Corrective Action Plans

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Finding 28310 (2022-081)
Material Weakness 2022
Department: Health and Human Services Title: Internal control over cases opened due to potential fraud, abuse, or questionable practices needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Program Manager will continue to run a quarterly r...
Department: Health and Human Services Title: Internal control over cases opened due to potential fraud, abuse, or questionable practices needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Program Manager will continue to run a quarterly report to identify any cases assigned to former staff and will evaluate the cases for closure or reassignment. The Program Manager will establish a separate quarterly meeting with the Director of Compliance to review and document the results of the quarterly report. The Program Manager will use best efforts to fill the staffing vacancies that contributed to this finding. Completion Date: March 29, 2023, May 7, 2023 and June 1, 2023 respectively Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093
Finding 28309 (2022-080)
Material Weakness 2022
Department: Health and Human Services Title: Internal control over Long Term Care Facility audits needs improvement Questioned Costs: None Status: LTCF - Nursing Facilities: Corrective action in progress LTCF ? ICF/IIDs: Management?s opinion is that corrective action is not required Corrective Acti...
Department: Health and Human Services Title: Internal control over Long Term Care Facility audits needs improvement Questioned Costs: None Status: LTCF - Nursing Facilities: Corrective action in progress LTCF ? ICF/IIDs: Management?s opinion is that corrective action is not required Corrective Action: LTCF - Nursing Facilities: The staff currently assigned to working on outbreak reconciliations resulting from COVID will be reassigned back to LTC audits at the end of the Public Health Emergency. The Director will work with Human resources to recruit candidates to fill the vacant audit positions. The Director and Audit Program Manager for LTCF audits will meet bi-weekly to monitor the completion of audit within identified timelines and reassign staff as necessary. LTCF ? ICF/IIDs: The Department disagrees with this finding in regard to LTCF - ICF/IID's. The ICF/IID audits do not have a specific time requirement in the MBM for completion. The federal regulations only require that periodic audits of financial records occur. All ICF/IID cost reports submitted to the Department are recorded in a database and tracked for audit purposes. All cost reports are audited as resources are available. We have worked with our Federal partners who have agreed with our interpretation of the regulation and the timing of our audits for the ICF/IIDs. Completion Date: May 31, 2023 (first item), and June 30, 2023 (second and third items) Agency Contact: Herb Downs, Director, Division of Audit, DHHS, 207-287-2778
Finding 28307 (2022-018)
Significant Deficiency 2022
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complet...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this 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: January 2023, December 2023, December 2024 and December 2026 respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28306 (2022-017)
Significant Deficiency 2022
Department: Redacted Title: ________ over ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complete co...
Department: Redacted Title: ________ over ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this 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: January 2023 (first and third items) and February 2023 (second item) Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28305 (2022-016)
Significant Deficiency 2022
Department: Redacted Title: ________ over the ________, ________, and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and s...
Department: Redacted Title: ________ over the ________, ________, and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this 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: June 30, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28304 (2022-015)
Significant Deficiency 2022
Department: Redacted Title: ________ over ________ within the ________ and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation ...
Department: Redacted Title: ________ over ________ within the ________ and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this 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: June 30, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28298 (2022-089)
Significant Deficiency 2022
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The comple...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this 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 31, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28297 (2022-088)
Significant Deficiency 2022
Department: Redacted Title: ________ over ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this finding. The Department?s corrective action plan as well as the explanation and specific reasons for disagre...
Department: Redacted Title: ________ over ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with this 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: June 1, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28289 (2022-079)
Significant Deficiency 2022
Department: Health and Human Services Title: Internal control over the CCDF Cluster eligibility determination process needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: DHHS believes the current internal controls that ar...
Department: Health and Human Services Title: Internal control over the CCDF Cluster eligibility determination process needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: DHHS believes the current internal controls that are in place provide reasonable assurance that DHHS is managing the funds in compliance with all regulations. Reasons include; ? The ongoing quality assurance process is one of the major controls in place. In 2019, the OCFS Quality Assurance (QA) team, separate from the Child Care Subsidy Program (CCSP) team, comprised of 10 staff, began conducting 23 CCSP case reviews per month. This is systematic monitoring. QA uses the initial documentation submitted by the parent (applications, proof of income, etc.) and checks it against the information in the MACWIS system to ensure eligibility is calculated correctly and data was entered accurately. ? A summary of findings from the QA check is provided to CCSP management each month. CCSP management documents the needed remediation plan, with the Financial Resource Specialist (FRS) making the necessary corrections as soon as possible. Additionally, CCSP management conducts internal periodic audits of files and evaluates deficiencies. ? Information Technology Controls minimizes potential errors by utilizing pre-defined drop-down menus of approved entries. Several fields limit the number of characters allowed to be entered or only allow numeric entries. ? The Information Technology system provides an enhanced internal control that provides visual cues to enter dollar amounts. Users receive an error message if data is entered incorrectly. ? The Financial Resource Specialist Staff Manual provides detailed, step-by-step instructions of the process for entering information into the Information Technology system to ensure accuracy and consistency of data entry. Staff are trained using this manual and are provided ongoing access to the manual. Staff undergo regular training on the eligibility determination process. DHHS believes the process and technical solutions in place are a reasonable attempt to assure proper eligibility determination for CCSP funding. Completion Date: N/A Agency Contact: Todd Landry, Director of the Office of Child and Family Services, DHHS, 207-624-7900
Finding 28288 (2022-078)
Material Weakness 2022
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. Th...
Department: Redacted Title: ________ over ________ and ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this 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: April 3, 2023 (first and second items) and December 31, 2023 (third item) Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28287 (2022-077)
Significant Deficiency 2022
Department: Administrative and Financial Services Title: Internal control over Child Support Enforcement expenditures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Division of Support Enforcement and Recovery and the Judicial Branch will revisi...
Department: Administrative and Financial Services Title: Internal control over Child Support Enforcement expenditures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Division of Support Enforcement and Recovery and the Judicial Branch will revisit and modify the terms and language of the cooperative agreement to help clarify that all allowable costs subject to federal financial participation are adequately and timely documented. Completion Date: June 1, 2023 Agency Contact: Jerry Joy, Director, Division of Support Enforcement and Recovery, DHHS, 207- 624-6985
Finding 28266 (2022-076)
Significant Deficiency 2022
Department: Health and Human Services Title: Internal control over TANF subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will revise the standard operating procedures to include a search for out of state su...
Department: Health and Human Services Title: Internal control over TANF subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will revise the standard operating procedures to include a search for out of state subrecipients. Completion Date: April 30, 2023 Agency Contact: Herb Downs, Director, Division of Audit, DHHS, 207-287-2778
Finding 28265 (2022-075)
Significant Deficiency 2022
Department: Health and Human Services Title: Internal control over TANF performance reporting and work participation procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: Due to the nature of corrective action pl...
Department: Health and Human Services Title: Internal control over TANF performance reporting and work participation procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: Due to the nature of corrective action plans, and the timing of recent edits to the standard operating procedures in February and May of 2022, a corrective action plan is not warranted at this time. Completion Date: N/A Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104
Finding 28264 (2022-074)
Material Weakness 2022
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this finding. The Department?s corrective action plan has been excluded to protect confidential information. The complet...
Department: Redacted Title: ________ over the ________ needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with this 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: September 30, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423
Finding 28263 (2022-073)
Material Weakness 2022
Department: Administrative and Financial Services Title: Internal control over TANF reporting needs improvement Questioned Costs: None Status: Corrective action is completed Corrective Action: Effective April 1, 2022, US Department of Health and Human Services grant recipients are no longer required...
Department: Administrative and Financial Services Title: Internal control over TANF reporting needs improvement Questioned Costs: None Status: Corrective action is completed Corrective Action: Effective April 1, 2022, US Department of Health and Human Services grant recipients are no longer required to complete the quarterly Federal Cash Transaction Report "FCTR" (also referred to as the FFR-425 or SF-425) to report cumulative Federal cash disbursements. Procedures are currently in place to ensure Federal financial reporting is reviewed accurately. Completion Date: April 1, 2022 Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626
Finding 28261 (2022-071)
Material Weakness 2022
Department: Health and Human Services Title: Internal control over TANF subrecipient risk evaluation procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with the finding. The Department...
Department: Health and Human Services Title: Internal control over TANF subrecipient risk evaluation procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with the finding. The Department has subrecipient monitoring procedures for all of its subrecipients whether they were competitively bid or not. The first assessment of risk, as noted in the finding, is when a subaward is competitively bid. Secondly, another risk assessment built into the Maine Uniform Accounting and Auditing Practices for Community Agencies (MAAP) in which requires higher risk subrecipients to undergo a higher level of testing. Additionally, there are audit and review requirements at a much lower threshold than that of the Uniform Guidance (UG). Finally, the Social Service Unit of the Division of Audit performs a risk assessment and tests transactions for those subrecipients that have been determined to be higher risk. The Department's subrecipient monitoring procedures ensures that we comply with the UG 200.332(d) Pass-through entity (PTE) monitoring of the subrecipient must include: 1) Review of financial and performance reports. 2) Following-up and ensuring that subrecipients take timely and appropriate action on all deficiencies. 3) Issues management decisions. 4) PTE is responsible for resolving audit findings specifically related to the subaward. Based on the Department's MAAP rules we ensure we comply with UG 200.332(e) Depending on the PTE's assessment of risk, the following tools may be useful: 1) Training and technical assistance. 2) On-site reviews. 3) Arranging for agreed upon procedures. The Department covers #3 by ensuring that all of our subrecipients have a requirement to submit to the Department a/an Audit, Review or Schedule of Expenditures of Department Awards (SEDA). Completion Date: N/A Agency Contact: Jim Lopatosky, Director, Division of Contract Management, DHHS, 207-287-5075
Finding 28260 (2022-070)
Material Weakness 2022
Department: Health and Human Services Title: Internal control over TANF client child support sanction procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Office f...
Department: Health and Human Services Title: Internal control over TANF client child support sanction procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Office for Family Independence (OFI) has sufficient internal controls in place to ensure compliance with Federal requirements. Specifically, based on the finding's stated condition, OSA did not take exception with the 22 items that were actually tested for compliance. Additionally, OFI has provided sufficient information for OSA to identify and conduct the audit and compliance testing of cases referred by DSER for sanction. The Department has provided OSA with the following material as requested: 1. The list of all sanction referrals generated by OFI-DSER, the Title IV-D agency. 2. The list of all OFI-TANF clients actually sanctioned by TANF Eligibility. 3. The list of all OFI-TANF clients 4. Copies of all emails pertaining to all sanction activity 5. Access to our Automated Client Eligibility System which includes all documented case notes. Completion Date: N/A Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104
Finding 28258 (2022-068)
Material Weakness 2022
Department: Health and Human Services Title: Internal control over Income Eligibility and Verification System procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The ...
Department: Health and Human Services Title: Internal control over Income Eligibility and Verification System procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Office for Family Independence (OFI) has conducted the required IEVS eligibility verifications. Additionally, sufficient evidence of these efforts has been provided to the Office of the State Auditor so that audit procedures can be performed in accordance with Federal regulations. OFI utilizes the Federally provided IEVS system which integrates the three named population groups (Medicaid, SNAP, TANF). The IEVS discrepancy reports have not contained Federal program indicators since program inception over 20 years ago. This is consistent with the methodology utilized by the Social Security Administration, as they too group the OFI programs together in their discrepancy reports. These same reports have been provided for prior Single Audits without being considered an exception condition. Upon request, the Department provided OSA: 1. All IEVS discrepancy reports for State fiscal year 2022, containing cases for Medicaid, SNAP, and TANF. 2. A complete listing of all TANF cases subject to IEVS in State fiscal year 2022. 3. Access to our Automated Client Eligibility System, which documents all IEVS related case notes. Completion Date: N/A Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104
Finding 28257 (2022-067)
Material Weakness 2022
Department: Health and Human Services Title: Internal control over payments made to and on behalf of TANF clients needs improvement Questioned Costs: Known: $1,447 Likely: $35,002 Status: Management?s opinion is that corrective action is not required Corrective Action: The Department?s effective int...
Department: Health and Human Services Title: Internal control over payments made to and on behalf of TANF clients needs improvement Questioned Costs: Known: $1,447 Likely: $35,002 Status: Management?s opinion is that corrective action is not required Corrective Action: The Department?s effective internal controls identified the overpayments, made the referrals, and followed procedures for two of the four exceptions noted. The two exceptions that we did not identify as overpayments we believe are in accordance with the reasonably calculated requirement to accomplish one or more of the four TANF purposes and should not be considered unallowable. The criteria cited do not indicate any requirement to recoup funds within a specific time frame and the exceptions noted demonstrate the effective internal controls rather than indicate any misuse of funds. Completion Date: N/A Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104
View Audit 32781 Questioned Costs: $1
Finding 2022-003 Internal Control Deficiency and Non-compliance over Reporting Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2...
Finding 2022-003 Internal Control Deficiency and Non-compliance over Reporting Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Finding: The Hospital?s reporting submissions did not follow the published HRSA guidance related to the reporting of lost revenue. Internal controls over the method used to report lost revenues in the HRSA and ARP reports were not precise enough to identify the submissions were not compliant with HRSA reporting guidance. Corrective Action Plan: Management will ensure internal controls are in place to identify the submissions are compliant with HRSA reporting guidelines. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2023
Finding 2022-002 Internal Control Deficiency over Allowable Activities Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Sum...
Finding 2022-002 Internal Control Deficiency over Allowable Activities Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Finding: Management did not retain evidence of controls surrounding the compliance with the terms and conditions of the award. Corrective Action Plan: Management will ensure documentation is retained to evidence the controls were performed. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2023
Finding 2022-001 Internal Control Deficiency over Reporting Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Fin...
Finding 2022-001 Internal Control Deficiency over Reporting Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to ensure lost revenues submitted for the Provider Relief Fund were allowable under the terms and conditions of the award, as reported in the HRSA filings. Corrective Action Plan: Management will ensure documentation is retained to evidence the controls were performed. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2023
Finding 28250 (2022-003)
Significant Deficiency 2022
We submitted two reports late resulting in this finding. The first late report, June 2022 Emergency Food and Shelter Program, due July 30th and submitted in August and the October ESFP report due November 30th and submitted in December. The reports were late because the program manager failed to tim...
We submitted two reports late resulting in this finding. The first late report, June 2022 Emergency Food and Shelter Program, due July 30th and submitted in August and the October ESFP report due November 30th and submitted in December. The reports were late because the program manager failed to timely provide the narrative portion to accounting. We will refine our company wide effort for tracking grant reporting timelines.
When CSC provided the 2022 SEFA to the Auditor, it contained errors, which resulted in this finding. The errors resulted from us not fully understanding the fields on the SEFA. We completed the SEFA thinking that it was only meant for 2022 transactions only. We shall continue to increase our familia...
When CSC provided the 2022 SEFA to the Auditor, it contained errors, which resulted in this finding. The errors resulted from us not fully understanding the fields on the SEFA. We completed the SEFA thinking that it was only meant for 2022 transactions only. We shall continue to increase our familiarity with this one-page report, required only for single audits.
Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. Management will continue to make extra deposits to resolve the replacement reserve deficiency. Mana...
Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. Management will continue to make extra deposits to resolve the replacement reserve deficiency. Management will ensure that the replacement reserve deposits are made on a timely basis in the future. Completion Date: September 9, 2022
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