Corrective Action Plans

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Finding Number: 2024-026 Finding Name: Untimely Review of Subrecipient Performance Reports Finding Condition(s): The Illinois State Board of Education (ISBE) did not review subrecipient performance reports in a timely manner according to its program monitoring policies and procedures for subrecipien...
Finding Number: 2024-026 Finding Name: Untimely Review of Subrecipient Performance Reports Finding Condition(s): The Illinois State Board of Education (ISBE) did not review subrecipient performance reports in a timely manner according to its program monitoring policies and procedures for subrecipients of the Education and Stabilization Fund - Elementary and Secondary Education (ESF) program for fiscal year 2024. Name of Contact Person(s): • Denise Blaney, Director – Illinois State Board of Education, Title Grant Administration Department • Lazell Logan, Supervisor – Illinois State Board of Education, Title Grant Administration Department • Annie Brooks, Executive Director – Illinois State Board of Education, Regulatory Services Corrective Action(s): To ensure proper review procedures are performed in a timely manner in accordance with its program monitoring policies and procedures, ISBE’s Title Grant Administration Department started to send bi-weekly lists of submitted, past due, and disapproved Grant Periodic Reports (GPRS) to each applicable ISBE department. The Title Grant Administration Department analyzes the GPRS reports and prioritizes reviews based on submission dates. The Title Grant Administration Department also trained team members to assist with the review process. Proposed Completion Date: November 15, 2025 – Completed
Finding Number: 2024-025 Finding Name: Inadequate Monitoring of 21st Century Subrecipients Finding Condition(s): The Illinois State Board of Education (ISBE) did not adequately monitor and document program monitoring procedures performed over subrecipients of the 21st Century Community Learning Cent...
Finding Number: 2024-025 Finding Name: Inadequate Monitoring of 21st Century Subrecipients Finding Condition(s): The Illinois State Board of Education (ISBE) did not adequately monitor and document program monitoring procedures performed over subrecipients of the 21st Century Community Learning Centers (21st Century) program. Additionally, ISBE’s internal controls over subrecipient on-site monitoring are not designed at an appropriate level of precision to ensure monitoring of subrecipients is completed, documented, and retained as required by ISBE’s policies and procedures. Name of Contact Person(s): • Jeffrey Judge, Director – Illinois State Board of Education, Wellness and Student Care Management Department • Nehemiah Ankoor, Supervisor; 21st Century Community Learning Centers (CCLC) State Education Agency Coordinator – Illinois State Board of Education, Wellness and Student Care Management Department Corrective Action(s): To ensure that 21st Century Community Learning Centers (21st CCLC) subgrantees’ progress and performance are monitored in accordance with 2 CFR 200.331(d), 2 CFR 200.331(b), and 2 CFR 200.303, Wellness and Student Care Management and the 21st CCLC team developed processes and structures to facilitate the procedures, protocols, and efficacy of subgrantee monitoring. Components of this work included, but were not limited to: • Evaluating and revising the program’s subgrantee risk analysis procedures and tools to ensure that they are relevant and accurately reflect the items/actions that suggest higher levels of subgrantee risk (2 CFR 200.331(b)). Complete. After careful examination, we have revised the risk analysis procedures and tools and have begun using them to inform our fiscal year 2026 monitoring. • Reviewing and revising the procedures and/or documentation that is collected for all three tiers of subgrantee monitoring to ensure that all processes are relevant; are not simply perfunctory; ensure compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that the subaward performance goals are achieved (2 CFR 200.331(d)). Complete. We have determined which of the documents we have historically collected meet those requirements, and we have evaluated all remaining documents (extraneous to ED requirements) to determine which we feel are most necessary to keep and what we are able to discontinue requiring. • Establishing and implementing specific processes and protocols to ensure that all components of subgrantee monitoring are timely, that management reviews and provides approval for key components of the process, and that accurate and complete documentation is produced and maintained (2 CFR 200.303). Complete. The expectations herein have been communicated to staff and have begun to be implemented (i.e. management approval, maintaining documentation, etc.). We still need to ensure that we precisely document these expectations and protocols, but through meetings and less formal communications, the required changes to our practices have been implemented. Proposed Completion Date: December 31, 2025 - Completed
Finding Number: 2024-024 Finding Name: Failure to Maintain Documentation to Evidence Timely Reporting of Subaward Information Required by Federally Funded Accountability and Transparency Act (FFATA) Finding Condition(s): The Illinois Department of Public Health (IDPH) did not maintain documentation ...
Finding Number: 2024-024 Finding Name: Failure to Maintain Documentation to Evidence Timely Reporting of Subaward Information Required by Federally Funded Accountability and Transparency Act (FFATA) Finding Condition(s): The Illinois Department of Public Health (IDPH) did not maintain documentation to evidence information required to be reported by the Federal Funding Accountability and Transparency Act (FFATA) was submitted within required timeframes for awards granted to subrecipients of the Immunization Cooperative Agreements (ICA) and Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) programs. Name of Contact Person(s): • Jacob Cisco, Chief Financial Officer/Bureau Chief, Finance – Illinois Department of Public Health, Office of Administrative Affairs • Sheila Jefferson, Chief Accountability Officer – Illinois Department of Public Health, Office of Performance Management • Timothy Stevens, Grant Management Auditor – Illinois Department of Public Health, Office of Performance Management Corrective Action(s): The IDPH revised its policy on the FFATA report submission to capture the change from a FSRS.gov batch upload to a manual entry in SAM.gov. Additionally, the IDPH documented its process to provide evidence of the original submission dates in SAM.gov. Proposed Completion Date: March 23, 2026
Finding Number: 2024-023 Finding Name: Failure to Provide Supporting Documentation for Payroll and Related Costs Finding Condition(s): The Illinois Department of Child and Family Services (DCFS) could not provide adequate supporting documentation to substantiate payroll and related costs claimed for...
Finding Number: 2024-023 Finding Name: Failure to Provide Supporting Documentation for Payroll and Related Costs Finding Condition(s): The Illinois Department of Child and Family Services (DCFS) could not provide adequate supporting documentation to substantiate payroll and related costs claimed for federal reimbursement under the Foster Care – Title IV-E (Foster Care), Adoption Assistance, and Temporary Assistance for Needy Families (TANF) programs. Additionally, the auditors noted the controls to ensure required documentation is obtained to support payroll and related costs and maintained to evidence management approval of payroll information were not operating effectively. Finally, the auditors noted adequate internal controls have not been established to ensure the data included in the timekeeping system and used to allocate personal services expenditures to Foster Care, Adoption Assistance, TANF, and other programs operated by DCFS is consistent with the hours reported on manual timesheets prepared by the employees and approved by supervisor. Name of Contact Person(s): David Riley, Director – Illinois Department of Child and Family Services, Budget and Finance Division Corrective Action(s): The new quality controls introduced have helped to identify and correct errors, but system modernization is needed to fully implement. The DCFS is working with the Illinois Department of Innovation and Technology to implement the systems to shift to electronic timesheets. Proposed Completion Date: October 31, 2026
Finding Number: 2024-022 Finding Name: Inadequate Process for Foster Care Daycare Maintenance Assistance Payments Finding Condition(s): The Illinois Department of Child and Family Services (DCFS) does not have an adequate process in place to ensure Foster Care daycare maintenance assistance payments...
Finding Number: 2024-022 Finding Name: Inadequate Process for Foster Care Daycare Maintenance Assistance Payments Finding Condition(s): The Illinois Department of Child and Family Services (DCFS) does not have an adequate process in place to ensure Foster Care daycare maintenance assistance payments are accurately paid based on its approved rate schedule. Name of Contact Person(s): Stacy Mixon, Daycare Eligibility Administrator – Illinois Department of Child and Family Services, Office of Contract Administration Corrective Action(s): In July 2025, the daycare eligibility program discontinued the use of certification rate forms. As a result, all childcare providers now receive the state established reimbursement rate, regardless of the rate they charge private-paying families. This change ensures that all childcare providers receive the funding that they are entitled to. Proposed Completion Date: July 1, 2025 – Completed
Finding Number: 2024-021 Finding Name: Failure to Perform Reviews over Home and Community Based Waiver Services (HCBS) Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) failed to conduct utilization reviews over home and community-based services for five of the n...
Finding Number: 2024-021 Finding Name: Failure to Perform Reviews over Home and Community Based Waiver Services (HCBS) Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) failed to conduct utilization reviews over home and community-based services for five of the nine waivers contracted out to its vendor during fiscal year 2024. Name of Contact Person(s): • Pamela Winsel, Bureau Chief, Waiver Operations Management - Illinois Department of Healthcare and Family Services, Division of Medical Programs • Tracy Anderson, Public Service Administrator, Waiver Operations Management - Illinois Department of Healthcare and Family Services, Division of Medical Programs • Sarah Myerschough-Mueller, Deputy Administrator - Illinois Department of Healthcare and Family Services, Division of Medical Programs Corrective Action(s): The DHFS will procure a new vendor to complete record reviews. An Invitation for Bid was been posted to procure a contractor to resume record reviews. The opening of bids occurred in January 2026. The new vendor will begin record reviews in fiscal year 2027. Proposed Completion Date: July 1, 2026
Finding Number: 2024-020 Finding Name: Inadequate Procedures to Determine Provider Eligibility Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) did not adequately screen providers of the Children’s Health Insurance Program (CHIP) and the Medicaid Cluster program...
Finding Number: 2024-020 Finding Name: Inadequate Procedures to Determine Provider Eligibility Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) did not adequately screen providers of the Children’s Health Insurance Program (CHIP) and the Medicaid Cluster programs to ensure that Medicaid providers were not on the USDHHS Office of the Inspector General’s (OIG) List of Excluded Individuals/Entities (LEIE) at the time the vouchers for the related services performed were paid. Name of Contact Person(s): Susie Brown, Interim Bureau Chief - Illinois Department of Healthcare and Family Services, Provider Enrollment Services Corrective Action(s): The Illinois Medicaid Program Advanced Cloud Technology (IMPACT) system is used by the DHFS for the enrollment and screening of CHIP and Medicaid providers. On a monthly basis, IMPACT automatically checks providers enrolled within IMPACT to the LEIE to verify the provider is not on the LEIE. The IMPACT system is updated through quarterly system releases. As part of the 1.6 quarterly release, the DHFS’ Provider Enrollment Services (PES) updated the system to address the monthly screening check box defect causing the issue. In the Lexis Nexis monthly job, as part of license information, the DHFS receives files from the American Board of Medical Specialties (ABMS), the Clinical Laboratory Improvement Amendments (CLIA), the Drug Enforcement Administration (DEA), and the NCPDP (National Council for Prescription Drug Programs (NCPDP) and other states (out-of-state license/medical license files). Only the corresponding license check boxes are checked for the provider. As an example, for a provider with an ABMS license, the corresponding ABMS check box would be checked. Furthermore, as part of sanction information, the DHFS receives a discipline file, which has the information from the Excluded Parties List System (EPLS), the LEIE, the Medicaid Services Administration (MSA), and other federal and state databases to ensure all databases are checked for active providers in a monthly batch. Any sanctions identified from the sources during the monthly batch screenings will be marked based on the corresponding data source where the sanction was found. If a sanction is found, the system generates an email to the OIG that the provider has been identified as having a potential sanction through the Medicaid Management Information System (MMIS) automated validation process. The email contains the provider name, the National Provider Identifier (NPI), the IMPACT provider identifier, the provider’s address, and the sanction type. The email instructs the OIG to verify the sanction and proceed with the appropriate administrative action. The OIG will provide the necessary administrative action to provider enrollment staff to handle appropriately. Proposed Completion Date: June 30, 2024 - Completed
Finding Number: 2024-019 Finding Name: Failure to Ensure Managed Care Organizations Properly Prepare Financial Reports Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) did not ensure the annual financial audits prepared during the year ended June 30, 2024, for M...
Finding Number: 2024-019 Finding Name: Failure to Ensure Managed Care Organizations Properly Prepare Financial Reports Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) did not ensure the annual financial audits prepared during the year ended June 30, 2024, for Managed Care Organizations (MCOs) of the Children’s Health Insurance Program (CHIP) and Medicaid Cluster programs met the requirements of the MCO contracts and federal regulations. Specifically, the auditors noted that the MCO annual financial reports were prepared on a statutory basis of accounting which is assumed to be materially different than Generally Accepted Accounting Principles (GAAP). Additionally, the auditors noted that the DHFS has not established internal control procedures to ensure the financial reports are prepared in accordance with GAAP. Name of Contact Person(s): • Helena Lefkow, Deputy Administrator - Illinois Department of Healthcare and Family Services, Division of Medical Programs, Bureau of Managed Care • Keshonna Lones, Bureau Chief, Quality and Compliance Operations Manager - Illinois Department of Healthcare and Family Services, Division of Medical Programs, Bureau of Managed Care • Jessica Pickens, Account Manager Supervisor - Illinois Department of Healthcare and Family Services, Division of Medical Programs, Bureau of Managed Care Corrective Action(s): Starting in calendar year 2025, the Bureau of Managed Care began receiving MCO GAAP reports that were determined to comply with the reporting requirements of 42 CFR 438.3(m) and the Managed Care Program Contracts. The MCOs that do not comply with the reporting requirements of the contracts, or 42 CFR 439.3(m), are subject to sanctions as outlined in the contracts, which include one or more of the following: initiating corrective action plans, monetary penalties, and suspension of enrollment. Note: As during its 2025 reviews, the DHFS noted that one MCO was deemed to be non-complaint for lack of a 2025 GAAP report submission. In addition to issuing sanctions to the MCO for reporting non-compliance, the DHFS’ Account Management team engaged in discussions with the MCO to determine the cause of the untimely report submission, next steps, and to identify a final report submission date. Per discussions with the MCO, the DHFS learned that the MCO’s board members required education on the distinction between statutory financial and GAAP financial reports. In addition, the MCO’s board is required to review and approve all financial reports prior to submitting them to the DHFS. That approval process was delayed, which resulted in the report not being available to submit to the DHFS timely. The DHFS has established a revised report due date that allows for the MCO’s Board to complete its review and approval process. As such, the MCO shall submit its final, approved 2025 GAAP report to the DHFS no later than Feb 20, 2026. Proposed Completion Date: December 9, 2024
Finding Number: 2024-018 Finding Name: Improper Calculation of Qualified Incentive Payments Claimed under the Medicaid Cluster Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) incorrectly calculated qualified incentive payments charged to the Medicaid Cluster pr...
Finding Number: 2024-018 Finding Name: Improper Calculation of Qualified Incentive Payments Claimed under the Medicaid Cluster Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) incorrectly calculated qualified incentive payments charged to the Medicaid Cluster program using the enhanced federal medical assistance percentage (FMAP) rate applicable to payments under the Affordable Care Act (ACA) rather than its regular FMAP rate. Additionally, the auditors noted the supervisory review procedures related to the calculation of the qualified incentive payments were not designed to and did not operate at a level of precision to identify an error of this nature. Name of Contact Person(s): Rene Corso, Senior Public Service Administrator - Illinois Department of Healthcare and Family Services, Long Term Care (LTC) Rate Setting Unit Corrective Action(s): The LTC Rate Setting Unit has updated the spreadsheet for calculating the Quality Incentive Payment (QIP) to ensure the percentages for the ACA and the FMAP are distinguishable. Peer checking has also been implemented to ensure amounts are correct before processing Proposed Completion Date: April 16, 2025
Finding Number: 2024-017 Finding Name: Inadequate Procedures to Determine and Document Beneficiary Eligibility Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) does not have adequate procedures to determine and document eligibility for beneficiaries of the Child...
Finding Number: 2024-017 Finding Name: Inadequate Procedures to Determine and Document Beneficiary Eligibility Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) does not have adequate procedures to determine and document eligibility for beneficiaries of the Children’s Health Insurance Program (CHIP) and the Medicaid Cluster programs. Additionally, the auditors noted that the DHFS does not have adequate resources to perform and document eligibility determinations. Finally, the auditors noted that the DHFS has not established appropriate monitoring procedures to ensure eligibility determinations are properly documented in accordance with program requirements. Name of Contact Person(s): • Jacqueline Myers, Interim Deputy Administrator - Illinois Department of Healthcare and Family Services, Eligibility Data and Systems • Pam Winsel, Bureau Chief, Waiver Operations Management - Illinois Department of Healthcare and Family Services, Division of Medical Programs • Jeremy Thomas, Impact Technical Lead - Illinois Department of Healthcare and Family Services, Bureau of Technical Support Corrective Action(s): A report will be created to identify those enrolled in the waiver program, but not receiving full Medicaid that makes them ineligible for payment. This report will be run monthly and worked on manually until a system edit is implemented to reject claims when there is no match on full Medicaid coverage coding. Program staff at the waiver operating agencies will also be trained to assist them in identifying certain criteria that would exclude a waiver program enrollee from being eligible for payment. Rules have been modified (PIR #53483) to make sure eligibility in the RDB (Medicaid Management Information System (MMIS)) gets closed. In addition, a monthly report has been developed and is run monthly to identify any case with the eligibility closed in the IES, yet open in the Recipient Database (RDB). Cases shown on this report are worked to ensure both the Integrated Eligibility System (IES) and the RDB (MMIS) match. Proposed Completion Date: September 1, 2026
Finding Number: 2024-016 Finding Name: Failure to Discontinue CHIP Benefits for Ineligible Individuals Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) improperly continued providing benefits under the Children’s Health Insurance Program (CHIP) program to indivi...
Finding Number: 2024-016 Finding Name: Failure to Discontinue CHIP Benefits for Ineligible Individuals Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) improperly continued providing benefits under the Children’s Health Insurance Program (CHIP) program to individuals who were over the age of 18. In addition, the auditors noted that the DHFS has not established adequate controls to identify and remove individuals over the age of 18 from the CHIP program and to determine if they are eligible for benefits under the Medicaid Cluster program. Name of Contact Person(s): • Katherine A. Yager, Administrator, Illinois Department of Healthcare and Family Servies, Division of Eligibility • George Jacaway, Deputy Administrator - Illinois Department of Healthcare and Family Services, Eligibility Operations • Jacqueline Myers, Interim Deputy Administrator - Illinois Department of Healthcare and Family Services, Eligibility Data and Systems Corrective Action(s): Currently, the DHFS identifies and redetermines eligibility for this population each month. Each month, DHFS systemically identifies this population and provides a report to both DHFS and DHS to redetermine eligibility. Previously, this population was not being systematically identified. The amount of medical payments have decreased by 85% from fiscal year 2024 to 2025. A review of FY26 data indicates a continual decrease, currently at 93%. The DHFS will continue to identity and redetermine eligibility for this population group on a monthly basis. Proposed Completion Date: April 30, 2025 - Completed
Finding Number: 2024-015 Finding Name: Failure to Report Drug Rebates on the Medicaid CMS-64 Report in a Timely Manner Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) did not accurately report certain Medicaid Cluster program drug rebates on quarterly federal f...
Finding Number: 2024-015 Finding Name: Failure to Report Drug Rebates on the Medicaid CMS-64 Report in a Timely Manner Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) did not accurately report certain Medicaid Cluster program drug rebates on quarterly federal financial (CMS-64) reports. The auditors also noted that adequate internal controls had not been established to ensure the data used to calculate drug rebates reported on the quarterly CMS-64 reports are complete and accurate. Specifically, the supervisory reviews and analytical procedures performed over the quarterly CMS-64 reports were not designed at an appropriate level of precision to detect the drug rebates errors. Name of Contact Person(s): • Jason Rosado Timmerhaus, Bureau Chief – Illinois Department of Human Services, Budget and Cash Management • Tyler White, Drug Rebate Manager – Illinois Department of Human Services, Budget and Cash Management Corrective Action(s): Issue: Medicare Part D claims were not being excluded from the Drug Rebate invoicing process. Root Cause: The system programming did not capture the necessary data points to identify and exclude Part D claims during rebate processing. Corrective Actions Taken: 1. System Programming Fix a. The DHFS’ Pharmacy Benefit Manager updated the rebate system coding to correctly identify and exclude Part D claims. b. Documentation was provided by the DHFS’ Pharmacy Benefit Manager detailing the parameters used for testing and confirming that Part D claims are now excluded from the rebate process. 2. Manufacturer Credit Process a. The HFS Drug Rebate team, in collaboration with the DHFS’ Pharmacy Benefit Manager, identified all drugs that were mistakenly invoiced as Part D claims. b. Prior Quarter Adjustments (PQA) are applied during each invoice cycle to credit manufacturers for any incorrect charges. c. The DHFS’ Pharmacy Benefit Manager provides documentation verifying claims eligible for PQA. d. The Drug Rebate team conducts sampling tests to ensure credits are accurately applied. 3. Ongoing Monitoring a. Continue quarterly review and sampling of claims to confirm Part D exclusions remain effective. b. Maintain documentation from the DHFS’ Pharmacy Benefit Manager for audit and compliance purposes. These actions began on January 9, 2025, and will continue until all PQAs are made. Proposed Completion Date: August 31, 2024 – Completed
Finding Number: 2024-014 Finding Name: Inaccurate Reporting of Federal Expenditures Finding Condition(s): The Illinois Department of Human Services (IDHS) did not accurately report federal expenditures, including amounts provided to subrecipients, under the Supplemental Nutrition Assistance (SNAP) C...
Finding Number: 2024-014 Finding Name: Inaccurate Reporting of Federal Expenditures Finding Condition(s): The Illinois Department of Human Services (IDHS) did not accurately report federal expenditures, including amounts provided to subrecipients, under the Supplemental Nutrition Assistance (SNAP) Cluster, the Food Distribution Cluster (FDC), the Supplemental Nutrition for Women, Infants, and Children (WIC) programs, the Vocational Rehabilitation (VR) program, the Temporary Assistance for Needy Families (TANF), the Child Care Development Funds (CCDF) Cluster, the Social Services Block Grants (SSBG), the Block Grants for Prevention and Treatment of Substance Abuse (SAPT) program, and the Disability Insurance/SSI (SSDI) Cluster. Specifically, the auditors noted differences between the expenditure amounts provided for audit by the IDHS and the Schedule of Expenditures of Federal Awards (SEFA) amounts reported to the IOC, differences relative to amounts provided to program subrecipients, the cash basis expenditures provided by the IDHS for audit procedures included accrued (not paid) expenditures, and amounts passed through to other State agencies from the IDHS provided by the IDHS for audit procedures included expenditures paid outside of the fiscal year. Finally, IDHS’ controls over reporting federal expenditures were not designed at a sufficient level of precision to ensure complete and accurate reporting in a timely manner. Name of Contact Person(s): Sarah Eves, Deputy Chief Financial Officer – Illinois Department of Human Services Corrective Action(s): The IDHS will hire additional staff to ensure accurate review, reconciliation, and presentation of its federal grant expenditure data. Additionally, the IDHS has written draft procedures that will include (1) the identification and exclusion of accruals from total expenditures, ensuring cash-basis reporting, (2) how to identify and include/exclude current and prior year vouchers in transit, and (3) the review and validation of federal expenditures (and subrecipient expenditures). Proposed Completion Date: June 1, 2026
Finding Number: 2024-013 Finding Name: Failure to Report Subaward Information Required by FFATA Finding Condition(s): The Illinois Department of Human Services (IDHS) failed to report information required by the Federal Funding Accountability and Transparency Act (FFATA) for awards granted to subrec...
Finding Number: 2024-013 Finding Name: Failure to Report Subaward Information Required by FFATA Finding Condition(s): The Illinois Department of Human Services (IDHS) failed to report information required by the Federal Funding Accountability and Transparency Act (FFATA) for awards granted to subrecipients of the Temporary Assistance for Needy Families (TANF), Child Care and Development Fund (CCDF) Cluster, Social Services Block Grant (SSBG), and Block Grants for Prevention and Treatment of Substance Abuse (SAPT) programs. Name of Contact Person(s): • Kyle Thomas, Bureau Chief of Planning and Evaluation – Illinois Department of Human Services, Division of Family and Community Services • Christina Miller, Fund Disbursement Manager, Illinois Department of Human Services, Behavioral Health and Recovery - SAPT Program Corrective Action(s): The IDHS will (1) revise its FFATA reporting procedures to address the timely reporting of contracts with new federal awards, (2) revise its contract procedures to require that the contract signature date be recorded in its financial management system (FMS) on the same day the contract is signed., (3) revise its contract procedures to include the verification of contract signature dates in its FMS, (4) develop a checklist for its contract staff, (5) hire a manager in its IDHS-SAPT Program to develop revised procedures and complete FFATA reporting, and (6) identify interim controls and milestones in its IDHS-SAPT Program that will operate prior to full automation. Proposed Completion Date: April 1, 2026
Finding Number: 2024-012 Finding Name: Failure to Meet the SAPT MOE Requirement Finding Condition(s): The Illinois Department of Human Services (IDHS) did not maintain the required aggregate State expenditures for the maintenance of effort (MOE) requirements for the Block Grants for Prevention and T...
Finding Number: 2024-012 Finding Name: Failure to Meet the SAPT MOE Requirement Finding Condition(s): The Illinois Department of Human Services (IDHS) did not maintain the required aggregate State expenditures for the maintenance of effort (MOE) requirements for the Block Grants for Prevention and Treatment of Substance Abuse (SAPT) program. In addition, the auditors noted that the IDHS has not established internal control procedures to monitor whether maintenance of effort requirements are met. Name of Contact Person(s): • Christina Miller, Fund Disbursement Manager, Illinois Department of Human Services, Behavioral Health and Recovery - SAPT Program • Brock Dunlap, Chief Financial Officer – Illinois Department of Human Services, Division of Behavioral Health and Recovery Corrective Action(s): The IDHS will (1) establish a procedure to run quarterly expenditure reports on the fund sources identified in the approved MOE methodology and compare them to expected expenditures, (2) train fiscal staff on the importance of running quarterly MOE reports so that the IDHS will not have repeat audit findings, and (3) will have grant managers communicate with providers who are funded by MOE-identified fund sources that are underutilized to understand possible reasons for underutilization and provide technical assistance as needed. Proposed Completion Date: July 30, 2026
Finding Number: 2024-011 Finding Name: Unallowable Costs Charged to the TANF and CCDF Cluster Programs Finding Condition(s): The Illinois Department of Human Services (IDHS) could not provide documentation to support payments made on behalf of beneficiaries of the Temporary Assistance for Needy Fami...
Finding Number: 2024-011 Finding Name: Unallowable Costs Charged to the TANF and CCDF Cluster Programs Finding Condition(s): The Illinois Department of Human Services (IDHS) could not provide documentation to support payments made on behalf of beneficiaries of the Temporary Assistance for Needy Families (TANF) and Child Care and Development Fund (CCDF) Cluster programs. Additionally, the auditors noted that the IDHS does not have adequate controls in place to ensure information provided by providers is accurate and the related child care payments made were appropriate. Name of Contact Person(s): Maureen Bilek, Audit Compliance and Programmatic Monitoring Administrator – Illinois Department of Human Services, Division of Early Childhood (DEC) Corrective Action(s): The IDHS will (1) develop and implement internal procedures to conduct quarterly reviews of billing certificates for payments entered through the Interactive Voice Response (IVR) system, (2) assess existing deliverables, its Child Care Assistance Program (CCAP) policy and its CCDF State Plan responses related to IVR payments and determine and implement any necessary revisions, (3) develop external guidance for providers and Child Care Resource & Referral (CCR&R) agencies outlining IVR payment requirements, documentation standards, record-retention expectations, and the review process, (4) initiate and continue implementation of a communication plan to announce upcoming reviews, including the Service Employees International Union (SEIU), the Division of Early Childhood (DEC), CCR&Rs, and all providers utilizing IVR (additional communications will be issued as the process is refined), (5) commence IVR payment reviews in June 2026 and continue on a quarterly basis, and (6) Establish and maintain a master tracking log of provider reviews by year, subject to management review and oversight. Proposed Completion Date: June 30, 2026
Finding Number: 2024-010 Finding Name: Improper TANF Beneficiary Payments Finding Condition(s): The Illinois Department of Human Services (IDHS) made improper payments to beneficiaries of the Temporary Assistance for Needy Families (TANF) program. In addition, the IDHS identified a system error in J...
Finding Number: 2024-010 Finding Name: Improper TANF Beneficiary Payments Finding Condition(s): The Illinois Department of Human Services (IDHS) made improper payments to beneficiaries of the Temporary Assistance for Needy Families (TANF) program. In addition, the IDHS identified a system error in June 2025 impacting beneficiaries whose benefit payments were calculated using diverted income. Finally, the IDHS did not establish control procedures at an adequate level of precision to ensure TANF program benefits were accurately calculated based on the beneficiary’s case file supporting documentation. Name of Contact Person(s): Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services Corrective Action(s): The IDHS has submitted a repair ticket to repair the system it uses to calculate its diverted income. Additionally, the cases affected by the diverted income error are being reviewed and referend to the Bureau of Collections for overpayment, as needed. The cases with incorrect beneficiary payments, outside of the diverted income errors, have been corrected and overpayment/supplements have been completed. Finally, the IDHS will require its TANF managers to conduct a monthly review of TANF cases to include all components of the cases. Proposed Completion Date: June 30, 2026
Finding Number: 2024-009 Finding Name: Missing Documentation in Beneficiary Files Finding Condition(s): The Illinois Department of Human Services (IDHS) could not locate case file documentation supporting certain eligibility and special test requirements for beneficiaries of the Temporary Assistance...
Finding Number: 2024-009 Finding Name: Missing Documentation in Beneficiary Files Finding Condition(s): The Illinois Department of Human Services (IDHS) could not locate case file documentation supporting certain eligibility and special test requirements for beneficiaries of the Temporary Assistance for Needy Families (TANF) program. Also, the auditors noted that the IDHS does not have adequate resources to perform and document eligibility determinations. Additionally, the auditors noted that the IDHS has not established appropriate monitoring procedures to ensure eligibility determinations are properly documented in accordance with program requirements. Name of Contact Person(s): Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services (FCS) Corrective Action(s): The IDHS’ TANF Managers will conduct a monthly review of TANF cases to include all components of the TANF cases. Additionally, an Integrated Eligibility System (IES) enhancement will be implemented to allow telephonic signatures for TANF Responsibility and Service Plans. This will eliminate the need to use a paper process. Proposed Completion Date: March 21, 2027
Finding Number: 2024-008 Finding Name: Inadequate Procedures to Determine Accuracy of the Post-Expenditure Report Finding Condition(s): The Illinois Department of Human Services (IDHS) failed to provide supporting documentation for the post-expenditure report including a key line item, the number of...
Finding Number: 2024-008 Finding Name: Inadequate Procedures to Determine Accuracy of the Post-Expenditure Report Finding Condition(s): The Illinois Department of Human Services (IDHS) failed to provide supporting documentation for the post-expenditure report including a key line item, the number of eligible individuals who received services paid for in part or in whole with federal funds under the Social Services Block Grant (Title XX) program. Name of Contact Person(s): Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services Corrective Action(s): The IDHS updated its funding requirements to include Social Services Block Grant (SSBG) reporting requirements. The updates included the shift from annual to quarterly reporting for the post-expenditure report and that every office or bureau awarded SSBG funding are required to include SSBG reporting requirements (i.e., quarterly reporting on expenditures and clients served) in their contract exhibits. These actions were implemented starting in fiscal year 2026. Offices and bureaus have met the expectations for the first 2 quarters of implementation, as the team is anticipating Q3 reporting on April 30, 2026. The first post-expenditure annual report under this structure will be completed later this year. Finally, the IDHS updated its procedures to have its supervisory reviews and approvals of the post-expenditure report completed within 90 days of the fiscal year end. The due date for the collection of all data needed for the post-expenditure is July 30th. The post-expenditure report is not due until December 30th. Supervisory approvals completed within 90 days allow the team to check for and request any missing data well before the deadline. These updated reporting requirements and procedures are critical in supporting the post-expenditure report with accurate information on dollars spent, clients served, and service type delivered. Proposed Completion Date: September 30, 2026
Finding Number: 2024-007 Finding Name: Failure to Follow Established Program Subrecipient Monitoring Procedures Finding Condition(s): The Illinois Department of Human Services (IDHS) did not follow its established program monitoring policies and procedures for subrecipients of the Temporary Assistan...
Finding Number: 2024-007 Finding Name: Failure to Follow Established Program Subrecipient Monitoring Procedures Finding Condition(s): The Illinois Department of Human Services (IDHS) did not follow its established program monitoring policies and procedures for subrecipients of the Temporary Assistance for Needy Families (TANF), Child Care Development Fund Cluster (CCDF), Social Services Block Grant (SSBG), and Block Grants for Prevention and Treatment of Substance Abuse (SAPT) programs. Further, the auditors noted that the IDHS did not have adequate policies or procedures to ensure fiscal and administrative reviews were completed timely to detect potential non-compliance. Name of Contact Person(s): • Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services (FCS) • Christina Miller, Fund Disbursement Manager – Illinois Department of Human Services, Division of Behavioral Health and Recovery (IDHS-SAPT-Program) • Maureen Bilek, Audit Compliance and Programmatic Monitoring Administrator – Illinois Department of Human Services, Division of Early Childhood (DEC) • Brian Bond, Director – Illinois Department of Human Services, Office of Contract Administration (OCA) Corrective Action(s): The IDHS has completed or will take the following actions within four of its divisions/offices: Division of Family and Community Services (FCS) The FCS (1) has worked to identify the late subrecipient monitoring reviews and created a plan to address the backlog, (2) will utilize the plan to eliminate the back log of subrecipient monitoring reviews, (3) will meet with staff to reinforce the importance of adhering to the agreed upon monitoring processes and timeframes, (4) will update and circulate to staff the revised monitoring standard operating procedure, and (5) will review staff adherence to monitoring SOP timeframes during weekly meetings with staff who conduct monitoring. Division of Behavioral Health and Recovery (IDHS-SAPT PROGRAM) The IDHS-SAPT PROGRAM will (1) hire an administrative assistant to assist with compliance monitoring tracking activities to maintain communication about important deadlines, (2) hire compliance monitors to engage in conducting compliance reviews, (3) meet weekly to track monitoring activities to ensure deadlines are met, (4) review policy and procedures to assess timelines associated with the monitoring process, and (5) train all monitors to use the updated tool, templates and updated policies and procedures and the new electronic system. Division of Early Childhood (DEC) The DEC will (1) develop and implement a standardized deadline tracking tool to monitor review completion dates and required subrecipient notifications, including documented supervisory review and management oversight to ensure timeliness, (2) establish and implement internal Corrective Action Plan (CAP) procedures that outline standardized processes for CAP tracking, documentation, and escalation efforts and define protocols when subrecipients fail to submit required CAPs within established timeframes, (3) initiate and implement a CAP tracking tool to monitor review dates, findings issuance, subrecipient notification dates, CAP receipt, and implementation follow-up activities, with documented management oversight and approval to ensure timeliness, accountability, and consistent monitoring, and (4) conduct formal staff training on procedures for accurately completing and maintaining the CAP tracking tool, including documentation standards, required data elements, and supervisory review expectations to ensure consistent and compliant use. Office of Contract Administration (OCA) The OCA (1) has formally briefed leadership and management the issues noted in the finding and initiated a cross-division review of current subrecipient monitoring execution to identify gaps, inconsistencies, and needed revisions, (2) will complete a structured validation of monitoring expectations to ensure programmatic on-site reviews and expenditure/performance report reviews are occurring at the required frequency and depth, consistent with pass-through monitoring responsibilities, (3) will review minimum documentation standards and supervisory quality control checkpoints for review workpapers, expenditure/performance report review evidence, and monitoring report issuance, to strengthen internal controls over compliance, (4) will standardize and revise the data tracking definitions to ensure program findings from subrecipient monitoring are issued, tracked, and followed through to corrective action completion, including defined escalation steps when responses are delinquent or incomplete, (5) will align enforcement actions with the Statewide Grantee Compliance Enforcement System (GCES) framework (e.g., stop-payment status triggers, notices, objection windows, and resolution and closure steps), and ensure staff understand how and when to apply GCES in response to unresolved monitoring deficiencies, (6) finalize recommendations to streamline Fiscal Administrative Review (FAR) production triggers (pre-draft and post-draft), clarify program engagement in special condition processing post-FAR, and reduce reliance on informal technical assistance in CAP in favor of documented compliance correction and closure, (7) revised procedures and controls will be implemented for FARs scheduled on/after August 1, 2026 (target), with interim guidance applied as feasible to active cases prior to that date, and (8) will conduct structured database integrity review and update process aligned with official guidance and source documentation to ensure accuracy, completeness, consistency, and reliability of all FAR database records. Proposed Completion Date: December 31, 2026
Finding Number: 2024-006 Finding Name: Inadequate Process for Monitoring Interagency Program Expenditures Finding Condition(s): The Illinois Department of Human Services (IDHS) does not have an adequate process for monitoring interagency expenditures claimed under or used to meet maintenance of effo...
Finding Number: 2024-006 Finding Name: Inadequate Process for Monitoring Interagency Program Expenditures Finding Condition(s): The Illinois Department of Human Services (IDHS) does not have an adequate process for monitoring interagency expenditures claimed under or used to meet maintenance of effort (MOE) requirements of the Temporary Assistance for Needy Families (TANF) and Child Care Development Fund (CCDF) Cluster programs. Name of Contact Person(s): Sarah Eves, Deputy Chief Financial Officer – Illinois Department of Human Services Corrective Action(s): The IDHS will request quarterly certifications, control assessments, and program expenditure questionnaires for those agencies receiving funds from federal awards. Additionally, the IDHS will sample interagency expenditures and request that the agency provide supporting documentation for the expenses. This documentation will be reviewed by the IDHS to ensure that the expenditures meet federal program requirements. Proposed Completion Date: October 1, 2026
Finding Number: 2024-005 Finding Name: Inadequate Review of Recipient Agencies of the Food Distribution Cluster Finding Condition(s): The Illinois Department of Human Services (IDHS) did not adequately review the recipient agencies of the Food Distribution Cluster (FDC) program. Name of Contact Pers...
Finding Number: 2024-005 Finding Name: Inadequate Review of Recipient Agencies of the Food Distribution Cluster Finding Condition(s): The Illinois Department of Human Services (IDHS) did not adequately review the recipient agencies of the Food Distribution Cluster (FDC) program. Name of Contact Person(s): • Liz Lusk, Audit Liaison, Deputy Chief Financial Officer – Illinois Department of Human Services, Division of Family and Community Services (FCS) • Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services (FCS) Corrective Action(s): The IDHS will update the Procedure Manual for The Emergency Food Assistance Program (TEFAP) to include the requirement that an annual inventory count and reconciliation of inventory records be submitted for all recipient agencies at the end of each State fiscal year. Additionally, the IDHS will collect annual inventory count and reconciliation from all food banks at the end of each State fiscal year. Finally, the IDHS will reconcile the annual inventory counts within 60 days of receipt. Proposed Completion Date: September 30, 2026
Finding Number: 2024-004 Finding Name: Inadequate Monitoring of Subrecipients of the CSLFRF Program Finding Condition(s): The Illinois Department of Human Services (IDHS) did not obtain and review periodic performance reports for subrecipients of the COVID-19 – Coronavirus State and Local Fiscal Rec...
Finding Number: 2024-004 Finding Name: Inadequate Monitoring of Subrecipients of the CSLFRF Program Finding Condition(s): The Illinois Department of Human Services (IDHS) did not obtain and review periodic performance reports for subrecipients of the COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program during the year ended June 30, 2024 Name of Contact Person(s): • Liz Lusk, Audit Liaison, Deputy Chief Financial Officer – Illinois Department of Human Services, Division of Family and Community Services (FCS) • Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services (FCS) Corrective Action(s): The IDHS will work to develop a process for the review of Periodic Performance Reports (PPR) that will include grantee certification of accuracy and staff certification of review and approval. Additionally, the IDHS will train staff in the importance of maintaining PPRs obtained from subrecipients and related documentation, including maintaining evidence of PPR reviews and appropriate reviewer signatures. Finally, the IDHS is exploring creating a centralized repository for each program area in the FCS (Division of Family & Community Services) to allow for PPR document files to be easily maintained, searched, and located to avoid any issues related to staffing changes. Proposed Completion Date: December 30, 2026
Finding Number: 2024-003 Finding Name: Failure to Accurately Prepare Performance Reports for the COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Program Finding Condition(s): The Illinois Governor’s Office of Management and Budget (GOMB) did not prepare accurate federal project and expe...
Finding Number: 2024-003 Finding Name: Failure to Accurately Prepare Performance Reports for the COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Program Finding Condition(s): The Illinois Governor’s Office of Management and Budget (GOMB) did not prepare accurate federal project and expenditure reports (Paperwork Reduction Act (PRA) 1505-0271) for the COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program. Name of Contact Person(s): Lesley Winbush, Accountant – Illinois Governor’s Office of Management and Budget Corrective Action(s): GOMB will improve the reporting process by implementing checks to ensure that all expenditures are reported by State agencies. The checks will include comparing reported data against agency financial reports to ensure that the data is complete. Proposed Completion Date: June 30, 2026
Finding Number: 2024-002 Finding Name: Inadequate Monitoring of Subrecipient Single Audit Reviews Finding Condition(s): The State of Illinois did not establish adequate controls to monitor the completion and documentation of the review of single audit reports for its subrecipients of the Special Sup...
Finding Number: 2024-002 Finding Name: Inadequate Monitoring of Subrecipient Single Audit Reviews Finding Condition(s): The State of Illinois did not establish adequate controls to monitor the completion and documentation of the review of single audit reports for its subrecipients of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Child and Adult Care Food Program (CACFP), the Crime Victims Assistance Program (CVA), the Workforce Innovation and Opportunity Act (WIOA) Cluster, the Highway and Planning Construction (Highway), the Coronavirus State and Local Fiscal Recovery Funds (SLFRF), the Title I Grants to Local Education Agencies (Title I), the Special Education Cluster (IDEA), the Twenty-First Century Community Learning Centers (Twenty-First Century), the Supporting Effective Instruction State Grants (SEISG), the Education Stabilization Funds (ESF), the Aging Cluster (Aging), the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), the Temporary Assistance for Needy Families (TANF), the Child Support Services (CSS), the Low-Income Home Energy Assistance Program (LIHEAP), the Child Care and Development Fund (CCDF) Cluster, the Social Services Block Grant (SSBG), the Block Grants for Prevention and Treatment of Substance Abuse (SAPT), and the Homeland Security Grant Program (Homeland Security) programs in the State's Grant Accountability and Transparency Act (GATA) Audit Report Review Management System (ARRMS). Name of Contact Person(s): Keyria Rodgers, Grant Accountability and Transparency Unit Director – Illinois Governor’s Office of Management and Budget Corrective Action(s): The Grant Accountability and Transparency Unit (GATU) provides a centralized, uniform process and a system to which State grant-making agencies are required to adhere throughout the lifecycle of the grant. Beginning November 2025, the Illinois Governor’s Office of Management and Budget (GOMB) sends a monthly analysis to agency Chief Accountability Officers (CAOs) detailing incomplete documentation of reviews within ARRMS. GOMB also provides monthly reminders of the importance of documenting the completeness of the reviews within our regular occurring CAO meetings and Subject Matter Expert (SME) meetings. Lastly, GOMB increased direct technical support by contacting CAOs to address questions, offered individualized live assistance, and provided a live demonstration during the February 2026 ARRMS meeting on how to generate and upload Management Decision Letters (MDLs) to ensure the system is updated by agencies and accurate as to the completeness of the agencies’ report reviews, letter issuances, and desk reviews. Proposed Completion Date: April 30, 2026
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