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Reference Number: 2025-008 Prior Year Finding: 2024-010 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17...
Reference Number: 2025-008 Prior Year Finding: 2024-010 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI372152255A10 (10/1/2021 – 12/31/2024) UI393142355A10 (10/1/2022 – 12/31/2025) 24A55UI000067 (10/1/2023 – 12/31/2026) 25A55UI000116 (1/1/2024 – 12/31/2027) Compliance Requirement: Allowable Cost/Cost Principles – Time and Effort Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should reevaluate its current process, implement proper controls, and perform additional training for time and effort reporting. The Division should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: We agree that the division was unable to provide documentation supporting the timesheet approval as asserted. However, we respectfully disagree that the lack of timesheet approval translates into charging the program with unallowed costs. It’s important that the auditors understand that the division’s responsibility to ensure that payroll charges to the program are appropriate begins with ensuring that each employee tasked with performing program functions are hired into the correct division internal program unit (“IPU”). And then further within that IPU, instruct employees to use a specific activity code that is assigned to various federal programs. In the samples reviewed, employees properly used the correct activity code to record time for the work performed. Action taken in response to finding: The business will continue to refine its process for demonstrating the appropriateness of allowed payroll costs to the program and present a substantial action plan in late FY2027. Name(s) of the contact person(s) responsible for corrective action: Marie Cameron, Director of DUI Planned completion date for corrective action plan: March 31, 2027
Reference Number: 2025-007 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17.225 A...
Reference Number: 2025-007 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI372152255A10 (10/1/2021 – 12/31/2024) UI393142355A10 (10/1/2022 – 12/31/2025) 24A55UI000067 (10/1/2023 – 12/31/2026) 25A55UI000116 (1/1/2024 – 12/31/2027) Compliance Requirement: Reporting – ETA 2112, UI Financial Transaction Summary Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the Division review and enhance internal controls to ensure that ETA 2112 reports are reviewed and approved prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: There is already a signature on the report we will now have that is signed and dated and will also add an additional line for preparer signature and date. Name(s) of the contact person(s) responsible for corrective action: Marie Cameron, Director of UI Planned completion date for corrective action plan: Quarter 1 2026.
Reference Number: 2025-006 Prior Year Finding: 2024-007 Federal Agency: U.S. Department of Labor State Agency: Department of Labor State Division: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17.225 Award Num...
Reference Number: 2025-006 Prior Year Finding: 2024-007 Federal Agency: U.S. Department of Labor State Agency: Department of Labor State Division: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: UI372152255A10 (10/1/2021 – 12/31/2024) UI393142355A10 (10/1/2022 – 12/31/2025) 24A55UI000067 (10/1/2023 – 12/31/2026) 25A55UI000116 (1/1/2024 – 12/31/2027) Compliance Requirement: Reporting – ETA 2208A, Quarterly UI Above-Base Report Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should review and update its reporting internal controls to ensure that ETA 2208A – Quarterly UI Above-Base Reports tie to supporting documentation and that supporting documentation is retained and readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We acknowledge the audit finding that the Division was unable to provide supporting documentation for QE 09/30/2024 ETA 2208A report. Procedures have been implemented to ensure documentation used to complete the ETA 2208A is saved in clearly marked folders on our Fiscal drive for ease of retrieval. Procedures will be documented and saved for ease of retrieval and use. Name(s) of the contact person(s) responsible for corrective action: Michael Soper, Fiscal Management Planned completion date for corrective action plan: Procedures are already in use for QE 12/31/2025 ETA 2208A report. Procedures will be documented by QE 06/30/2026 with revisions as needed.
Reference Number: 2025-005 Prior Year Finding: 2024-005 Federal Agency: U.S. Department of Labor State Agency: Department of Labor State Division: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17.225 Award Num...
Reference Number: 2025-005 Prior Year Finding: 2024-005 Federal Agency: U.S. Department of Labor State Agency: Department of Labor State Division: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 – Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: UI372152255A10 (10/1/2021 – 12/31/2024) UI393142355A10 (10/1/2022 – 12/31/2025) 24A55UI000067 (10/1/2023 – 12/31/2026) 25A55UI000116 (1/1/2024 – 12/31/2027) Compliance Requirement: Special Tests and Provisions – UI Benefit Payments Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend the Division review and enhance procedures and controls to ensure that it performs weekly claim investigations and that case investigations are completed timely in accordance with the time limits established in the ET Handbook No. 395. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Unemployment Insurance (Division) acknowledges the finding and agrees that improvements are necessary to ensure full compliance with Benefits Accuracy Measurement (BAM) program requirements. The Division recognizes the importance of conducting weekly investigations and adhering to established timeliness standards to maintain the integrity and accuracy of unemployment insurance benefit payments and denied claims. The Division notes that the identified deficiencies were primarily due to significant staffing shortages and competing operational demands, which were further exacerbated by the sustained workload associated with pandemic-related programs. These challenges affected the Division’s capacity to complete the required number of weekly investigations and to meet prescribed case completion timeframes. To address these issues, the Division has taken and will continue to take corrective actions, including: · Actively recruiting and onboarding additional staff dedicated to BAM operations. · Providing enhanced training to ensure staff are equipped to conduct timely and thorough investigations. · Implementing improved case management and tracking mechanisms to monitor timeliness and workload distribution. · Evaluating internal processes to identify efficiencies and reduce delays in case completion. The Division is committed to strengthening internal controls and ensuring compliance with federal requirements. Management will continue to monitor progress and take additional corrective actions as necessary to meet BAM performance standards moving forward. Name(s) of the contact person(s) responsible for corrective action: Evan Douglass, DUI Quality Control and Continuous Improvement Administrator Planned completion date for corrective action plan: March 31, 2027
Reference Number: 2025-004 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division: Division of Public Health Federal Program: WIC Special Supplemental Nutrition Program for Women, Infants, and...
Reference Number: 2025-004 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division: Division of Public Health Federal Program: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Award Number and Year: 241DE701W1003 (10/1/2023 – 9/30/2024) Compliance Requirement: Cash Management Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: The Division should enhance procedures and controls to ensure that drawdown requests are reviewed and approved prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division confirmed the drawdown transaction was accurate and appropriate. The Division reiterated the Cash Management procedure to all staff and confirmed their understanding. In addition, the Division has in place a review process for new stsaff regarding procedures with confirmation of completion. There is an established training manual which has been reviewed to ensure it contains the most update to date process. Manuals and procedures will be reviewed regularly and updated, as needed. Name(s) of the contact person(s) responsible for corrective action: Gary Owens – primary Deborah Fisher and Jennifer Heesh – backups Planned completion date for corrective action plan: March 31, 2026.
Reference Number: 2025-003 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division: Division of Public Health Federal Program: WIC Special Supplemental Nutrition Program for Women, Infants, and...
Reference Number: 2025-003 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division: Division of Public Health Federal Program: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Award Number and Year: 241DE701W1003 (10/1/2023 – 9/30/2024) 251DE701W1003 (10/1/2024 – 9/30/2025) Compliance Requirement: Allowable Costs/Cost Principles – Time and Effort Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: The Division should enhance procedures, implement proper controls, and perform additional training over time and effort reporting. The Division should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: On March 12, 2026, an email to all WIC supervisors was issued notifying the dates that all T&E reports are due to the Administration Office. The policy was reiterated during the March 17,2026 Supervisors meeting held via Zoom. Name(s) of the contact person(s) responsible for corrective action: Joanne White – Public Health Program Administrator Planned completion date for corrective action plan: March 31, 2026
Reference Number: 2025-002 Prior Year Finding: No Federal Agency: U.S. Department Agriculture State Agency: Department of Education Federal Program: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.556, 10.559, 10.582 Award Number and Year: 202424N109941 (10/1/2023 – 1/30/2025);...
Reference Number: 2025-002 Prior Year Finding: No Federal Agency: U.S. Department Agriculture State Agency: Department of Education Federal Program: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.556, 10.559, 10.582 Award Number and Year: 202424N109941 (10/1/2023 – 1/30/2025); 202424L160341 (10/1/2023 – 1/30/2025); 202525N109941 (10/1/2024 – 1/28/2026); 202522L160341 (10/1/2024 – 1/28/2026). Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately no later than the end of the month following the month of issuance of each subaward. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Department will revise and strengthen our policies and procedures to ensure full compliance with FFATA reporting requirements. Updated procedures will require that all applicable child nutrition subawards of $30,000 or more are reported in SAM.gov no later than the end of the month following the month in which the subaward is made, in accordance with Uniform Grant Guidance. Name(s) of the contact person(s) responsible for corrective action: Drew Fioravanti Planned completion date for corrective action plan: June 30, 2026
2025-001 Cash Management ALN: Research and Development Cluster (R&D) - Various ALNs Finding: The College did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by the College within 30 days of requests for reimbursements received by the College. Correctiv...
2025-001 Cash Management ALN: Research and Development Cluster (R&D) - Various ALNs Finding: The College did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by the College within 30 days of requests for reimbursements received by the College. Corrective Action Plan: Management acknowledges that some of the payments to subrecipients selected for audit were not made within 30 days of receipt. We value the relationships with our subrecipient partners and endeavor to pay all of them timely. Substantially all subrecipient payments are made by the College within the prescribed timeline subject to the underlying transactions being properly approved. This includes the approval by principal investigators and approval of supply chain personnel after the performance of standard controls surrounding disbursements. Management will continue to identify root causes around identified delayed payments and evaluate go-forward process improvements with supply chain services, treasury and academic department personnel. Person(s) Responsible: Rob Falivene, Vice President, Supply Chain Services, and Oswaldo Ramirez, Vice President, Treasurer Expected Completion: December 2026
The University acknowledges the findings related to NSLDS enrollment reporting, including discrepancies involving OPEID reporting, program-level status effective dates, and other enrollment reporting data elements. The University agrees with the recommendation to enhance the precision of the control...
The University acknowledges the findings related to NSLDS enrollment reporting, including discrepancies involving OPEID reporting, program-level status effective dates, and other enrollment reporting data elements. The University agrees with the recommendation to enhance the precision of the control surrounding the review of enrollment status records, program-level data records, and campus-level data records included in NSLDS reporting submissions. Several corrective actions have already been implemented to address the identified exceptions. Updates have been made within the National Student Clearinghouse (NSC) reporting processes to ensure students are assigned to the appropriate branch codes and that campus-level records reflect the correct OPEID for each reporting entity. In addition, affected student records have been reviewed and updated to ensure program-level status records and effective dates are accurate within the NSC system. Going forward, the Registrar’s Office will monitor enrollment status changes and campus assignments within the NSC reporting process to ensure that status changes, program updates, and campus-level reporting elements are reflected accurately and transmitted in accordance with NSLDS reporting requirements. To further strengthen oversight and prevent recurrence, the Office of Student Financial Aid will implement documented post-submission reconciliation procedures following NSC reporting cycles. These reviews will focus on high-risk enrollment reporting elements, including campus changes, program status changes, and other updates affecting NSLDS reporting, and will validate the accuracy of OPEID assignments and program-level effective dates against institutional records. These enhancements are intended to improve the precision of the University’s existing controls and ensure the accuracy and completeness of future NSLDS enrollment reporting submissions.
We acknowledge the critical importance of establishing and maintaining an effective system of internal control over compliance, including allowable costs under federal awards per Title 2 Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirement...
We acknowledge the critical importance of establishing and maintaining an effective system of internal control over compliance, including allowable costs under federal awards per Title 2 Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) that a non-federal entity may charge only allowable costs that are adequately documented and are necessary and reasonable for performance of the federal award under the principles of 2 CFR Part 200, Subpart E. As such, we are committed to taking immediate corrective actions to address the deficiencies to ensure accurate billing rates for equipment charges are used and that charges for internally generated fees, such as burn mix, are documented prior to charging the fees to the program. We have outlined below the specific steps we have already undertaken and will undertake: 1.Development of Standardized Equipment Rate Schedule The District has developed and will maintain a standardized schedule of approved equipment billing rates used for federal and state grant programs. This schedule will be based on published or internally approved rates and will be reviewed annually to ensure accuracy. 2.Verification of Billing Rates Prior to Grant Charges Prior to charging equipment usage to any federal award, finance staff will verify that the billing rate applied matches the approved rate schedule. This verification will be documented and retained with the supporting grant expenditure documentation. 3.Documentation of Internally Generated Rates For internally generated fees, including burn mix or similar materials, the District will develop and maintain formal documentation supporting the calculation of the rate. This documentation will include the components used to determine the rate (such as material cost, labor, and overhead where applicable) and will be retained in the grant support files. 4.Pre-Approval of Internally Generated Charges Internally generated billing rates will be reviewed and approved by management prior to being charged to any federal grant program. The approved rate documentation will be maintained as part of the grant compliance records. 5.Enhanced Grant Expenditure Review Process The District will implement a secondary review process for grant-related expenditures. Finance staff or management will review charges to federal awards to ensure the expenditures are supported, reasonable, allowable under Uniform Guidance, and calculated using the correct approved billing rates. 6.Training on Uniform Guidance Requirements Finance staff and personnel responsible for preparing or submitting grant-related charges will receive refresher training on federal grant compliance requirements under 2 CFR Part 200, specifically related to allowable costs, documentation requirements, and internal controls over grant expenditures. 7.Ongoing Monitoring of Grant Compliance As part of the year-end grant reporting process, management will periodically review equipment charges and internally generated fees charged to federal awards to ensure the established procedures are consistently followed and that adequate supporting documentation is maintained. Responsible Parties and Accountability to be designated: 1.Jackie Dunklee, CFO, and Isaac Pawning, Division Chief: Responsible for overseeing the development and update of a standardized schedule of approved equipment billing rates and ensuring compliance with state, local, and federal regulations. 2.Thelesa Montoya-Neves, Accounting Manager: Responsible for ongoing monitoring and review of equipment charges to federal awards. 3.Erick Rodriguez, Compliance Officer: Responsible for ensuring that federal grant expenditures are supported, reasonable, allowable under Uniform Guidance, and calculated using the correct approved billing rates. By implementing these corrective actions, we are committed to addressing the significant deficiency of internal controls over compliance to ensure accurate billing rates for equipment charges are used and that charges for internally generated fees, such as burn mix, are documented prior to charging the fees to the program. Anticipated Completion Date: June 2026
Condition: Expenditures for the Child and Adult Care Food Program were incorrectly reported as expenditures to other nutrition programs. Recommendation: The auditors recommend that the School properly identify and report nutrition program expenditures by program. Contact Name: Anastacia Europa Ruiz,...
Condition: Expenditures for the Child and Adult Care Food Program were incorrectly reported as expenditures to other nutrition programs. Recommendation: The auditors recommend that the School properly identify and report nutrition program expenditures by program. Contact Name: Anastacia Europa Ruiz, Chief Operating Officer Corrective Action Planned: The School Management will identify nutrition program expenditures by each separately funded program and report such expenditures by each separately funded program. Anticipated Completion Date: June 30, 2026
Condition: For FAL 10.185, all 40 vendor disbursements tested lacked evidence of supervisory approval, as the payment request forms were not signed by the designated approver prior to payment. For FAL 10.558, 27 of thirty-two vendor disbursements tested lacked documented supervisory approval prior t...
Condition: For FAL 10.185, all 40 vendor disbursements tested lacked evidence of supervisory approval, as the payment request forms were not signed by the designated approver prior to payment. For FAL 10.558, 27 of thirty-two vendor disbursements tested lacked documented supervisory approval prior to payment. Finally for FAL 84.010A, two of the ten vendor disbursements tested lacked documented supervisory approval prior to payment. In each noted instance, payments were processed without evidence that the School performed and documented a review in accordance with established internal control procedures. Recommendation: The auditors recommend that the School enforce existing policies requiring documented supervisory approval prior to processing payments and implement monitoring procedures to ensure approval documentation is completed and retained. In addition, the School should strengthen pre-payment review procedures to ensure expenditures are evaluated for allowability, necessity, reasonableness, and proper allocation in accordance with 2 CFR Part 200 and applicable program requirements. Training should be provided to personnel responsible for processing and approving federal program expenditures to reinforce compliance responsibilities. Contact Name: Anastacia Europa Ruiz, Chief Operating Officer Corrective Action Planned: The School Management will require documented supervisory approval, including signature and date, on all payment request forms prior to processing vendor disbursements charged to federal programs. Accounts payable staff will not release payments without evidence of required authorization. Written disbursement procedures will be reviewed and the applicable staff will be retrained within 90 days. The School will perform monthly oversight of disbursement activity and quarterly sample reviews to ensure ongoing compliance. Anticipated Completion Date: June 30, 2026
Finding 2025-002: Significant Deficiency in Internal Control Over Compliance and Non-Material Noncompliance Federal Awarding Agency: Department of Housing and Urban Development (HUD) Responsible Person: Eric Keeler, Director, Department of Housing and Community Development Estimated Completion: Apri...
Finding 2025-002: Significant Deficiency in Internal Control Over Compliance and Non-Material Noncompliance Federal Awarding Agency: Department of Housing and Urban Development (HUD) Responsible Person: Eric Keeler, Director, Department of Housing and Community Development Estimated Completion: April 15, 2026 Corrected Action: 1. The Housing Choice Voucher (HCV) Program transitioned to a new client management software on August 1, 2025 and program staff are reviewing all of the existing inspection due dates in the software to ensure the dates are correct based on the last biennial inspection or initial inspection. 2. Staff will continue to utilize the monthly Section Eight Management Assessment Program (SEMAP) Indicators Report in HUD’s Public and Indian Housing Information Center (PIC) database and provide that information to the inspectors monthly. 3. Staff will begin to utilize the Housing Quality Standards (HQS) Inspection Report that is now available in HUD’s Public and Indian Housing Information Center (PIC) database. This report allows staff to see all inspections that will be due in the next year, according to PIC data. The HCV Program Manager will review the report with the Housing Inspectors monthly to verify that all of the upcoming inspections are scheduled. 4. The HCV Program Manager will schedule monthly meetings to review upcoming Inspections Due with the two Housing Inspectors on staff. The HCV Program Manager will verify that each of the inspections due are scheduled in advance and check the next month’s list of completed inspections to ensure all of the inspections scheduled were completed in a timely manner. If the inspections are not completed in a timely manner, the HCV Program Manager will investigate the cause and determine if corrective action and/or additional quality assurance is needed. 5. The HCV Program Manager will review the Completed Inspections Report from the software provider to ensure that it provides a complete list of all failed inspections. This will be completed on a monthly basis with the Housing Inspectors by comparing the list with Inspection Records for the month. 6. An additional Housing Inspector position was added in FY 2026, which allows the inspections to be divided between the two Housing Inspectors. This added position will allow more time for Housing Inspectors to review reports, prepare for, and schedule inspections.
Finding Number: 2025-002 Equipment Property Management Recommendation: The University needs to enhance the precision of the controls over equipment purchases to ensure that a property record is created within the system containing the required information, inclusive of the federal award, for all fed...
Finding Number: 2025-002 Equipment Property Management Recommendation: The University needs to enhance the precision of the controls over equipment purchases to ensure that a property record is created within the system containing the required information, inclusive of the federal award, for all federally funded equipment. Management concurs with the auditor’s recommendation. The University has taken immediate steps to comply with 2CFR 200.313 and implemented the following actions: Planned Corrective Action (1): The University has established a bi-weekly reconciliation process for federally funded assets to strengthen compliance and ensure the timely and accurate inclusion of all federally funded asset purchases in the asset register. Anticipated Completion Date: Completed Responsible Contact Person: Eric Hughey, Fiscal Manager, Asset Accounting & Surplus/Nataliya Samodov, GCA Director Planned Corrective Action (2): The University has implemented an additional control through exception reporting and follow-up with responsible parties to ensure that all registered assets are tagged at the time of installation. Anticipated Completion Date: Completed Responsible Contact Person: Eric Hughey, Fiscal Manager, Asset Accounting & Surplus/Nataliya Samodov, GCA Director
VIEWS OF RESPONSIBLE OFFICIALS Management reviewed the reporting process and identified that the discrepancy resulted from reliance on PMS drawdown and cash-basis payment activity rather than cumulative accrualbased expenditures recorded in SAP. Internal procedures have been revised to ensure that L...
VIEWS OF RESPONSIBLE OFFICIALS Management reviewed the reporting process and identified that the discrepancy resulted from reliance on PMS drawdown and cash-basis payment activity rather than cumulative accrualbased expenditures recorded in SAP. Internal procedures have been revised to ensure that Line 10.e reflects total cumulative expenditure recorded on an accrual basis, consistent with the accounting records. Implemented or Planned Corrective Measures: 1. Management Action: The interim SF-425 for Grant 02TD0022301 was formally reviewed on February 11, 2026, corrected to properly reflect cumulative expenditures in Line 10.e, and resubmitted through the Payment Management System (PMS). 2. Management Meeting: On February 25, 2026, a formal meeting was held with the Fiscal Team, Program Director, Sub-Director, Budget/Fiscal Analyst, and Fiscal Consultant to review the finding and establish the enhanced corrective plan. 3. Corrective Measure Related to Root Cause: The reporting process has been revised to ensure that all SF-425 reports are prepared using cumulative accrual-based expenditure data directly extracted from SAP, consistent with accrual accounting principles and 2 CFR §200.302(b)(2). This enhancement strengthens internal controls over financial reporting in accordance with 2 CFR §200.303 4. Implementation of a formal reconciliation process between the general ledger (SAP), supporting expenditure reports, and the SF-425 prior to submission. 5. Comprehensive Preventive Review: Management initiated a comprehensive review of all SF-425 reports submitted from July 1, 2025, to the present. This review includes reconciliation of Lines 10.e and 10.f to SAP general ledger data to confirm compliance with accrual-based reporting standards. The review will be completed no later than March 30, 2026. Results will be formally documented in accordance with the Federal Reporting Procedures Manual and presented to the Governing Board at its meeting on March 30, 2026. 6. Structural Improvements Implemented: 1. Budget/Fiscal Analyst formally responsible for extracting cumulative data from SAP, preparing SF-425, and completing standardized reconciliation of Lines 10.e and 10.f. 2. Fiscal Consultant responsible for independent review, validation of compliance with 2 CFR §§200.302 and 200.303, certification, and submission in PMS. 3. Implementation of a standardized reconciliation worksheet. 4. Training for fiscal personnel scheduled for March 5, 2026, covering revised procedures and Uniform Guidance requirements. 7. Governance and Monitoring: • Adoption of the formal Federal Reporting Procedures Manual. • Establishment of an Annual Federal Reporting Calendar reviewed monthly. • Monitoring by the Sub-Director with documentation in fiscal meeting minutes. • Formal presentation of the audit finding and revised procedures to the Governing Board on March 30, 2026. 8. All corrective actions are expected to be fully implemented no later than March 30, 2026. IMPLEMENTATION DATE March 30, 2026 RESPONSIBLE PERSONS Margot Vélez Meléndez, Director of Head Start Program
The Municipality agrees with the finding and stated that it will implement corrective actions to improve compliance with reporting requirements. Management plans to formalize reporting procedures, assign responsible personnel, and require reconciliations between reported amounts and accounting recor...
The Municipality agrees with the finding and stated that it will implement corrective actions to improve compliance with reporting requirements. Management plans to formalize reporting procedures, assign responsible personnel, and require reconciliations between reported amounts and accounting records prior to submission of reports to ACUDEN, along with enhanced supervisory review. Implementation Date: July 1, 2026 Responsible Person: Mr. Luis A. Velez Rivera, Finance Director
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will publish revised subrecipient monitoring procedures. ...
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will publish revised subrecipient monitoring procedures. The Department will cross-train relevant agency staff on the procedures. The Department will implement a quarterly FAC review cycle with revised procedures. Completion Date: April 30, 2026, June 30, 2026, and July 1, 2026, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will publish revised Federal financial reporting procedures. The De...
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will publish revised Federal financial reporting procedures. The Department will train relevant staff. The Department will implement new Federal Financial Reporting procedures with increased staff resource allocations. Completion Date: April 30, 2026, June 30, 2026, and July 1, 2026, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program special reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will develop same-month internal validation workbook/tool to ensure t...
Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program special reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will develop same-month internal validation workbook/tool to ensure that subawards have been reported timely, completely and accurately. The Department will update agency FFATA reporting procedure to reflect changes in reporting process and selection of unique identifier and distribute to all grant managers and reporting personnel. Completion Date: March 31, 2026, and April 30, 2026, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507
Department: Health and Human Services Title: Internal control over Medicaid utilization control needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. This finding represents a mis...
Department: Health and Human Services Title: Internal control over Medicaid utilization control needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. This finding represents a misunderstanding of the applicable federal regulations and the state entity responsible for compliance. A Utilization Control (UC) program is the responsibility of the State Medicaid Agency as a whole, not the Program Integrity Unit (PIU). Additionally, there are many more federal regulations governing UC programs than cited by the Office of State Auditor (OSA) in the finding and touch on a host of controls that were not reviewed or considered in this audit. Moreover, the OSA appears to be basing findings on interpretations that are unsupported by the regulatory text cited. Second, the OSA confuses PIU's annual review plan (a yearly plan of focused program integrity areas of focus and review) with an agency-wide UC program: these are not the same, nor are they required to be. The Department's current processes for PIU's annual review plan were implemented in response to OSA findings in 2015 relating to an OSA finding that the Department was not fully utilizing available data analytics. In the intervening years, the OSA has not found Program Integrity's annual review plan, or the process of developing the plan, to be deficient. There has been no change in the Department's process or the regulation to justify the OSA's newly found position here. The OSA's criticism of PIU's use of data analytics contradicts a prior OSA findings on data analytics use, is contrary to accepted Department adjustments made in response, and represents a significant departure from federal guidance and industry standards around best practices for leveraging data analytics to prevent and detect improper payments and/or utilization. The PIU's annual review plan supplements post-payment reviews that PIU conducts based upon complaints and referrals. Finally, this finding’s singular focus on PIU's annual review plan fails to account for a myriad of other systems and processes the Department has in place to monitor utilization, including, but not limited to: 1. A contracted vendor (HMS) performing post-payment reviews of hospitals, nursing facilities, and other long-term care facilities; 2. MaineCare's Case Mix unit - performing look back reviews of documentation and services in nursing facilities and other long-term care units; 3. A contracted vendor (Acentra) reviewing authorization requests for behavioral health services and continuing stay reviews of services at designated intervals; 4. A contracted vendor (Maximus) that performs assessments and authorizations for nursing and personal care services; 5. A contracted vendor (Optum) that performs prior authorization reviews for pharmacy services and produces a variety of reports on drug utilization; 6. Fiscal intermediaries performing oversight and administrative support for self-directed services; 7. State staff who review and approve plans of care for Home and Community Based Waiver Services and conduct quality reviews of providers; 8. State staff performing quality assurance reviews of providers of mental and behavioral health services; 9. State staff monitoring and addressing inappropriate emergency department usage by beneficiaries; and 10. State staff with oversight and performing qualitative and quantitative reviews of a variety of programs operated under delivery service reform, including: Accountable Communities, Behavioral Health Homes, Certified Community Behavioral Health Clinics, Community Care Teams, MaineMOM, Opioid Health Homes, and Primary Care Plus. 11. State and contracted vendor (Gainwell) staff reviewing medical necessity and other allowability for medical services requiring prior authorization for initial requests and renewals. 12. A CMS-compliant Electronic Visit Verification (EVV) system, in accordance with Section 12006 of the 21st Century Cures Act, that ensures payment for applicable services is tied to an EVV record demonstrating that the service occurred; data from the system also contributes to post-payment reviews for applicable services. Completion Date: N/A Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093
Department: Administrative and Financial Services Title: Internal control over Medicaid SEFA reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Service Center will update the internal SEFA procedure to include the step of removing app...
Department: Administrative and Financial Services Title: Internal control over Medicaid SEFA reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Service Center will update the internal SEFA procedure to include the step of removing appropriations 0129, 0147 and 0148 from the subrecipient queries. The DHHS Service Center will update the reviewer's checklist for the SEFA to include a check that appropriations 0129, 0147 and 0148 are being excluded from subrecipient queries. The DHHS Service Center will add a note within the "Subrecipient" tab of the internal SEFA Cubes Workbook to exclude appropriations 0129, 0147 and 0148. Completion Date: February 20, 2026 (first item), and October 31, 2026 (second and third items) Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626
Department: Health and Human Services Title: Internal control over Medicaid drug rebates needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. Drug Rebate pre-invoicing and post-i...
Department: Health and Human Services Title: Internal control over Medicaid drug rebates needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. Drug Rebate pre-invoicing and post-invoicing is completed quarterly. As demonstrated during walkthroughs and during our meetings Maine completes specific tasks to ensure accuracy of the invoicing process. The pre-invoicing and post-invoicing procedures are documented in the Pharmacy Rebate Information Management System (PRIMS) Desk Level Procedure (DLP). The pre-invoicing work is performed by the State that compares drug utilization data to the number of dispensed units invoiced. Upon the completion of the pre-invoicing review approval is provided to the vendor allowing them to continue with the invoicing process. There is no requirement regarding how we select our sample of invoices to review. Based on OSA noting no exceptions to the drug rebate amounts, our system in place to review invoiced drug rebates is functioning as intended. Completion Date: N/A Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093
Department: Administrative and Financial Services Health and Human Services Title: Internal control over Medicaid procurement needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Department of Administrative and Financial Services (DAFS): The Department w...
Department: Administrative and Financial Services Health and Human Services Title: Internal control over Medicaid procurement needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Department of Administrative and Financial Services (DAFS): The Department will develop a specific policy document that balances agency authority/responsibility with procurement best practices regarding contract dates, clearly communicating risks and responsibilities. The Department will create a companion communication document to this policy document for distribution purposes. The Department will spotlight the policy and communication documents in the OSPS monthly electronic newsletter to all agencies. The Department will post the policy statement and communications documents on the OSPS intranet site. The Department will integrate the new content into the draft OSPS Policy Manual. The Department will release the related module in the new, updated, digital OSPS Policy Manual. Department of Health and Human Services (DHHS): The Department will collaborate with OSPS and program offices to implement procedures to ensure the timeliness of procurement documents. Completion Date: DAFS: April 30, 2026 (first item), May 15, 2026 (second item), May 31, 2026 (third and fourth items), June 30, 2026 (fifth item), and September 30, 2026 (sixth item) DHHS: May 31, 2026 Agency Contact: DAFS: David Morris, Acting Chief Procurement Officer, OSPS, 207-624-7335 DHHS: Jim Lopatosky, Director, Division of Contract Management, DHHS, 207-287-5075
Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Director and Deputy director will meet biweekly to review the audit assignments and discuss the st...
Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Director and Deputy director will meet biweekly to review the audit assignments and discuss the status of the nursing facility audits. The Division of Audit management team will actively recruit for the ten vacant audit positions. The Deputy Director will adjust the audit procedures for the Nursing Facilities to limit the testing to just capital costs starting with the December 31, 2025, cost reports. The Department has assigned four of the seven current staff auditors to nursing facility audits. Completion Date: Ongoing (first and fourth items), June 30, 2026 (second item), and May 31, 2026 (third item) Agency Contact: Herb Downs, Director, Division of Audit, DHHS, 207-287-2403
Department: Health and Human Services Title: Internal control over the Adoption Assistance eligibility and benefit determination process needs improvement Questioned Costs: Known: $1,645 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Office of Child and Family Se...
Department: Health and Human Services Title: Internal control over the Adoption Assistance eligibility and benefit determination process needs improvement Questioned Costs: Known: $1,645 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Office of Child and Family Services made changes to the Katahdin System in August 2025 to stop duplicate payments. The Office of Child and Family Services will develop training information regarding children in adoption assistance agreements who are no longer receiving support from the adoptive parents. The Office of Child and Family Services will develop a training and train the appropriate staff. Completion Date: August 1, 2025, May 1, 2026, and December 31, 2026, respectively Agency Contact: Denise Merrill, Manager of Child Welfare Statewide Programs, DHHS, 207-822-2255
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