Corrective Action Plans

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2025-002 – Subrecipient Monitoring Cluster: Research and Development Cluster (“R&D”) Sponsoring Agency: Various – All R&D awards with subrecipients from 1 campus Award Name: Various - All R&D awards with subrecipients from 1 campus Award Number: Various Assistance Listing Title: Various – All R&D aw...
2025-002 – Subrecipient Monitoring Cluster: Research and Development Cluster (“R&D”) Sponsoring Agency: Various – All R&D awards with subrecipients from 1 campus Award Name: Various - All R&D awards with subrecipients from 1 campus Award Number: Various Assistance Listing Title: Various – All R&D awards with subrecipients from 1 campus Assistance Listing Number: Various - All R&D awards with subrecipients from 1 campus Award Year: 2024-2025 Pass-through entity: All pass-through awards for 1 campus with subrecipients The Sponsored Programs Office will implement a new process to ensure all Uniform Guidance reports for all subrecipients of federal funding are reviewed annually to ensure findings affecting our awards are appropriately addressed and that we issue a management decision to the extent applicable. The process will involve setting event reminders on all active subrecipients under federally funded projects to trigger review every 10-11 months regardless of any upcoming amendments. The targeted implementation date is August 1, 2026. For inquiries regarding this finding, please contact Patrick Woods at pjwoods@ucdavis.edu.
2025-001 – Federal Equipment Inventory Cluster: Research and development Sponsoring Agency: Various Award Name: All awards for 3 campuses with federal equipment expenditures in the Schedules of Expenditures of Federal Awards (SEFA) Award Number: Various Assistance Listing Title: All awards for 3 cam...
2025-001 – Federal Equipment Inventory Cluster: Research and development Sponsoring Agency: Various Award Name: All awards for 3 campuses with federal equipment expenditures in the Schedules of Expenditures of Federal Awards (SEFA) Award Number: Various Assistance Listing Title: All awards for 3 campuses with federal equipment expenditures in the SEFA Assistance Listing Number: All awards for 3 campuses with federal equipment expenditures in the SEFA Award Year: 2024-2025 Pass-through entity: All pass-through awards for 3 campuses with equipment expenditures in the SEFA Campus One The campus acknowledges the audit finding that the requirement under 2 CFR 200.313(d) to conduct a physical inventory of federally funded equipment at least once every two years and reconcile the results with property records was not met. The campus is committed to maintaining accurate equipment records and ensuring sustained compliance with federal equipment management requirements. The delay in completing the required inventory cycle occurred in two phases: • Post-COVID Inventory Cycle (2021–2022): We received a federal exception for the inventory due June 30, 2021, with the expectation that the cycle would resume and be completed by June 30, 2022. Although partial inventory activity occurred in July 2022, covering a portion of campus assets, a full campus-wide validation was not completed by the required deadline. Continued operational recovery challenges, including limited access to research spaces and staffing constraints until campus fully reopened in May 2023, contributed to the delay in restoring the full two-year cycle. • Staffing Disruption (2024–Mid 2025): From early 2024 through mid-2025, the campus’s sole dedicated equipment administrator was on extended leave. While Accounting Services staff maintained essential functions such as new equipment tagging and property record maintenance, the department did not have sufficient specialized capacity to complete the full physical inventory validation process during that period. We are pleased to report that the equipment inventory process was successfully restarted in July 2025. Following the return of dedicated staff and the department's stabilization in mid-2025, we prioritized the backlog of equipment validations. As of the date of this response, we have made significant progress in bringing our physical inventory records into compliance with federal standards. We anticipate completing the full physical inventory and reconciliation of all federally funded equipment by June 30, 2026, thereby restoring full compliance with the required two-year cycle. To ensure that such delays do not recur, the campus has, as of January 2026, implemented a strategic realignment of the teams responsible for equipment and property management. Key improvements include: • Cross-Training and Redundancy. We have implemented a cross-training program in which multiple members of the Accounting team are now trained on the physical inventory validation protocols. This ensures that the process is no longer dependent on a single individual and can continue uninterrupted during future personnel absences. • Enhanced Oversight: We have integrated equipment inventory status into our regular financial control reviews to provide management with earlier visibility into potential reporting or timing gaps. • Team Realignment: The team structure has been adjusted to provide better coverage of federal equipment and real property management, enabling more consistent rolling inventory cycles as required by federal guidelines. The campus remains dedicated to meeting all federal compliance requirements and believes these structural changes will provide the necessary resilience for our equipment management program. Since July 2025, the equipment validation has resumed on a structured schedule, and backlogged activities have been resolved. Physical verification and reconciliation are progressing toward full completion. Oversight mechanisms and staffing redundancies are operational. These measures significantly reduce the risk of future noncompliance. For inquiries regarding this finding, please contact Biju Kamaleswaran at biju@ucsc.edu. Campus Two The root causes for equipment certifications not being completed or being completed late were that departments overlooked the deadline and that some department staff were not familiar with the certification process. To address these issues, we will implement several corrective actions: • Include the Dean’s and Vice Chancellor’s offices in equipment certification notifications to alert senior management of the requirement and keep them apprised of progress toward completion. • Increase the frequency of communications with departments prior to the certification deadline and will include certification status in those communications. • Notify the campus of the requirement to provide justification for equipment certifications submitted after the deadline and will include this requirement in the initial annual notifications, reminder emails, and the Equipment Certification form. • For equipment certifications not received by the deadline, Accounting will notify the applicable Dean’s and Vice Chancellor’s offices and inform them of the department’s Care and Control of Equipment policy. This campus’ inventory is split into two cycles. Cycle 1 is notified of their inventory certifications being due in odd years, and Cycle 2 in even years. Implementation will begin with the initial annual equipment certification notification in August 2026, with reminder notifications sent periodically from August through the October certification deadline. Departments may complete their equipment certifications at any time and do not need to wait for notification emails, as instructions and information are available on the campus Finance website. Accounting will monitor compliance by tracking progress toward completion through the certification deadline, comparing completion and delinquency rates with prior years, validating that certifications previously submitted late are submitted on time in subsequent years, and notifying the relevant Dean’s and Vice Chancellor’s offices of repeat violations. For inquiries regarding this finding, please contact Taylor Urban at turban@ucdavis.edu. Campus Three Based on the campus’s internal review, both assets reached the end of their operational utility and were handled in a manner consistent with university policy and reasonable effort. The NSF-funded research equipment purchased on September 29, 2006, was fully depreciated by 2011 and physically validated in 2024 as non-operational. During the 2026 inventory cycle, the department confirmed the unit had been cannibalized for parts to maintain active laboratory equipment. The university-titled physics equipment purchased on October 23, 2002, remained in service for over two decades and was fully depreciated prior to disposal. Its tracking was affected by the administrative split of the Department of Physics and Astrophysics and the retirement of the Principal Investigator, after which the office contents were sent to Surplus following standard university procedures. Both assets exceeded their expected service lives and have now been retired. The campus will implement mandatory targeted training for departmental equipment custodians to ensure policy alignment and will establish a rolling custodial training schedule, with completion required prior to gaining access to the asset system. Training completion will be tracked through metrics provided by UC Learning. The campus will also launch recurring campus-wide communications providing guidance on equipment inventory best practices and compliance requirements and will formalize an enhanced workflow with Surplus Sales to verify and scan inventorial assets upon pickup or arrival at the warehouse to improve the timeliness of inventory record updates. Campus communications and departmental training will begin prior to May 1, 2026 and continue on an ongoing basis through June 30, 2028, with training prioritized by risk. The Surplus Sales Alignment will also begin prior to May 1, 2026, with protocol finalization by the third quarter of 2026. As immediate remediation, the assets identified in the finding have been reconciled and updated in the system, and the campus is consulting with departments that previously bypassed standard procedures to establish more robust internal controls. For inquiries regarding this finding, please contact Daniel Clipson at dclipson@ucsd.edu.
CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2025 AUDITOR FINDING: 2025-001 – Research and Development Cluster Area: Equipment Uniform Guidance (2 CFR 200.313(d)) requires non-federal entities to maintain effective control and accountability for all federally funded equipment, including p...
CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2025 AUDITOR FINDING: 2025-001 – Research and Development Cluster Area: Equipment Uniform Guidance (2 CFR 200.313(d)) requires non-federal entities to maintain effective control and accountability for all federally funded equipment, including procedures to ensure assets exist, are used for authorized purposes, and are properly disposed of when no longer needed. Uniform Guidance further contemplates periodic physical inventories of equipment and reconciliation to property records at least once every two years. Policies and procedures should address all federal awards, regardless of awarding agency. Based on testing performed, assets had been disposed but not removed from the asset subledger. In addition, a full inventory of federally funded assets was not completed within a two year timeframe and key data was not reconciled. It is recommended that the fixed asset policy is expanded and formalizes alignment with Uniform Guidance requirements, including (1) Performing and documenting a physical inventory of federally funded equipment at least once every two years, with reconciliation to the fixed asset subledger. (2) Ensuring timely communication and documentation of asset disposals to Finance for record updates. CLIENT PLANNED ACTION: (1) Amend Capital Assets policy to align with Uniform Guidance including periodic physical inventories of equipment and reconciliation to property records at least once every two years. (2) Perform inventory and reconcile asset listing. (3) Develop training materials focusing on the policies and procedures around federal equipment management including period inventories, reconciliations and processing of disposal requests. (4) Provide training to grant and research department staff, administrators, and principal investigators in equipment compliance requirements. CLIENT RESPONSIBLE PARTIES: Carrie Kopsch, Manager of Research Administration Kelli Varney, Executive Director of Financial Reporting and Systems COMPLETION DATE: Action plan items (1) and (3) will be completed by June 30, 2026, and items (2) and (4) will be completed by June 30, 2027.
Corrective Actions: Housing Authority of the City of Baldwin Park (HACBP) has taken immediate corrective actions. All required inspections now are current and supporting documentation is complete and properly filed. Management continues to monitor inspection activities to prevent recurrence of the c...
Corrective Actions: Housing Authority of the City of Baldwin Park (HACBP) has taken immediate corrective actions. All required inspections now are current and supporting documentation is complete and properly filed. Management continues to monitor inspection activities to prevent recurrence of the conditions noted. Management has also taken immediate and comprehensive corrective measures, including: • Removal of the external consultant from all inspection-related responsibilities. • Return of HACBP’s in‑house inspector from extended leave, restoring full internal oversight of the HQS inspection process. • Assignment of inspection responsibilities solely to trained HACBP inspection and management staff. • Implementation of strengthened procedures for tracking, scheduling, and documenting all inspections including, initial, re-inspections, and annual/biennial inspections. • Verification that all inspection files are properly uploaded, retained, and accessible in accordance with HACBP’s file management policies.
Corrective Actions: Staff will ensure that the Monitoring Policy will be fully implemented as recommended. In addition , changes in staffing will be addressed by additional training to ensure that consistent processes are maintained. Name of Responsible Person: Okina Dor, Director of Community Devel...
Corrective Actions: Staff will ensure that the Monitoring Policy will be fully implemented as recommended. In addition , changes in staffing will be addressed by additional training to ensure that consistent processes are maintained. Name of Responsible Person: Okina Dor, Director of Community Development Ryan Mulligan, Housing Manager Rose Tam, Director of Finance
Corrective Actions: Housing Authority of the City of Baldwin Park (HACBP) is committed to full compliance with all CDBG reporting requirements and will ensure that future submissions are accurate, timely, and properly documented. HACBP has implemented the following corrective actions: • Established ...
Corrective Actions: Housing Authority of the City of Baldwin Park (HACBP) is committed to full compliance with all CDBG reporting requirements and will ensure that future submissions are accurate, timely, and properly documented. HACBP has implemented the following corrective actions: • Established an internal reporting calendar with earlier internal deadlines to ensure adequate time for review and submission. • Documented key reporting procedures to strengthen continuity and reduce reliance on individual staff knowledge. • Initiated cross training to ensure multiple staff members can support CDBG reporting functions as needed. • Implemented automated reminders and tracking tools to improve oversight of reporting cycles. Name of Responsible Person: Okina Dor, Director of Community Development Ryan Mulligan, Housing Manager
Finding 2025-003 – Special Test and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance (See table in Management's Corrective Action Plan"). Condition/Context – Out of a population of approximately 1,000 student status changes a...
Finding 2025-003 – Special Test and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance (See table in Management's Corrective Action Plan"). Condition/Context – Out of a population of approximately 1,000 student status changes and 230 permanent address changes, a sample of 74 federal aid recipient students were selected from system generated reports of students who graduated, reported a physical address change, withdrew, or dropped during the 2024-2025 academic year. Auditors believe this to be a representative sample although not a statistical sample. The enrollment information and withdrawal, address change, or graduation date per the University’s records was compared to the information reported to the National Student Loan Data System (NSLDS) in order to determine if status changes were reported within the required timeframes. Corrective Action Plan: The finding has been addressed through staffing changes and scheduled reporting which took effect January 2026. The office of the University Registrar did not previously have a dedicated staff member to submit reports in a timely manner. With the departure of the Associate Registrar in April 2025, the task fell to several staff members to share the responsibility along with their other tasks. The office currently has an assistant registrar as well as a transcript evaluator who share the responsibility and submit reports once every 30 days, with the exception of winter reporting, which is on a different schedule due to breaks. Internal controls have been revised to check conferral dates prior to submitting the enrollment report for the Main Campus. Name of Contact Person: Julie Khella, University Registrar at jkhella@laverne.edu Projected Completion Date: This was corrected as of March 22, 2026
FINDING 2025-002 – Special Tests and Provisions – Cash Management: Significant Deficiency in Internal Control over Compliance (See table in "Management's Corrective Action Plan"). Condition/Context – The University made 48 draws for various student financial assistance cluster programs. Auditors sel...
FINDING 2025-002 – Special Tests and Provisions – Cash Management: Significant Deficiency in Internal Control over Compliance (See table in "Management's Corrective Action Plan"). Condition/Context – The University made 48 draws for various student financial assistance cluster programs. Auditors selected a sample of 7 and believe this to be a representative sample; however, it was not a statistical sample; Corrective Action Plan: This was done due to the perceived understanding that the new Federal Administration indicated that all grants were at risk of being cancelled and that the G5 website would go dark. Due to the unique nature of the Federal Administration’s perceived announcement, the University would not handle this in the same manner, in the future. If for some reason they were to cancel any future grants, the University would endure the cancellation and close out the grant in the usual process, which is by reimbursement only. Name of Contact Person: Lori Gordien Case, Associate Vice President of Finance and Controller at lgordien@laverne.edu Projected Completion Date: This was corrected as of March 31, 2025.
FINDING 2025-001 – Special Tests and Provisions – Return of Title IV Funds: Significant Deficiency in Internal Control over Compliance; (See table in "Management's Corrective Action Plan"); Condition/Context – Auditors selected a sample of 20 students out of a population of 109 that were identified ...
FINDING 2025-001 – Special Tests and Provisions – Return of Title IV Funds: Significant Deficiency in Internal Control over Compliance; (See table in "Management's Corrective Action Plan"); Condition/Context – Auditors selected a sample of 20 students out of a population of 109 that were identified by the University as having received some federal assistance and withdrew from the University during the year under audit. Auditors believed this to be a representative sample of the population; however, it was not a statistical sample. Corrective Action Plan: The finding has been addressed through the implementation of our FY2024 Corrective Action Plan. The Office of Financial Aid has collaborated with the University Registrar to develop a comprehensive report identifying non-completed courses inclusive of all grade codes. This report is reviewed on the day following faculty submission of final grades for both semester and modular terms. Students subject to R2T4 processing are identified by the Associate Director of Compliance & Special Programs and subsequently assigned to a team of three Program Managers for COD processing. Timely review of this report ensures that all required funds are returned within the 45-day regulatory timeframe. Internal controls have been revised to include a secondary review of all processed R2T4’s. Additionally, an internal control document will be established to demonstrate that R2T4 calculations were reviewed for accuracy and completeness. Name of Contact Person: Laura Evans, Director of Financial Aid at levans2@laverne.edu Projected Completion Date: This was corrected as of March 22, 2026
Reference Number: 2025-001 Awarding Agency: U.S. Department of Housing and Urban Development Program Name: Community Development Block Grants/Entitlement Grants Assistance Listing Number: 14.218 Award Number: B-24-MC-06-0011 Federal Award Year: Fiscal Year Ended June 30, 2024 Category of Finding: Re...
Reference Number: 2025-001 Awarding Agency: U.S. Department of Housing and Urban Development Program Name: Community Development Block Grants/Entitlement Grants Assistance Listing Number: 14.218 Award Number: B-24-MC-06-0011 Federal Award Year: Fiscal Year Ended June 30, 2024 Category of Finding: Reporting Type of Finding: Instance of Noncompliance; Significant Deficiency in Internal Control Over Compliance 1. Person responsible: CDBG Administrator 2. Corrective Action Plan: The City of Fremont agrees with the finding and recommendation. To strengthen compliance with FFATA reporting requirements, program staff will provide the subrecipient or contractor with the FFATA reporting notice, including the request for the five most highly compensated officers, at the same time the contract is sent for signature. Aligning these documents will improve tracking, as the subrecipient or contractor will return both the signed contract and the FFATA reporting notice together. Once staff receives the fully executed contract, the FFATA reporting system will be updated promptly. A screenshot showing the date and time of the submission will be retained in the contract file to document timely reporting and ensure continued compliance. 3. Anticipated implementation date: April 1, 2026
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER (ALN 10.555 AND 10.553) 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summar...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER (ALN 10.555 AND 10.553) 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires Independent School District No. 719, Prior Lake-Savage Area Schools (the District) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster federal programs. During our audit, we noted the District did not have sufficient controls in place within its child nutrition cluster federal programs to ensure compliance with federal requirements related to assuring that the District was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District will review its policies and procedures relating to suspension and debarment for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to assure that district personnel are following the requirements of the Uniform Guidance related to suspension and debarment, including maintaining appropriate documentation. Official Responsible – The District’s Executive Director of Business Services, Lisa Rider. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Executive Director of Business Services, Lisa Rider, will assure appropriate internal controls and procedures are in place to ensure compliance with suspension and debarment requirements.
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
Finding 2025‐003 Reimbursement Request Approval Documentation ‐ Significant Deficiency Management Response: The Association acknowledges this finding and agrees that reimbursement request files should contain clearer documentation evidencing the preparation and approval process required under intern...
Finding 2025‐003 Reimbursement Request Approval Documentation ‐ Significant Deficiency Management Response: The Association acknowledges this finding and agrees that reimbursement request files should contain clearer documentation evidencing the preparation and approval process required under internal policy. Although reimbursement requests were prepared and submitted as part of routine grant administration, the supporting documentation did not consistently reflect the full preparation trail and approval record expected for audit purposes. Management has already identified the need to formalize this process and will implement a standardized reimbursement request file structure for all future reimbursement submissions. This process will include documentation showing who prepared the request, the date of preparation, the review and approval path, and the supporting expenditure records associated with the reimbursement period. Where applicable, the Association will incorporate a formal checklist or cover sheet to ensure each request file demonstrates compliance with internal procedures and grant requirements. Management does not believe the issue resulted from intentional noncompliance, but rather from inadequate documentation of a process that had been operationally performed. Even so, management agrees that documentation standards must be improved to reduce risk and strengthen compliance controls over federal reimbursement activity. The Association is committed to implementing this corrective action immediately for all future reimbursement requests to ensure that preparation and approval procedures are clearly evidenced and consistently retained. The draft audit notes that the comparable prior-year federal finding appears to be resolved, and management intends to similarly resolve this finding through standardized documentation and retention procedures. Responsible Official: Director / Business Manager Planned Corrective Action Date: Immediately for all reimbursement requests submitted after audit issuance
Corrective Action Plan 2025-003 Non-Compliance with JOM Annual Report Submission Federal Program Information Funding Agency US Bureau of Indian Education Title: Johnson O’Malley Federal Assistance Listing: 15.130 Pass Through Zuni Tribe Award Year 2022-2027 Responsible Official’s Plan Due to unfores...
Corrective Action Plan 2025-003 Non-Compliance with JOM Annual Report Submission Federal Program Information Funding Agency US Bureau of Indian Education Title: Johnson O’Malley Federal Assistance Listing: 15.130 Pass Through Zuni Tribe Award Year 2022-2027 Responsible Official’s Plan Due to unforeseen circumstances, the Federal Programs Director for Zuni Public Schools retired mid year. Because of the abrupt timing of the retirement, the new Federal Programs Director did not receive an optimal amount of training. Additional training has been received regarding federal fund report compliance. The Johnson O’Mallley report referenced in the finding has been completed and submitted. Specific corrective action plan for funding: It is being completed and will be submitted by the new Federal Programs Director, Ms. Florence Acque. Timeline for completion of corrective action March 31, 2026 Employee Position responsible for meeting the timeline: Florence Acque Federal Programs Director
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: Redacted Title: Redacted Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with the finding. The Department’s explanation and specific reasons for disagreement have been excluded to protect confidenti...
Department: Redacted Title: Redacted Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with the finding. The Department’s explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: N/A Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department’s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protec...
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department’s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete corrective action plan as well as the explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: February 5, 2026, April 10, 2026, May 15, 2026, June 26, 2026, and June 30, 2027 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been pro...
Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: May 1, 2026, May 29, 2026, June 12, 2026, September 18, 2026, and September 21, 2026, respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Department: Health and Human Services Title: Internal control over Medicaid utilization control needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. This finding represents a mis...
Department: Health and Human Services Title: Internal control over Medicaid utilization control needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. This finding represents a misunderstanding of the applicable federal regulations and the state entity responsible for compliance. A Utilization Control (UC) program is the responsibility of the State Medicaid Agency as a whole, not the Program Integrity Unit (PIU). Additionally, there are many more federal regulations governing UC programs than cited by the Office of State Auditor (OSA) in the finding and touch on a host of controls that were not reviewed or considered in this audit. Moreover, the OSA appears to be basing findings on interpretations that are unsupported by the regulatory text cited. Second, the OSA confuses PIU's annual review plan (a yearly plan of focused program integrity areas of focus and review) with an agency-wide UC program: these are not the same, nor are they required to be. The Department's current processes for PIU's annual review plan were implemented in response to OSA findings in 2015 relating to an OSA finding that the Department was not fully utilizing available data analytics. In the intervening years, the OSA has not found Program Integrity's annual review plan, or the process of developing the plan, to be deficient. There has been no change in the Department's process or the regulation to justify the OSA's newly found position here. The OSA's criticism of PIU's use of data analytics contradicts a prior OSA findings on data analytics use, is contrary to accepted Department adjustments made in response, and represents a significant departure from federal guidance and industry standards around best practices for leveraging data analytics to prevent and detect improper payments and/or utilization. The PIU's annual review plan supplements post-payment reviews that PIU conducts based upon complaints and referrals. Finally, this finding’s singular focus on PIU's annual review plan fails to account for a myriad of other systems and processes the Department has in place to monitor utilization, including, but not limited to: 1. A contracted vendor (HMS) performing post-payment reviews of hospitals, nursing facilities, and other long-term care facilities; 2. MaineCare's Case Mix unit - performing look back reviews of documentation and services in nursing facilities and other long-term care units; 3. A contracted vendor (Acentra) reviewing authorization requests for behavioral health services and continuing stay reviews of services at designated intervals; 4. A contracted vendor (Maximus) that performs assessments and authorizations for nursing and personal care services; 5. A contracted vendor (Optum) that performs prior authorization reviews for pharmacy services and produces a variety of reports on drug utilization; 6. Fiscal intermediaries performing oversight and administrative support for self-directed services; 7. State staff who review and approve plans of care for Home and Community Based Waiver Services and conduct quality reviews of providers; 8. State staff performing quality assurance reviews of providers of mental and behavioral health services; 9. State staff monitoring and addressing inappropriate emergency department usage by beneficiaries; and 10. State staff with oversight and performing qualitative and quantitative reviews of a variety of programs operated under delivery service reform, including: Accountable Communities, Behavioral Health Homes, Certified Community Behavioral Health Clinics, Community Care Teams, MaineMOM, Opioid Health Homes, and Primary Care Plus. 11. State and contracted vendor (Gainwell) staff reviewing medical necessity and other allowability for medical services requiring prior authorization for initial requests and renewals. 12. A CMS-compliant Electronic Visit Verification (EVV) system, in accordance with Section 12006 of the 21st Century Cures Act, that ensures payment for applicable services is tied to an EVV record demonstrating that the service occurred; data from the system also contributes to post-payment reviews for applicable services. Completion Date: N/A Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093
Department: 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
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