Corrective Action Plans

Finding 1187286 (2025-003)

Material Weakness 2025

CA

Student Financial Aid Subrecipient Monitoring Reporting

Finding 2025-003 – Special Test and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance (See table in Management's Corrective Action Plan"). Condition/Context – Out of a population of approximately 1,000 student status changes a...

Finding 2025-003 – Special Test and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance (See table in Management's Corrective Action Plan"). Condition/Context – Out of a population of approximately 1,000 student status changes and 230 permanent address changes, a sample of 74 federal aid recipient students were selected from system generated reports of students who graduated, reported a physical address change, withdrew, or dropped during the 2024-2025 academic year. Auditors believe this to be a representative sample although not a statistical sample. The enrollment information and withdrawal, address change, or graduation date per the University’s records was compared to the information reported to the National Student Loan Data System (NSLDS) in order to determine if status changes were reported within the required timeframes. Corrective Action Plan: The finding has been addressed through staffing changes and scheduled reporting which took effect January 2026. The office of the University Registrar did not previously have a dedicated staff member to submit reports in a timely manner. With the departure of the Associate Registrar in April 2025, the task fell to several staff members to share the responsibility along with their other tasks. The office currently has an assistant registrar as well as a transcript evaluator who share the responsibility and submit reports once every 30 days, with the exception of winter reporting, which is on a different schedule due to breaks. Internal controls have been revised to check conferral dates prior to submitting the enrollment report for the Main Campus. Name of Contact Person: Julie Khella, University Registrar at jkhella@laverne.edu Projected Completion Date: This was corrected as of March 22, 2026

View Audit 394918

Finding 1187285 (2025-002)

Material Weakness 2025

University of La Verne

CA

Cash Management Student Financial Aid

FINDING 2025-002 – Special Tests and Provisions – Cash Management: Significant Deficiency in Internal Control over Compliance (See table in "Management's Corrective Action Plan"). Condition/Context – The University made 48 draws for various student financial assistance cluster programs. Auditors sel...

FINDING 2025-002 – Special Tests and Provisions – Cash Management: Significant Deficiency in Internal Control over Compliance (See table in "Management's Corrective Action Plan"). Condition/Context – The University made 48 draws for various student financial assistance cluster programs. Auditors selected a sample of 7 and believe this to be a representative sample; however, it was not a statistical sample; Corrective Action Plan: This was done due to the perceived understanding that the new Federal Administration indicated that all grants were at risk of being cancelled and that the G5 website would go dark. Due to the unique nature of the Federal Administration’s perceived announcement, the University would not handle this in the same manner, in the future. If for some reason they were to cancel any future grants, the University would endure the cancellation and close out the grant in the usual process, which is by reimbursement only. Name of Contact Person: Lori Gordien Case, Associate Vice President of Finance and Controller at lgordien@laverne.edu Projected Completion Date: This was corrected as of March 31, 2025.

View Audit 394918

Finding 1187284 (2025-001)

Material Weakness 2025

University of La Verne

CA

Special Tests & Provisions Student Financial Aid Significant Deficiency

FINDING 2025-001 – Special Tests and Provisions – Return of Title IV Funds: Significant Deficiency in Internal Control over Compliance; (See table in "Management's Corrective Action Plan"); Condition/Context – Auditors selected a sample of 20 students out of a population of 109 that were identified ...

FINDING 2025-001 – Special Tests and Provisions – Return of Title IV Funds: Significant Deficiency in Internal Control over Compliance; (See table in "Management's Corrective Action Plan"); Condition/Context – Auditors selected a sample of 20 students out of a population of 109 that were identified by the University as having received some federal assistance and withdrew from the University during the year under audit. Auditors believed this to be a representative sample of the population; however, it was not a statistical sample. Corrective Action Plan: The finding has been addressed through the implementation of our FY2024 Corrective Action Plan. The Office of Financial Aid has collaborated with the University Registrar to develop a comprehensive report identifying non-completed courses inclusive of all grade codes. This report is reviewed on the day following faculty submission of final grades for both semester and modular terms. Students subject to R2T4 processing are identified by the Associate Director of Compliance & Special Programs and subsequently assigned to a team of three Program Managers for COD processing. Timely review of this report ensures that all required funds are returned within the 45-day regulatory timeframe. Internal controls have been revised to include a secondary review of all processed R2T4’s. Additionally, an internal control document will be established to demonstrate that R2T4 calculations were reviewed for accuracy and completeness. Name of Contact Person: Laura Evans, Director of Financial Aid at levans2@laverne.edu Projected Completion Date: This was corrected as of March 22, 2026

View Audit 394918

Finding 1187265 (2025-001)

Material Weakness 2025

City of Fremont

CA

Subrecipient Monitoring Reporting

Reference Number: 2025-001 Awarding Agency: U.S. Department of Housing and Urban Development Program Name: Community Development Block Grants/Entitlement Grants Assistance Listing Number: 14.218 Award Number: B-24-MC-06-0011 Federal Award Year: Fiscal Year Ended June 30, 2024 Category of Finding: Re...

Reference Number: 2025-001 Awarding Agency: U.S. Department of Housing and Urban Development Program Name: Community Development Block Grants/Entitlement Grants Assistance Listing Number: 14.218 Award Number: B-24-MC-06-0011 Federal Award Year: Fiscal Year Ended June 30, 2024 Category of Finding: Reporting Type of Finding: Instance of Noncompliance; Significant Deficiency in Internal Control Over Compliance 1. Person responsible: CDBG Administrator 2. Corrective Action Plan: The City of Fremont agrees with the finding and recommendation. To strengthen compliance with FFATA reporting requirements, program staff will provide the subrecipient or contractor with the FFATA reporting notice, including the request for the five most highly compensated officers, at the same time the contract is sent for signature. Aligning these documents will improve tracking, as the subrecipient or contractor will return both the signed contract and the FFATA reporting notice together. Once staff receives the fully executed contract, the FFATA reporting system will be updated promptly. A screenshot showing the date and time of the submission will be retained in the contract file to document timely reporting and ensure continued compliance. 3. Anticipated implementation date: April 1, 2026

View Audit 394903

Finding 1187264 (2025-001)

Material Weakness 2025

Independent School District 719 Prior Lake-Savage Area Schools

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties School Nutrition Programs § 200.318

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER (ALN 10.555 AND 10.553) 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summar...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER (ALN 10.555 AND 10.553) 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires Independent School District No. 719, Prior Lake-Savage Area Schools (the District) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster federal programs. During our audit, we noted the District did not have sufficient controls in place within its child nutrition cluster federal programs to ensure compliance with federal requirements related to assuring that the District was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District will review its policies and procedures relating to suspension and debarment for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to assure that district personnel are following the requirements of the Uniform Guidance related to suspension and debarment, including maintaining appropriate documentation. Official Responsible – The District’s Executive Director of Business Services, Lisa Rider. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Executive Director of Business Services, Lisa Rider, will assure appropriate internal controls and procedures are in place to ensure compliance with suspension and debarment requirements.

View Audit 394893

Finding 1187262 (2025-002)

Material Weakness 2025

Medical University of South Carolina

SC

Equipment & Real Property Management Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.1 § 200.303 § 200.313

Finding Number: 2025-002 Equipment Property Management Recommendation: The University needs to enhance the precision of the controls over equipment purchases to ensure that a property record is created within the system containing the required information, inclusive of the federal award, for all fed...

Finding Number: 2025-002 Equipment Property Management Recommendation: The University needs to enhance the precision of the controls over equipment purchases to ensure that a property record is created within the system containing the required information, inclusive of the federal award, for all federally funded equipment. Management concurs with the auditor’s recommendation. The University has taken immediate steps to comply with 2CFR 200.313 and implemented the following actions: Planned Corrective Action (1): The University has established a bi-weekly reconciliation process for federally funded assets to strengthen compliance and ensure the timely and accurate inclusion of all federally funded asset purchases in the asset register. Anticipated Completion Date: Completed Responsible Contact Person: Eric Hughey, Fiscal Manager, Asset Accounting & Surplus/Nataliya Samodov, GCA Director Planned Corrective Action (2): The University has implemented an additional control through exception reporting and follow-up with responsible parties to ensure that all registered assets are tagged at the time of installation. Anticipated Completion Date: Completed Responsible Contact Person: Eric Hughey, Fiscal Manager, Asset Accounting & Surplus/Nataliya Samodov, GCA Director

View Audit 394870

Finding 1187261 (2025-003)

Material Weakness 2025

Fremont County Association of Governments

WY

Cash Management Significant Deficiency

Finding 2025‐003 Reimbursement Request Approval Documentation ‐ Significant Deficiency Management Response: The Association acknowledges this finding and agrees that reimbursement request files should contain clearer documentation evidencing the preparation and approval process required under intern...

Finding 2025‐003 Reimbursement Request Approval Documentation ‐ Significant Deficiency Management Response: The Association acknowledges this finding and agrees that reimbursement request files should contain clearer documentation evidencing the preparation and approval process required under internal policy. Although reimbursement requests were prepared and submitted as part of routine grant administration, the supporting documentation did not consistently reflect the full preparation trail and approval record expected for audit purposes. Management has already identified the need to formalize this process and will implement a standardized reimbursement request file structure for all future reimbursement submissions. This process will include documentation showing who prepared the request, the date of preparation, the review and approval path, and the supporting expenditure records associated with the reimbursement period. Where applicable, the Association will incorporate a formal checklist or cover sheet to ensure each request file demonstrates compliance with internal procedures and grant requirements. Management does not believe the issue resulted from intentional noncompliance, but rather from inadequate documentation of a process that had been operationally performed. Even so, management agrees that documentation standards must be improved to reduce risk and strengthen compliance controls over federal reimbursement activity. The Association is committed to implementing this corrective action immediately for all future reimbursement requests to ensure that preparation and approval procedures are clearly evidenced and consistently retained. The draft audit notes that the comparable prior-year federal finding appears to be resolved, and management intends to similarly resolve this finding through standardized documentation and retention procedures. Responsible Official: Director / Business Manager Planned Corrective Action Date: Immediately for all reimbursement requests submitted after audit issuance

View Audit 394868

Finding 1187259 (2025-003)

Material Weakness 2025

Zuni Public Schools

NM

Reporting Significant Deficiency

Corrective Action Plan 2025-003 Non-Compliance with JOM Annual Report Submission Federal Program Information Funding Agency US Bureau of Indian Education Title: Johnson O’Malley Federal Assistance Listing: 15.130 Pass Through Zuni Tribe Award Year 2022-2027 Responsible Official’s Plan Due to unfores...

Corrective Action Plan 2025-003 Non-Compliance with JOM Annual Report Submission Federal Program Information Funding Agency US Bureau of Indian Education Title: Johnson O’Malley Federal Assistance Listing: 15.130 Pass Through Zuni Tribe Award Year 2022-2027 Responsible Official’s Plan Due to unforeseen circumstances, the Federal Programs Director for Zuni Public Schools retired mid year. Because of the abrupt timing of the retirement, the new Federal Programs Director did not receive an optimal amount of training. Additional training has been received regarding federal fund report compliance. The Johnson O’Mallley report referenced in the finding has been completed and submitted. Specific corrective action plan for funding: It is being completed and will be submitted by the new Federal Programs Director, Ms. Florence Acque. Timeline for completion of corrective action March 31, 2026 Employee Position responsible for meeting the timeline: Florence Acque Federal Programs Director

View Audit 394863

Finding 1187258 (2025-001)

Material Weakness 2025

Autonomous Municipality of Caguas

PR

Reporting § 200.302 § 200.303 § 200.450

VIEWS OF RESPONSIBLE OFFICIALS Management reviewed the reporting process and identified that the discrepancy resulted from reliance on PMS drawdown and cash-basis payment activity rather than cumulative accrualbased expenditures recorded in SAP. Internal procedures have been revised to ensure that L...

VIEWS OF RESPONSIBLE OFFICIALS Management reviewed the reporting process and identified that the discrepancy resulted from reliance on PMS drawdown and cash-basis payment activity rather than cumulative accrualbased expenditures recorded in SAP. Internal procedures have been revised to ensure that Line 10.e reflects total cumulative expenditure recorded on an accrual basis, consistent with the accounting records. Implemented or Planned Corrective Measures: 1. Management Action: The interim SF-425 for Grant 02TD0022301 was formally reviewed on February 11, 2026, corrected to properly reflect cumulative expenditures in Line 10.e, and resubmitted through the Payment Management System (PMS). 2. Management Meeting: On February 25, 2026, a formal meeting was held with the Fiscal Team, Program Director, Sub-Director, Budget/Fiscal Analyst, and Fiscal Consultant to review the finding and establish the enhanced corrective plan. 3. Corrective Measure Related to Root Cause: The reporting process has been revised to ensure that all SF-425 reports are prepared using cumulative accrual-based expenditure data directly extracted from SAP, consistent with accrual accounting principles and 2 CFR §200.302(b)(2). This enhancement strengthens internal controls over financial reporting in accordance with 2 CFR §200.303 4. Implementation of a formal reconciliation process between the general ledger (SAP), supporting expenditure reports, and the SF-425 prior to submission. 5. Comprehensive Preventive Review: Management initiated a comprehensive review of all SF-425 reports submitted from July 1, 2025, to the present. This review includes reconciliation of Lines 10.e and 10.f to SAP general ledger data to confirm compliance with accrual-based reporting standards. The review will be completed no later than March 30, 2026. Results will be formally documented in accordance with the Federal Reporting Procedures Manual and presented to the Governing Board at its meeting on March 30, 2026. 6. Structural Improvements Implemented: 1. Budget/Fiscal Analyst formally responsible for extracting cumulative data from SAP, preparing SF-425, and completing standardized reconciliation of Lines 10.e and 10.f. 2. Fiscal Consultant responsible for independent review, validation of compliance with 2 CFR §§200.302 and 200.303, certification, and submission in PMS. 3. Implementation of a standardized reconciliation worksheet. 4. Training for fiscal personnel scheduled for March 5, 2026, covering revised procedures and Uniform Guidance requirements. 7. Governance and Monitoring: • Adoption of the formal Federal Reporting Procedures Manual. • Establishment of an Annual Federal Reporting Calendar reviewed monthly. • Monitoring by the Sub-Director with documentation in fiscal meeting minutes. • Formal presentation of the audit finding and revised procedures to the Governing Board on March 30, 2026. 8. All corrective actions are expected to be fully implemented no later than March 30, 2026. IMPLEMENTATION DATE March 30, 2026 RESPONSIBLE PERSONS Margot Vélez Meléndez, Director of Head Start Program

View Audit 394859

Finding 1187241 (2025-006)

Material Weakness 2025

Municipality of Maricao

PR

Subrecipient Monitoring Reporting § 200.303 § 200.328 § 200.329

The Municipality agrees with the finding and stated that it will implement corrective actions to improve compliance with reporting requirements. Management plans to formalize reporting procedures, assign responsible personnel, and require reconciliations between reported amounts and accounting recor...

The Municipality agrees with the finding and stated that it will implement corrective actions to improve compliance with reporting requirements. Management plans to formalize reporting procedures, assign responsible personnel, and require reconciliations between reported amounts and accounting records prior to submission of reports to ACUDEN, along with enhanced supervisory review. Implementation Date: July 1, 2026 Responsible Person: Mr. Luis A. Velez Rivera, Finance Director

View Audit 394852

Finding 1187239 (2025-071)

Material Weakness 2025

State of Maine

ME

Subrecipient Monitoring § 200.303 § 200.332 § 200.521

Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will publish revised subrecipient monitoring procedures. ...

Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will publish revised subrecipient monitoring procedures. The Department will cross-train relevant agency staff on the procedures. The Department will implement a quarterly FAC review cycle with revised procedures. Completion Date: April 30, 2026, June 30, 2026, and July 1, 2026, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507

View Audit 394838

Finding 1187238 (2025-070)

Material Weakness 2025

State of Maine

ME

Reporting Internal Control / Segregation of Duties § 200.302 § 200.303

Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will publish revised Federal financial reporting procedures. The De...

Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will publish revised Federal financial reporting procedures. The Department will train relevant staff. The Department will implement new Federal Financial Reporting procedures with increased staff resource allocations. Completion Date: April 30, 2026, June 30, 2026, and July 1, 2026, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507

View Audit 394838

Finding 1187237 (2025-069)

Material Weakness 2025

State of Maine

ME

Subrecipient Monitoring Reporting Material Weakness § 200.303

Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program special reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will develop same-month internal validation workbook/tool to ensure t...

Department: Defense, Veterans and Emergency Management Title: Internal control over DG – PA program special reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will develop same-month internal validation workbook/tool to ensure that subawards have been reported timely, completely and accurately. The Department will update agency FFATA reporting procedure to reflect changes in reporting process and selection of unique identifier and distribute to all grant managers and reporting personnel. Completion Date: March 31, 2026, and April 30, 2026, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507

View Audit 394838

Finding 1187233 (2025-068)

Material Weakness 2025

State of Maine

ME

Significant Deficiency Special Tests & Provisions

Department: Redacted Title: Redacted Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with the finding. The Department’s explanation and specific reasons for disagreement have been excluded to protect confidenti...

Department: Redacted Title: Redacted Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with the finding. The Department’s explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: N/A Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423

View Audit 394838

Finding 1187230 (2025-067)

Material Weakness 2025

State of Maine

ME

Significant Deficiency Special Tests & Provisions

Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department’s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protec...

Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department partially agrees with the finding. The Department’s corrective action plan as well as the explanation and specific reasons for disagreement have been excluded to protect confidential information. The complete corrective action plan as well as the explanation and specific reasons for disagreement have been provided to the Office of the State Auditor under separate cover. Completion Date: February 5, 2026, April 10, 2026, May 15, 2026, June 26, 2026, and June 30, 2027 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423

View Audit 394838

Finding 1187227 (2025-066)

Material Weakness 2025

State of Maine

ME

Significant Deficiency Special Tests & Provisions

Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been pro...

Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: May 1, 2026, May 29, 2026, June 12, 2026, September 18, 2026, and September 21, 2026, respectively Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423

View Audit 394838

Finding 1187224 (2025-064)

Material Weakness 2025

State of Maine

ME

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

Department: Health and Human Services Title: Internal control over Medicaid utilization control needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. This finding represents a mis...

Department: Health and Human Services Title: Internal control over Medicaid utilization control needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. This finding represents a misunderstanding of the applicable federal regulations and the state entity responsible for compliance. A Utilization Control (UC) program is the responsibility of the State Medicaid Agency as a whole, not the Program Integrity Unit (PIU). Additionally, there are many more federal regulations governing UC programs than cited by the Office of State Auditor (OSA) in the finding and touch on a host of controls that were not reviewed or considered in this audit. Moreover, the OSA appears to be basing findings on interpretations that are unsupported by the regulatory text cited. Second, the OSA confuses PIU's annual review plan (a yearly plan of focused program integrity areas of focus and review) with an agency-wide UC program: these are not the same, nor are they required to be. The Department's current processes for PIU's annual review plan were implemented in response to OSA findings in 2015 relating to an OSA finding that the Department was not fully utilizing available data analytics. In the intervening years, the OSA has not found Program Integrity's annual review plan, or the process of developing the plan, to be deficient. There has been no change in the Department's process or the regulation to justify the OSA's newly found position here. The OSA's criticism of PIU's use of data analytics contradicts a prior OSA findings on data analytics use, is contrary to accepted Department adjustments made in response, and represents a significant departure from federal guidance and industry standards around best practices for leveraging data analytics to prevent and detect improper payments and/or utilization. The PIU's annual review plan supplements post-payment reviews that PIU conducts based upon complaints and referrals. Finally, this finding’s singular focus on PIU's annual review plan fails to account for a myriad of other systems and processes the Department has in place to monitor utilization, including, but not limited to: 1. A contracted vendor (HMS) performing post-payment reviews of hospitals, nursing facilities, and other long-term care facilities; 2. MaineCare's Case Mix unit - performing look back reviews of documentation and services in nursing facilities and other long-term care units; 3. A contracted vendor (Acentra) reviewing authorization requests for behavioral health services and continuing stay reviews of services at designated intervals; 4. A contracted vendor (Maximus) that performs assessments and authorizations for nursing and personal care services; 5. A contracted vendor (Optum) that performs prior authorization reviews for pharmacy services and produces a variety of reports on drug utilization; 6. Fiscal intermediaries performing oversight and administrative support for self-directed services; 7. State staff who review and approve plans of care for Home and Community Based Waiver Services and conduct quality reviews of providers; 8. State staff performing quality assurance reviews of providers of mental and behavioral health services; 9. State staff monitoring and addressing inappropriate emergency department usage by beneficiaries; and 10. State staff with oversight and performing qualitative and quantitative reviews of a variety of programs operated under delivery service reform, including: Accountable Communities, Behavioral Health Homes, Certified Community Behavioral Health Clinics, Community Care Teams, MaineMOM, Opioid Health Homes, and Primary Care Plus. 11. State and contracted vendor (Gainwell) staff reviewing medical necessity and other allowability for medical services requiring prior authorization for initial requests and renewals. 12. A CMS-compliant Electronic Visit Verification (EVV) system, in accordance with Section 12006 of the 21st Century Cures Act, that ensures payment for applicable services is tied to an EVV record demonstrating that the service occurred; data from the system also contributes to post-payment reviews for applicable services. Completion Date: N/A Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093

View Audit 394838

Finding 1187221 (2025-063)

Material Weakness 2025

State of Maine

ME

Reporting Internal Control / Segregation of Duties § 200.303 § 200.510

Department: Administrative and Financial Services Title: Internal control over Medicaid SEFA reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Service Center will update the internal SEFA procedure to include the step of removing app...

Department: Administrative and Financial Services Title: Internal control over Medicaid SEFA reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Service Center will update the internal SEFA procedure to include the step of removing appropriations 0129, 0147 and 0148 from the subrecipient queries. The DHHS Service Center will update the reviewer's checklist for the SEFA to include a check that appropriations 0129, 0147 and 0148 are being excluded from subrecipient queries. The DHHS Service Center will add a note within the "Subrecipient" tab of the internal SEFA Cubes Workbook to exclude appropriations 0129, 0147 and 0148. Completion Date: February 20, 2026 (first item), and October 31, 2026 (second and third items) Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626

View Audit 394838

Finding 1187218 (2025-062)

Material Weakness 2025

State of Maine

ME

Allowable Costs / Cost Principles Internal Control / Segregation of Duties HUD Housing Programs § 200.303

Department: Health and Human Services Title: Internal control over Medicaid drug rebates needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. Drug Rebate pre-invoicing and post-i...

Department: Health and Human Services Title: Internal control over Medicaid drug rebates needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. Drug Rebate pre-invoicing and post-invoicing is completed quarterly. As demonstrated during walkthroughs and during our meetings Maine completes specific tasks to ensure accuracy of the invoicing process. The pre-invoicing and post-invoicing procedures are documented in the Pharmacy Rebate Information Management System (PRIMS) Desk Level Procedure (DLP). The pre-invoicing work is performed by the State that compares drug utilization data to the number of dispensed units invoiced. Upon the completion of the pre-invoicing review approval is provided to the vendor allowing them to continue with the invoicing process. There is no requirement regarding how we select our sample of invoices to review. Based on OSA noting no exceptions to the drug rebate amounts, our system in place to review invoiced drug rebates is functioning as intended. Completion Date: N/A Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093

View Audit 394838

Finding 1187215 (2025-065)

Material Weakness 2025

State of Maine

ME

Procurement, Suspension & Debarment § 200.303 § 200.317

Department: Administrative and Financial Services Health and Human Services Title: Internal control over Medicaid procurement needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Department of Administrative and Financial Services (DAFS): The Department w...

Department: Administrative and Financial Services Health and Human Services Title: Internal control over Medicaid procurement needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Department of Administrative and Financial Services (DAFS): The Department will develop a specific policy document that balances agency authority/responsibility with procurement best practices regarding contract dates, clearly communicating risks and responsibilities. The Department will create a companion communication document to this policy document for distribution purposes. The Department will spotlight the policy and communication documents in the OSPS monthly electronic newsletter to all agencies. The Department will post the policy statement and communications documents on the OSPS intranet site. The Department will integrate the new content into the draft OSPS Policy Manual. The Department will release the related module in the new, updated, digital OSPS Policy Manual. Department of Health and Human Services (DHHS): The Department will collaborate with OSPS and program offices to implement procedures to ensure the timeliness of procurement documents. Completion Date: DAFS: April 30, 2026 (first item), May 15, 2026 (second item), May 31, 2026 (third and fourth items), June 30, 2026 (fifth item), and September 30, 2026 (sixth item) DHHS: May 31, 2026 Agency Contact: DAFS: David Morris, Acting Chief Procurement Officer, OSPS, 207-624-7335 DHHS: Jim Lopatosky, Director, Division of Contract Management, DHHS, 207-287-5075

View Audit 394838

Finding 1187212 (2025-061)

Material Weakness 2025

State of Maine

ME

Special Tests & Provisions Cash Management Material Weakness § 200.303

Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Director and Deputy director will meet biweekly to review the audit assignments and discuss the st...

Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Director and Deputy director will meet biweekly to review the audit assignments and discuss the status of the nursing facility audits. The Division of Audit management team will actively recruit for the ten vacant audit positions. The Deputy Director will adjust the audit procedures for the Nursing Facilities to limit the testing to just capital costs starting with the December 31, 2025, cost reports. The Department has assigned four of the seven current staff auditors to nursing facility audits. Completion Date: Ongoing (first and fourth items), June 30, 2026 (second item), and May 31, 2026 (third item) Agency Contact: Herb Downs, Director, Division of Audit, DHHS, 207-287-2403

View Audit 394838

Finding 1187209 (2025-060)

Material Weakness 2025

State of Maine

ME

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.403

Department: Health and Human Services Title: Internal control over the Adoption Assistance eligibility and benefit determination process needs improvement Questioned Costs: Known: $1,645 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Office of Child and Family Se...

Department: Health and Human Services Title: Internal control over the Adoption Assistance eligibility and benefit determination process needs improvement Questioned Costs: Known: $1,645 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Office of Child and Family Services made changes to the Katahdin System in August 2025 to stop duplicate payments. The Office of Child and Family Services will develop training information regarding children in adoption assistance agreements who are no longer receiving support from the adoptive parents. The Office of Child and Family Services will develop a training and train the appropriate staff. Completion Date: August 1, 2025, May 1, 2026, and December 31, 2026, respectively Agency Contact: Denise Merrill, Manager of Child Welfare Statewide Programs, DHHS, 207-822-2255

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Finding 1187208 (2025-058)

Material Weakness 2025

State of Maine

ME

Cash Management Internal Control / Segregation of Duties Student Financial Aid § 200.302 § 200.303

Department: Health and Human Services Administrative and Financial Services Title: Internal control over Foster Care and Adoption Assistance cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Financial Service Center will update...

Department: Health and Human Services Administrative and Financial Services Title: Internal control over Foster Care and Adoption Assistance cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Financial Service Center will update the IV-E cash on hand analysis to ensure the cash balances are tracked separately by each of the following Title IV-E programs: Foster Care, Adoption Assistance, Prevention Program and Guardianship Assistance. Completion Date: March 31, 2026 Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626

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Finding 1187206 (2025-059)

Material Weakness 2025

State of Maine

ME

Significant Deficiency Special Tests & Provisions

Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been pro...

Department: Redacted Title: Redacted Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department agrees with the finding. The Department’s corrective action plan has been excluded to protect confidential information. The complete corrective action plan has been provided to the Office of the State Auditor under separate cover. Completion Date: May 1, 2026 Agency Contact: Shirley Browne, Deputy State Controller, Office of the State Controller, 207-626-8423

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Finding 1187204 (2025-057)

Material Weakness 2025

State of Maine

ME

Procurement, Suspension & Debarment § 200.303 § 200.317

Department: Administrative and Financial Services Health and Human Services Title: Internal control over Foster Care procurement needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Department of Administrative and Financial Services (DAFS): The Departmen...

Department: Administrative and Financial Services Health and Human Services Title: Internal control over Foster Care procurement needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Department of Administrative and Financial Services (DAFS): The Department will develop a specific policy document that balances agency authority/responsibility with procurement best practices regarding contract dates, clearly communicating risks and responsibilities. The Department will create a companion communication document to this policy document for distribution purposes. The Department will spotlight the policy and communication documents in the OSPS monthly electronic newsletter to all agencies. The Department will post the policy statement and communications documents on the OSPS intranet site. The Department will integrate the new content into the draft OSPS Policy Manual. The Department will release the related module in the new, updated, digital OSPS Policy Manual. Department of Health and Human Services (DHHS): The Department will collaborate with OSPS and program offices to implement procedures to ensure the timeliness of procurement documents. Completion Date: DAFS: April 30, 2026 (first item), May 15, 2026 (second item), May 31, 2026 (third and fourth items), June 30, 2026 (fifth item), and September 30, 2026 (sixth item) DHHS: May 31, 2026 Agency Contact: DAFS: David Morris, Acting Chief Procurement Officer, OSPS, 207-624-7335 DHHS: Jim Lopatosky, Director, Division of Contract Management, DHHS, 207-287-5075

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