implemented the FAIN number on 9/20/2025, amendments and new contracts after this date show this number. Name(s) of the contact person(s) responsible for corrective action: Matt Courchene, Chief Financial Officer Planned completion date for corrective action plan: 9/30/2026
2025-034 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and that this documentation is readily available for audit. Action taken in response to finding: Current...
2025-034 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and that this documentation is readily available for audit. Action taken in response to finding: Currently, when a document is received at a MassHealth Enrollment Center, it is the worker’s responsibility to collect the documentation and send it to the Electronic Document Management Center (EDMC) in New Bedford. Once the document is received it is prepped, scanned, and indexed to enable a worker to process the documentation within our eligibility system. We are proposing a short-term and long-term solution to address the audit finding. Short term solution: This approach involves minimal modifications to the current operational process and can be quickly put into practice across all locations. All staff at the MassHealth document received at a MEC that was submitted by applicants or members. Subsequently, the document must be mailed to EDMC for further processing. Long term solution: Implementing this solution will involve modifications to the current operational processes and workflows within MassHealth Eligibility Operations and the system. To facilitate this, we plan to initiate a comprehensive internal discussion involving different teams to gather insights, understand existing procedures, and identify areas where changes are needed to support the new solution. Once these preliminary discussions are completed, we will work with the relevant stakeholders to begin the development of the specific requirements that the new process will entail. Name(s) of the contact person(s) responsible for corrective action: Tosin Adebiyi, Director of Special Eligibility Programs and Audits, Marco Gonzales, Eligibility Quality Assurance Team Leader, April Aguiar, Director of EDMC, Rosana Senise, Director of MassHealth Eligibility Planned completion date for corrective action plan: Short Term solution: April 1, 2026, Long Term solution: December 2027
2025-033 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation that claims are paid only to eligible providers and that documentation is readily available for audit. Action taken in response to ...
2025-033 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation that claims are paid only to eligible providers and that documentation is readily available for audit. Action taken in response to finding: MassHealth plans to run a quarterly report to identify dental providers who are 3 months away from revalidation. MassHealth plans to share the report with DentaQuest to ensure that the revalidation process begins in a timely manner. Additionally, MassHealth has streamlined the maintenance of revalidation documentation by requiring DentaQuest to upload the documentation directly into MassHealth’s Medicaid Management Information System (MMIS). MassHealth has updated its provider agreement processing procedures and now requires DentaQuest to upload executed provider agreements directly into MassHealth’s MMIS. MassHealth plans to identify any additional dental providers (if any) who may be overdue for revalidation and share such information with DentaQuest and plans to instruct DentaQuest to reach out to the identified providers in order to begin the revalidation process. MassHealth instructed DentaQuest to: (1) generate revalidation letters; and (2) send providers revalidation letters, as appropriate, via email. Name(s) of the contact person(s) responsible for corrective action: Tuyen Vu, Deputy Director, Dental Planned completion date for corrective action plan: MassHealth anticipates implementing the above updated processes in the second quarter of calendar year 2026.
2025-032 Children's Health Insurance Program (CHIP) 93.767 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation that claims are paid only to eligible providers and that documentation is readily available for audit. Action taken in re...
2025-032 Children's Health Insurance Program (CHIP) 93.767 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation that claims are paid only to eligible providers and that documentation is readily available for audit. Action taken in response to finding: MassHealth instructed the Third-Party Affiliation vendor, DentaQuest to: (1) generate revalidation letters; and (2) send providers revalidation letters, as appropriate, via email. MassHealth plans to run a quarterly report to identify dental providers who are 3 months away from revalidation. MassHealth plans to share the report with DentaQuest to ensure that the revalidation process begins in a timely manner. Additionally, MassHealth has streamlined the maintenance of revalidation documentation by requiring DentaQuest to upload the documentation directly into MassHealth’s Medicaid Management Information System (MMIS). MassHealth plans to identify any additional dental providers (if any) who may be overdue for revalidation and share such information with DentaQuest and plans to instruct DentaQuest to reach out to the identified providers in order to begin the revalidation process. MassHealth has updated its provider agreement processing procedures and now requires DentaQuest to upload executed provider agreements directly into MassHealth’s Medicaid Management Information System (MMIS). MassHealth has instructed DentaQuest to complete sanction verifications for all individuals listed on the disclosure forms. MassHealth has updated its provider agreement processing procedures and now requires DentaQuest to: (1) send provider agreements to MassHealth directly for countersigning; and (2) upload executed provider agreements directly into MassHealth’s MMIS. Name(s) of the contact person(s) responsible for corrective action: Tuyen Vu, Deputy Director, Dental Planned completion date for corrective action plan: MassHealth anticipates implementing the above updated processes in the second quarter of calendar year 2026.
2025-031 Adoption Assistance 93.659 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and child abuse and neglect registry checks, and that this documentation is readily available for audit. We also reco...
2025-031 Adoption Assistance 93.659 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and child abuse and neglect registry checks, and that this documentation is readily available for audit. We also recommend the Department enhance the renewal letter to include the reaffirmation of the original subsidy agreement date by the participant. Action taken in response to finding: For the finding related to signed adoption subsidy agreements, the Department has already implemented corrective actions to improve its process of maintaining signed adoption subsidy agreements. We built the capacity to upload electronic documents into iFamilyNet in July 2022, and we now ensure that all prospectively signed agreements are uploaded into the child’s iFamilyNet record. In addition, since July 2023, during the Title IV-E eligibility determination process, the eligibility specialist verifies that the signed adoption subsidy agreement has been uploaded. The Department will also explore the auditor’s recommendation to enhance the renewal letter to include the reaffirmation of the original subsidy agreement date by the participant to see if it is technically feasible. Although the Department was unable to produce a copy of a signed subsidy agreement, the Department has controls to oversee that a subsidy agreement was executed prior to legalization of the adoption through a built-in workflow process in our i-FamilyNet system. For the other 39 sample cases, the dates of the signatures by the Department and the pre-adoptive parents recorded in iFamilyNet matched the signature dates on the copies of the original signed agreements. Hence, the Department asserts the dates entered were accurate. We unfortunately could not produce the document to demonstrate that to the auditors. For the finding relating to out-of-state child welfare checks, the Department has already implemented corrective actions to improve its process of documenting requests of out-of-state child welfare checks. In February 2023, the Department integrated the out-of-state child welfare check into the Background Record Check (BRC) section of the foster home licensing process where it can be documented and included as part of the assessment. The Department also added a value to our “contact purpose” drop down menu within the dictation screen in iFamilyNet to capture structured data that an out-of-state child welfare check was made. Name(s) of the contact person(s) responsible for corrective action: Sharon Silvia, Assistant Commissioner of Permanency COMMONWEALTH OF MASSACHUSETTS CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Planned completion date for corrective action plan: Signed Subsidy Agreements: • July 2022 – capacity to upload electronic documents into iFamilyNet (complete) • July 2023 – eligibility specialist verifies that the signed adoption subsidy agreement has been uploaded (complete) • July 2026 – assess technical feasibility of enhancing the renewal letter Out-of-State Child Welfare Checks: • February 2023 – integrated out-of-state child welfare checks into BRC section and added value to contact purpose drop down (complete)
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