Corrective Action Plans

Finding 28147 (2022-046)

Significant Deficiency 2022

State of Maine

ME

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Department: Administrative and Financial Services Title: Internal control over monitoring of employee classification and compensation needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will require Service Center and Agency HR Directors t...

Department: Administrative and Financial Services Title: Internal control over monitoring of employee classification and compensation needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will require Service Center and Agency HR Directors to notify supervisors at least twice per year of overdue performance evaluations. The Department will require Service Center and Agency HR Directors to review Hiring Requests to ensure duties identified are consistent with classifications. The Department will require Service Center and Agency HR Directors and/or HR recruiters to review job vacancy postings to ensure duties are consistent with classifications. The Department will implement a 'review of classification specification date' on class specs (currently only note date when a change is made). Completion Date: October 1, 2023 (first item), and April 30, 2023 (remaining items) Agency Contact: Breena D Bissell, Director, Bureau of Human Resources, DAFS, 207-215-0886

View Audit 32781

Finding 28117 (2022-020)

Significant Deficiency 2022

State of Maine

ME

Significant Deficiency Special Tests & Provisions

Department: Redacted Title: ________ over the ________ 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 disa...

Department: Redacted Title: ________ over the ________ 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: May 1, 2024 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423

View Audit 32781

Finding 28116 (2022-019)

Significant Deficiency 2022

State of Maine

ME

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Department: Administrative and Financial Services Health and Human Services Title: Internal control over financial reporting of OFI overpayments needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department of Health and Human Services and the Offic...

Department: Administrative and Financial Services Health and Human Services Title: Internal control over financial reporting of OFI overpayments needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department of Health and Human Services and the Office of the State Controller agree that the variance between the receivable and reserve should be booked as a deferred inflow. A claim termination policy will be established in accordance with federal regulations. Completion Date: June 30, 2023 Agency Contact: Sandra Royce, Director of Financial Reporting, OSC, 207-626-8451 Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104

View Audit 32781

Finding 28106 (2022-044)

Significant Deficiency 2022

State of Maine

ME

Subrecipient Monitoring § 200.303 § 200.332

Department: Education Title: Internal control over CACFP subrecipient risk evaluation procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The CACFP team will create a risk assessment tool to use in scheduling subrecipient reviews. Completion D...

Department: Education Title: Internal control over CACFP subrecipient risk evaluation procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The CACFP team will create a risk assessment tool to use in scheduling subrecipient reviews. Completion Date: June 30, 2023 Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

View Audit 32781

Finding 28105 (2022-043)

Significant Deficiency 2022

State of Maine

ME

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Department: Education Title: Internal control over CACFP eligibility needs improvement Questioned Costs: Known: $50,275 Likely: Undeterminable Status: Corrective action complete Corrective Action: The Department added to the check list a space for the on-site documentation for the pre-approval site ...

Department: Education Title: Internal control over CACFP eligibility needs improvement Questioned Costs: Known: $50,275 Likely: Undeterminable Status: Corrective action complete Corrective Action: The Department added to the check list a space for the on-site documentation for the pre-approval site visit to be uploaded into CNPWeb. The Department made the pre-site visit mandatory before the start of the program. Completion Date: March 6, 2023 Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

View Audit 32781 Questioned Costs: $1

Finding 28104 (2022-042)

Material Weakness 2022

State of Maine

ME

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.332

Department: Education Title: Internal control over CACFP subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will implement policies and procedures for the tracking, receipt, and review of audits for subre...

Department: Education Title: Internal control over CACFP subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will implement policies and procedures for the tracking, receipt, and review of audits for subrecipients that expend over $750,000, in accordance with Federal regulations. Completion Date: June 30, 2023 Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

View Audit 32781

Finding 28103 (2022-041)

Material Weakness 2022

State of Maine

ME

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403

Department: Education Title: Internal control over CACFP claim reimbursements needs improvement Questioned Costs: Known: $11,222 Likely: Undeterminable Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. As explained t...

Department: Education Title: Internal control over CACFP claim reimbursements needs improvement Questioned Costs: Known: $11,222 Likely: Undeterminable Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. As explained to OSA by DOE, DHHS, and USDA, Child Care Centers/Providers can enroll and claim over the licensed capacity. The claim edit check that was in place for SY22 for DCH Providers was Total Monthly Attendance x Approved Meal Types due to the fact that providers can enroll over the licensed capacity. Sponsors have been trained: Total Monthly Attendance equals the number of unique kids who attended during the day, are enrolled in CACFP and who ate at least one meal or snack during the day, then add up those daily totals for the month. To use licensed capacity as an edit check, which OSA did to calculate the costs in question, disallows provider reimbursement for eligible meals. CACFP Total Monthly Attendance is a better edit check as it only calculates attendance for enrolled participants. For the provider claims in question the CACFP Team tested them against the Total Monthly Attendance edit check and none suggest an overclaim. The CACFP Team discovered the missing enrollment edit check on 8/24/22 and immediately submitted a ticket to the web designers. This correction required multiple meetings with the web designers and in-depth system testing. The correction to the edit check was completed on 12/23/22. The claim edit checks now in place are: Attendance x Approved Meal Types (same as before) ? AND- Enrollment x Operating Days x Approved Meal Types. Completion Date: N/A Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

View Audit 32781 Questioned Costs: $1

Finding 28102 (2022-001)

Significant Deficiency 2022

Ashe Memorial Hospital, Inc.

NC

Reporting Significant Deficiency Internal Control / Segregation of Duties

Department of Health and Human Services Ashe Memorial Hospital, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 through December 31, 2022 The finding from the schedule of findings and questioned costs i...

Department of Health and Human Services Ashe Memorial Hospital, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 through December 31, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2022-001 Provider Relief Funding ? Assistance Listing No. 93.498 Recommendation: We recommend the organization review the lost revenue calculation in future periods to ensure that all hospital revenue is being included in calculation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. While we are not anticipating any future Lost Revenue calculations, we will have this reviewed by our accounting firm if the situation arises. Name of the contact person responsible for corrective action: Charles Wright, CFO Planned completion date for corrective action plan: 9/30/23 If the Department of Health and Human Services has questions regarding this plan, please call Charles Wright, CFO at 336-846-0798.

View Audit 30816

Finding 28101 (2022-003)

Significant Deficiency 2022

Los Angeles Jewish Home for the Aging

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

FINDING 2022-003 ? Significant Deficiency in Internal Controls over Compliance Recommendation: Policies and procedures over federal grant reporting should be modified to ensure reports are submitted in a timely manner. Corrective Action Plan: We have implemented new processes to make sure our third ...

FINDING 2022-003 ? Significant Deficiency in Internal Controls over Compliance Recommendation: Policies and procedures over federal grant reporting should be modified to ensure reports are submitted in a timely manner. Corrective Action Plan: We have implemented new processes to make sure our third party preparers are engaged on time with enough lead-time to prepare the reports. Since the filing of the Period 2 PRF report for Grancell Village, we have filed all other reports timely. Contact Person Responsible for Corrective Action Plan: Mark C de Baca, Corporate Controller Anticipated Completion of Corrective Action Plan: June 30, 2023

View Audit 28712

Finding 28100 (2022-002)

Significant Deficiency 2022

Los Angeles Jewish Home for the Aging

CA

Reporting HUD Housing Programs Significant Deficiency

FINDING 2022-002 ? Significant Deficiency in Internal Controls over Compliance Recommendation: Policies and procedures over federal grant reporting should be modified to ensure reports are prepared using complete and accurate information. Review controls should be in place by someone other than the ...

FINDING 2022-002 ? Significant Deficiency in Internal Controls over Compliance Recommendation: Policies and procedures over federal grant reporting should be modified to ensure reports are prepared using complete and accurate information. Review controls should be in place by someone other than the preparer of the report to ensure information is accurate prior to submission of the report. Corrective Action Plan: We have strengthened controls over review procedures over grant reporting by having the corporate controller review all PRF reports for accuracy and agree amounts to LAJH?s financial statements prior to filing. We have also improved our system generated financial reports to assist with the verification of the report preparer?s work. Contact Person Responsible for Corrective Action Plan: Mark C de Baca, Corporate Controller Anticipated Completion of Corrective Action Plan: June 30, 2023

View Audit 28712

Finding 28099 (2022-001)

Significant Deficiency 2022

Acled Analysis Incorporated

WI

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Name of contract person: Amanda Bertran, Senior Finance Manager Corrective Action: Currently, the Finance Coordinator reviews the timesheets completed on time each pay period. Then, the Senior Finance Manager reviews the proper grants allocation in the journal entry. The management will strengthen t...

Name of contract person: Amanda Bertran, Senior Finance Manager Corrective Action: Currently, the Finance Coordinator reviews the timesheets completed on time each pay period. Then, the Senior Finance Manager reviews the proper grants allocation in the journal entry. The management will strengthen the controls to review personnel allocations processes to ensure accuracy. The Finance Coordinator will generate payroll reports to review timesheet allocations to grants and complete the effort table accordingly to provide the outside accounting firm for the review and recording. The Senior Finance Manager will review the journal entry posted by the accounting firm to make sure there are no discrepancies between timesheets and payroll grant allocations. Proposed Completion Date: The Organization will implement the above procedure starting January 01, 2023.

View Audit 27895 Questioned Costs: $1

Finding 28098 (2022-002)

None 2022

East Alton Elementary School District No. 13

IL

Reporting

SEE SEFA REPORT, FINDING #2022-002.

View Audit 28611

Finding 28097 (2022-001)

None 2022

East Alton Elementary School District No. 13

IL

Reporting

SEE SEFA REPORT, FINDING #2022-001.

View Audit 28611

Finding 28089 (2022-072)

Material Weakness 2022

State of Maine

ME

Subrecipient Monitoring Reporting Material Weakness § 200.303

Department: Health and Human Services Title: Internal control over special reporting needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department implemented the corrective action plan from FY21, and it is currently in place. In summary, the Departmen...

Department: Health and Human Services Title: Internal control over special reporting needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department implemented the corrective action plan from FY21, and it is currently in place. In summary, the Department revised the standard operating procedure and improved the technology to ensure data accuracy and added a layer of review to ensure accuracy of the FFATA reporting. This was finalized in November of 2022. Completion Date: November 30, 2022 Agency Contact: Jim Lopatosky, Director, Division of Contract Management, DHHS, 207-287-5075

View Audit 32781

Finding 28088 (2022-069)

Material Weakness 2022

State of Maine

ME

Cash Management Subrecipient Monitoring § 200.303 § 200.305

Department: Health and Human Services Title: Internal control over subrecipient cash management 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 reviews budget...

Department: Health and Human Services Title: Internal control over subrecipient cash management 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 reviews budgeted expenses to determine their timing and nature (one time, recurring, allowability); reviews quarterly expense reports and alters payments to meet immediate cash needs, and finally, monitors subrecipient single audits to ensure there are no cash management findings. The Department's approach is administratively reasonable and does minimize the time elapsing between the payment of Federal funds to the subrecipient and the subrecipient?s actual disbursement for program purposes given administrative and operational needs. We believe we have procedures in place that can be corroborated by the fact that our subrecipients do not receive single audit findings related to cash management. Completion Date: N/A Agency Contact: Jim Lopatosky, Director, Division of Contract Management, DHHS, 207-287-5075

View Audit 32781

Finding 28087 (2022-040)

Significant Deficiency 2022

State of Maine

ME

Cash Management Reporting Significant Deficiency § 200.302 § 200.303

Department: Health and Human Services Administrative and Financial Services Title: Internal control over WIC cash balances needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will finalize the reconciliations and take the necessary steps t...

Department: Health and Human Services Administrative and Financial Services Title: Internal control over WIC cash balances needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will finalize the reconciliations and take the necessary steps to put the cash balances where they belong. Completion Date: December 31, 2023 Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626

View Audit 32781

Finding 28086 (2022-039)

Material Weakness 2022

State of Maine

ME

Subrecipient Monitoring Internal Control / Segregation of Duties Material Weakness § 200.303

Department: Health and Human Services Title: Internal control over WIC subrecipient monitoring needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will complete training and planning with DHHS Internal Audit for completing the financia...

Department: Health and Human Services Title: Internal control over WIC subrecipient monitoring needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will complete training and planning with DHHS Internal Audit for completing the financial component of MERs and begin reviews. The Department will complete catch up on overdue MERs. Completion Date: May 1, 2023 and March 3, 2024 Respectively Agency Contact: Ginger Roberts-Scott, Senior Health Program Manager, DHHS, 207-287-5342

View Audit 32781

Finding 28058 (2022-038)

Significant Deficiency 2022

State of Maine

ME

Significant Deficiency Special Tests & Provisions

Department: Redacted Title: ________ over the ________ 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 disa...

Department: Redacted Title: ________ over the ________ 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: March 31, 2023 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423

View Audit 32781

Finding 28057 (2022-037)

Significant Deficiency 2022

State of Maine

ME

Significant Deficiency Special Tests & Provisions

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

View Audit 32781

Finding 28056 (2022-036)

Significant Deficiency 2022

State of Maine

ME

Reporting Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Department: Education Title: Internal control over Child Nutrition donated food inventory needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: A Food Distribution Program (FDP) staff member and Director will attend the American Commodity Distribution Conf...

Department: Education Title: Internal control over Child Nutrition donated food inventory needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: A Food Distribution Program (FDP) staff member and Director will attend the American Commodity Distribution Conference in April to get a better understanding of the program. FDP staff and the Director will evaluate the program for efficiencies. FDP staff and the Director will work to align CNPWeb with the needs of the program. Completion Date: April 30, 2023, July 1, 2023 and September 1, 2023 respectively Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

View Audit 32781

Finding 28055 (2022-035)

Significant Deficiency 2022

State of Maine

ME

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.332

Department: Education Title: Internal control over CNC subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will create policies and procedures to collect, track, and review single audits for private schools re...

Department: Education Title: Internal control over CNC subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will create policies and procedures to collect, track, and review single audits for private schools receiving over $750,000 in Federal awards. Completion Date: September 1, 2023 Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

View Audit 32781

Finding 28054 (2022-034)

Significant Deficiency 2022

State of Maine

ME

Reporting School Nutrition Programs Internal Control / Segregation of Duties § 200.303 § 200.502 § 200.510

Department: Education Administrative and Financial Services Title: Internal control over the submission of CNC Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will report expenditu...

Department: Education Administrative and Financial Services Title: Internal control over the submission of CNC Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will report expenditures for the School Breakfast Program and Special Milk Program under the individual ALNs rather than including those expenditures in the broader ALN 10.555. The Department will report noncash assistance at the amount actually used rather than the amount authorized for use. The Department will add a note to the SEFA report indicating any COVID-19 expenditures that cannot be isolated due to waivers. Completion Date: June 30, 2023 Agency Contact: Nicole Denis, Director of Finance, DOE, 207-530-2161

View Audit 32781

Finding 28053 (2022-033)

Material Weakness 2022

State of Maine

ME

Material Weakness Special Tests & Provisions

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 rea...

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: April 1, 2023 June 1, 2023 and December 31, 2023 Respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423

View Audit 32781

Finding 28052 (2022-032)

Material Weakness 2022

State of Maine

ME

Material Weakness Special Tests & Provisions

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: June 30, 2023 and December 31, 2023 respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423

View Audit 32781

Finding 28051 (2022-031)

Material Weakness 2022

State of Maine

ME

Allowable Costs / Cost Principles School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Department: Education Title: Internal control over Child Nutrition claim reimbursements needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will offer updated SSO training to include specific procedure on meal counting and claiming by buil...

Department: Education Title: Internal control over Child Nutrition claim reimbursements needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will offer updated SSO training to include specific procedure on meal counting and claiming by building. The Department will create a policy for oversight of claiming procedures during SSO operations. The Department will implement policies and procedures to review and approved CNP system changes. Completion Date: June 1, 2023 (first two items) and June 30, 2023 (third item) Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

View Audit 32781

Corrective Action Plans

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