Corrective Action Plans

Finding 1220170 (2025-006)

Material Weakness 2025

DC

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.403

The Office of the Deputy Mayor for Planning and Economic Development (DMPED) does not concur with the auditor’s finding regarding the allowability of subtenant improvement allowance per the CPF guidance. DMPED has sought express approval from the Federal awarding agency (U.S. Department of Treasury)...

The Office of the Deputy Mayor for Planning and Economic Development (DMPED) does not concur with the auditor’s finding regarding the allowability of subtenant improvement allowance per the CPF guidance. DMPED has sought express approval from the Federal awarding agency (U.S. Department of Treasury) regarding the use of funds. DMPED has evaluated its procedures to ensure only allowable expenses are charged to the program as required under 2 CFR Section 200.403. DMPED determined in FY25 that it needed to seek approval from the awarding Federal agency on allowable costs, which it completed in 2026.

View Audit 405318

Finding 1220162 (2025-002)

Material Weakness 2025

Government of the District of Columbia

DC

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

The Office of the Chief Financial Officer/Office of Finance and Treasury (OCFO/OFT) for Department of Human Services (DHS) concurs with this finding. Quarterly UPO internal audits and Quarterly Regis audits will continue to assist in identifying areas of noncompliance and improvement. In addition, t...

The Office of the Chief Financial Officer/Office of Finance and Treasury (OCFO/OFT) for Department of Human Services (DHS) concurs with this finding. Quarterly UPO internal audits and Quarterly Regis audits will continue to assist in identifying areas of noncompliance and improvement. In addition, the EBT Manager and Supervisors will implement enhanced review and validation procedures of daily card production documentation, including targeted quality checks and supervisory oversight, to ensure alignment with established requirements. Employees will be held accountable for performing in accordance with documented procedures, and corrective actions will be applied as needed to address gaps. These efforts are intended to improve consistency, reduce risk, and ensure sustained compliance with program requirements.

View Audit 405318

Finding 1220160 (2025-001)

Material Weakness 2025

Government of the District of Columbia

DC

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.303

The Department of Human Services (DHS) and Department of Health Care Finance (DHCF) DC Access System (DCAS) team agree with the findings. For the twelve (12) findings, DHS/ESA has identified the description of the deficiencies, examined the magnitude and geographic extent of the deficiencies, identi...

The Department of Human Services (DHS) and Department of Health Care Finance (DHCF) DC Access System (DCAS) team agree with the findings. For the twelve (12) findings, DHS/ESA has identified the description of the deficiencies, examined the magnitude and geographic extent of the deficiencies, identified the actions completed to eliminate the deficiencies. The District will focus on efforts that will create the maximum impact, which includes creating new options for collaboration, streamlining current communication, and introducing cross-functional prioritization. These strategies will help the District move projects toward completion and are rooted in continuous quality improvement. To guide its strategic efforts and track its impact, DHS has outlined the following four phases of corrective action plans to be taken to ensure the deficiencies will be eliminated: • Review and Prioritization, • Design and Development, • Implementation, and • Monitor and Evaluation. Each phase has several process steps including a completion document that signals the permission to move to the next phase. The detailed process steps are documented under DHS’ Consolidated Semi-Annual SNAP Advance Warning Letter Corrective Action Plan and FFY2026 Quality Control Corrective Action Plan reports. The corrective action plan is facilitated by the Quality Improvement Program and since implementing this process in January 2021, the District has identified root causes for errors and gaps in internal auditing and evaluation processes. Therefore, the flow of the semi-annual corrective action plans reflects the District’s commitment to a collaborative corrective action plan - expanding the data analysis section to include data and analysis of internal methods, a complete summary of each phase completed, and a timeline for upcoming phase/project completion.

View Audit 405318

Finding 1220158 (2025-002)

Material Weakness 2025

United Planning Organization

DC

Questioned Costs Eligibility Significant Deficiency § 200.303 § 200.403

Finding 2025-002: Agency: U.S. Department of Health and Human Services (CSBG) Program: Community Service Block Grant (AL No. 93.569) Significant Deficiency and Noncompliance over Eligibility Condition: During our testing of participant eligibility for the CSBG program, we noted the following excepti...

Finding 2025-002: Agency: U.S. Department of Health and Human Services (CSBG) Program: Community Service Block Grant (AL No. 93.569) Significant Deficiency and Noncompliance over Eligibility Condition: During our testing of participant eligibility for the CSBG program, we noted the following exceptions out of a sample size of 40: (1) for one participant, the CSBG eligibility form was not signed by the case manager; and (2) for two participants, we were unable to obtain documentation to support proof of residence. Recommendation: We recommend that management strengthen internal controls over eligibility determination and documentation to ensure compliance with federal program requirements. Management should establish procedures to require complete and signed eligibility forms prior to approving or providing program benefits and consider implementing a standardized eligibility checklist to ensure all required supporting documentation (e.g., income verification, residency, other criteria) is obtained and retained. Auditee Response and Corrective Action Plan: UPOManagement acknowledges the audit finding and will ensure that staff follow established internal control activities to ensure compliance with CSBG participant eligibility. UPO will institute continuous training and increased monitoring of compliance by the internal Office of Performance Management regarding the review, retention, and documentation of eligibility determination evidence submitted by program participants. Anticipated Completion Date: September 30, 2026

View Audit 405313

Finding 1220137 (2025-003)

Material Weakness 2025

Dallas County

TX

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

Corrective Action Plan: Dallas County HCVP leadership addressed EIV compliance during the April 2026 and May 2026 monthly staff meetings and will continue to emphasize the requirement. Review of meetings agendas dated April 22, 2026, and May 20, 2026, confirm that EIV compliance was discussed. Addit...

Corrective Action Plan: Dallas County HCVP leadership addressed EIV compliance during the April 2026 and May 2026 monthly staff meetings and will continue to emphasize the requirement. Review of meetings agendas dated April 22, 2026, and May 20, 2026, confirm that EIV compliance was discussed. Additionally, the HCVP Housing Supervisor issued an email to all staff reiterating the requirement to retain EIV reports for all transactions, including but limited to recertifications, interims, and relocations. Implementation Date: June 11, 2026 Responsible Party: Kesete Yohannes, Assistant Director of Housing

View Audit 405307

Finding 1219681 (2025-001)

Material Weakness 2025

Broward County, Florida

FL

Eligibility Questioned Costs Procurement, Suspension & Debarment

Management concurs with this finding. The expenditure understatement in the initial Schedule of Expenditures of Federal Awards (SEFA) for ALN 97.036 (Disaster Grants – Public Assistance) was caused by an operating deficiency in year-end review procedures, rather than the design of the control itself...

Management concurs with this finding. The expenditure understatement in the initial Schedule of Expenditures of Federal Awards (SEFA) for ALN 97.036 (Disaster Grants – Public Assistance) was caused by an operating deficiency in year-end review procedures, rather than the design of the control itself. Although the discrepancy was not identified internally prior to the initial draft submission, the error was isolated to the aforementioned program and fully corrected before the final draft SEFA was issued to the Auditors. Management is committed to strengthening the controls necessary to ensure complete and accurate SEFA reporting going forward. The FASD Division, in coordination with the Emergency Management Division and the Broward Sheriff’s Office (BSO), will enhance the SEFA Preparation and Reconciliation Protocol for year-end September 30, 2026. To ensure compliance, all departments administering and reporting under ALN 97.036 will receive comprehensive training on Uniform Guidance and FEMA Public Assistance (PA) reporting requirements prior to the fiscal year-end.

View Audit 405215

Finding 1219677 (2025-001)

Material Weakness 2025

Jacksonville Housing Authority

FL

HUD Housing Programs Questioned Costs Eligibility

FINDING SUMMARY: Jacksonville Housing Authority (JHA) identified deficiencies within the Low-Income Public Housing and Housing Choice Voucher Program related to eligibility determinations, including missing documentation, incomplete reexaminations, incorrect income calculations, and insufficient qua...

FINDING SUMMARY: Jacksonville Housing Authority (JHA) identified deficiencies within the Low-Income Public Housing and Housing Choice Voucher Program related to eligibility determinations, including missing documentation, incomplete reexaminations, incorrect income calculations, and insufficient quality control processes. These deficiencies resulted in non-compliance with 24 CFR 960.257 and 24 CFR 960.259. CORRECTIVE ACTION FRAMEWORK: JHA has established a PHAS and SEMAP-aligned compliance tracking framework which includes: • Defined compliance indicators • Measurable performance thresholds • Monthly monitoring and reporting • Documented corrective actions and outcomes Each corrective action below is tied to an audit find. Corrective Action: • JHA will continue to monitor deficiencies to effectively streamline internal process controls including but not limited to the hiring of quality control analysts, data integrity analysts and monthly file auditing • JHA will create a sample file to ensure standardization. • JHA will provide training to all new employees within 60 days and refresher course training for all existing employees. • JHA performs monthly audits of 10% of files and maintains a quality control system to track error trends, identify deficiencies

View Audit 405213

Finding 1219674 (2025-004)

Material Weakness 2025

City of Long Beach

CA

HUD Housing Programs Eligibility Reporting § 200.303

Program: Section 8 Housing Choice Vouchers (HCV) Finding: 2025-004 Finding Title: Internal Controls Over Participants Reexaminations Identification as a repeat finding if applicable: 2024-007 Contact Person: Michelle Mel-Duch, Housing Administrative and Financial Services Officer, Health & Human Ser...

Program: Section 8 Housing Choice Vouchers (HCV) Finding: 2025-004 Finding Title: Internal Controls Over Participants Reexaminations Identification as a repeat finding if applicable: 2024-007 Contact Person: Michelle Mel-Duch, Housing Administrative and Financial Services Officer, Health & Human Services Department, (562) 570-5344, Michelle.Mel-Duch@longbeach.gov Planned Actions: HACLB has updated its SEMAP Quality Control sample size worksheet to ensure the minimum required sample size is calculated using the total number of assisted families, in accordance with HUD SEMAP Indicator 3 requirements. The revised worksheet will be used for future quality control reviews to ensure compliance with federal requirements. In addition, HACLB has transitioned to the MRI housing management software platform, which provides enhanced reporting capabilities to generate accurate listings of assisted families, support the selection and tracking of quality control samples. To strengthen internal controls, HACLB will implement and document completion of reviews of reexamination files selected for SEMAP quality control. Expected Completion Date: December 31, 2026

View Audit 405210

Finding 1219670 (2025-002)

Material Weakness 2025

City of Long Beach

CA

HUD Housing Programs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303

Program: Section 8 Housing Choice Vouchers (HCV) Finding: 2025-002 Finding Title: Internal Controls and Compliance over the Timeliness of Housing Choice Voucher Participant Re-examination and Recertification Identification as a repeat finding if applicable: 2024-003 Contact Person: Michelle Mel-Duch...

Program: Section 8 Housing Choice Vouchers (HCV) Finding: 2025-002 Finding Title: Internal Controls and Compliance over the Timeliness of Housing Choice Voucher Participant Re-examination and Recertification Identification as a repeat finding if applicable: 2024-003 Contact Person: Michelle Mel-Duch, Housing Administrative and Financial Services Officer, Health & Human Services Department, (562) 570-5344, Michelle.Mel-Duch@longbeach.gov Planned Actions: Staffing Augmentation and Organizational Support HACLB has recruited additional Housing Specialists to support management of the high-volume Housing Choice Voucher (HCV) Program, improve processing efficiency, and ensure compliance with HUD requirements and program deadlines. HACLB has hired a Housing Administrative and Financial Services Officer and a Housing Operations Program Officer. These positions provide strategic oversight of program operations, staff productivity, workload management, resource allocation, and performance monitoring. As of June 23, 2026, eight Housing Specialists have been hired and have undergone training. HACLB has requested renewal of the supervisory eligibility list to fill several vacant supervisory positions critical to operational oversight and staff development. To further reduce the backlog, HACLB has reassigned duties and created a dedicated team responsible for tracking overdue recertifications, monitoring progress, and implementing measures to ensure ongoing compliance. Contracted Support Services To accelerate backlog reduction efforts, HACLB renewed its contract with an external agency to provide dedicated assistance with processing overdue reexaminations. Additionally, HACLB has initiated a competitive procurement process to secure supplemental third-party support services to assist with backlog clearance and provide additional operational capacity while newly hired staff complete training and onboarding. Technology Improvements HACLB has transitioned to a new housing management software platform (MRI PHA Pro) designed to improve annual recertification tracking, workflow management, reporting capabilities, and productivity monitoring. The software system provides: • Enhanced monitoring of annual recertification deadlines. • Improved workflow tracking and assignment management. • Dashboard reporting and exception monitoring. • Increased visibility into staff productivity and workload distribution. • Improved compliance monitoring Additional Actions Taken to Date HACLB has implemented several operational improvements to strengthen internal controls and maintain compliance: Process Improvements • Revised recertification workflows and assignment procedures. • Established productivity targets and performance expectations for Housing Specialists. • Utilized MRI dashboards and exception reports to identify overdue cases and trigger management escalation procedures. • Increased supervisory oversight of workload distribution and case processing. Data Monitoring and Oversight Program management and data analytics staff actively monitor program performance and backlog reduction efforts through: • Regular forecasting and workload analysis. • Prioritization of high-risk and overdue cases. • Exception reporting and trend monitoring. • Ongoing evaluation of staffing needs and productivity levels. Staff Training HACLB continues to provide training for both new and existing staff on: • HUD recertification requirements. • Timeliness standards. • Case processing procedures. • Workflow management and quality assurance practices. Expected Completion Date: December 31, 2026

View Audit 405210

Finding 1219129 (2025-002)

Material Weakness 2025

Kearsarge Elderly Housing, Inc.

NH

Internal Control / Segregation of Duties Eligibility Material Weakness

Finding 2025-002 Plan: The Human Resource Director will work with Paylocity to find out why the mapping on the file they provide was incorrect. The Human Resource Director will have Paylocity (our third party payroll provider) make the necessary corrections on their end, so this will not happen agai...

Finding 2025-002 Plan: The Human Resource Director will work with Paylocity to find out why the mapping on the file they provide was incorrect. The Human Resource Director will have Paylocity (our third party payroll provider) make the necessary corrections on their end, so this will not happen again. Anticipated Completion Date: 12/31/2025 Contact: Jill Lesmerises, CFO

View Audit 405074

Finding 1219062 (2025-001)

Material Weakness 2025

The Salvation Army Northwest Division

WA

Subrecipient Monitoring Questioned Costs Eligibility

PLANNED CORRECTIVE ACTION The Division will contact each unit distributing TEFAP assistance to reinforce the requirement to retain documentation regarding the determination of client eligibility and will review and strengthen existing policies and procedures related to form completion and retention....

PLANNED CORRECTIVE ACTION The Division will contact each unit distributing TEFAP assistance to reinforce the requirement to retain documentation regarding the determination of client eligibility and will review and strengthen existing policies and procedures related to form completion and retention. The Division's Social Services department will implement a quarterly internal review process to provide increased oversight and monitoring across all distributing units. ANTICIPATED COMPLETION DATE 10/1/26 RESPONSIBLE CONTACT PERSON Julie Luft, NW Social Services Director

View Audit 405060

Finding 1219039 (2025-002)

Material Weakness 2025

Almost Home, Inc.

CO

Subrecipient Monitoring Eligibility Material Weakness § 200.303

Almost Home, Inc. has formalized this through our required client file checklist and related policy. The policy was in place and was applied improperly. Staff members who failed to apply the policy were given corrective action at the time. Our quality/compliance control processes did not catch this ...

Almost Home, Inc. has formalized this through our required client file checklist and related policy. The policy was in place and was applied improperly. Staff members who failed to apply the policy were given corrective action at the time. Our quality/compliance control processes did not catch this mistake in time, and our management corrective action plan will include improvements on the quality/compliance control to ensure that all necessary documentation is maintained. Also necessary to note is the fact that Almost Home, Inc. will no longer receive TANF funding as of December 31, 2025.

View Audit 405057

Finding 1219026 (2025-001)

Material Weakness 2025

Disability Rights Mississippi

MS

Eligibility

Name of Responsible Official: Polly Tribble, Executive Director Anticipated Completion Date: September 30, 2026 Disability Rights Mississippi Response Disability Rights Mississippi (DRMS) acknowledges the audit finding and has reviewed the circumstances that resulted in the identified deficiency. Th...

Name of Responsible Official: Polly Tribble, Executive Director Anticipated Completion Date: September 30, 2026 Disability Rights Mississippi Response Disability Rights Mississippi (DRMS) acknowledges the audit finding and has reviewed the circumstances that resulted in the identified deficiency. The finding was attributable to a case being incorrectly assigned to a grant and the absence of required eligibility documentation in the DAD case management system. Although policies and procedures were in place to ensure proper eligibility documentation and grant coding, those procedures were not followed in this instance. Management believes this finding was isolated in nature; however, the corrective actions outlined below are intended to further strengthen controls and prevent similar occurrences in the future. To address this finding, DRMS will implement the following corrective actions: 1. Review and Update Procedures • Existing eligibility verification and grant coding procedures will be reviewed and revised as necessary to clarify documentation requirements and grant assignment responsibilities. • Written guidance will be provided to staff outlining required eligibility documentation for each program and funding source. 2. Staff Training • All legal advocacy, monitoring, and investigations staff will receive refresher training on eligibility determination requirements, documentation standards, and proper grant coding procedures. • Supervisors will reinforce expectations regarding complete and accurate case documentation. 27 ~i■ DISABILITY ~~l~I IRIIGIHITS I MISSISSIPPI 3. Enhanced Supervisory Review • Supervisors will review newly opened cases to verify that required eligibility documentation has been obtained and uploaded into the DAD system prior to final case approval. • Designated funding sources in DAD will be reviewed to ensure cases are charged to the appropriate grant. 4. Quarterly Quality Assurance Reviews • Beginning in FY 2026, management will conduct quarterly reviews of a sample of case files from each program. • Reviews will assess the presence of required eligibility documentation, accuracy of funding source coding in DAD, and compliance with applicable program requirements. • Any deficiencies identified will be corrected promptly, and recurring issues will be addressed through additional training and process improvements. 5. Monitoring and Documentation • Results of quarterly reviews will be documented and maintained for management oversight. • Corrective actions resulting from identified deficiencies will be tracked to ensure timely resolution and ongoing compliance. DRMS is committed to maintaining compliance with applicable grant requirements and to ensuring that case documentation, eligibility determinations, and grant assignments are completed accurately and consistently. The corrective actions described above are designed to enhance monitoring and oversight, reinforce staff accountability, and reduce the likelihood of future documentation or coding deficiencies.

View Audit 405050

Finding 1219010 (2025-005)

Material Weakness 2025

State of Alabama

AL

Eligibility

DHR’s Children and Family Services division is working with FACTS to implement a system enhancement for adoption subsidy extensions. However, until that enhancement is in place, the following process has been implemented: 1. A query will be run quarterly producing a report listing any children who a...

DHR’s Children and Family Services division is working with FACTS to implement a system enhancement for adoption subsidy extensions. However, until that enhancement is in place, the following process has been implemented: 1. A query will be run quarterly producing a report listing any children who are turning 18 with a federal subsidy or 19 with a state subsidy within the next 90 days and sent to the adoption unit program manager. Adoptive parents will be sent a letter explaining the extension process and detailing the information required to request a subsidy extension. a. If a request is received and the youth is eligible, an extension will be granted. b. If a request is not received, the subsidy will be end dated on the 18th or 19th birthday, depending on the type of subsidy. 2. Effective June 1, 2026, an actual end date will be entered in FACTS during approval of the subsidy.

View Audit 405017

Finding 1218926 (2025-002)

Material Weakness 2025

Park City Communities, INC

CT

HUD Housing Programs Questioned Costs Eligibility

2025-002 - Eligibility: Public Housing Operating Fund (FALN #14.850) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the ...

2025-002 - Eligibility: Public Housing Operating Fund (FALN #14.850) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the collection and retention of certain tenant information to document the eligibility determination for each recipient. Condition The results of our testing indicated that certain items were not completed in a timely matter as follows: • In fifteen instances, the income verification form was not found in the file or not performed timely. Questioned Costs Not determinable. Context We selected a sample of 60 files for review. Our sample was a statistically valid sample. Effect or Possible Effect The tenant income verification form was not performed timely. Cause The cause is unknown. Identification as a Repeat Finding This finding is a repeat finding (see prior year finding number: 2024-002). Recommendation We recommend that Park City continue to improve its internal processes to ensure tenant income verification is performed timely. Park City's Response A Compliance Manager has been hired to randomly review resident files to make sure all documentation is maintained. An email reminder is sent monthly to managers to insure that EIV for move-ins is done on a timely basis. Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900

View Audit 404966

Finding 1218925 (2025-001)

Material Weakness 2025

Park City Communities, INC

CT

HUD Housing Programs Questioned Costs Special Tests & Provisions

2025-001 – Eligibility and Special Tests and Provisions: Housing Voucher Cluster (FALN #14.871) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (2...

2025-001 – Eligibility and Special Tests and Provisions: Housing Voucher Cluster (FALN #14.871) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the collection and retention of certain tenant information to document the eligibility determination for each recipient. Condition The results of our testing indicated that certain items were unable to be located in the file, as follows: • In five instances, supporting documentation (Form HUD-52580) was not available to verify that HQS inspections were completed and passed • In five instances, social security verification was missing from the tenant file. • In six instances, income verification form was missing from the tenant file or performed timely. • In fourteen instances, signed HAP contracts were not maintained in the tenant file for review. • In one instance, income was incorrectly calculated on Form HUD-50058. Questioned Costs Not determinable. Context We selected a sample of 60 files for review. Our sample was a statistically valid sample. Effect or Possible Effect The tenant file documentation was incomplete and tenant income verification was not performed timely. Cause The cause is unknown. Identification as a Repeat Finding This finding is a repeat finding (see prior year finding number: 2024-001). Recommendation We recommend that Park City continue to improve its internal processes to ensure tenant files contain the required documentation and tenant income verification is performed timely. Park City's Response Income verification: PCC has implemented software tracking of income verification attempts. Inspections: An SOP was issued to staff to review/compare lines 5I and 5H on the 50058 to inspection result history, to confirm dates populating are accurate. HAP Contracts and Social Security Card Documentation: Implemented internal tracking review of ongoing executions are in place and monitored. HAP payments are not released until HAP contract is executed by both parties. Automated process to perform a review of electronically indexed files will be put into place to identify active units that may not display an indexed document relevant to HAP contract. A request for submission of the documents will be made. Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900

View Audit 404966

Finding 1218896 (2025-002)

Material Weakness 2025

The Salvation Army Golden State Division

CA

Eligibility Questioned Costs Subrecipient Monitoring

The Division is in the process of designing and implementing a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and that such evidence is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major,...

The Division is in the process of designing and implementing a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and that such evidence is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.

View Audit 404948

Finding 1218820 (2025-002)

Material Weakness 2025

Corpus Christi Housing Authority

TX

Questioned Costs Eligibility HUD Housing Programs

Authority's Response and Planned Corrective Plan: The Authority accepts the auditor’s recommendation. Management acknowledges the importance of maintaining complete and readily available tenant file documentation to support eligibility determinations and ongoing program compliance for the Housing Vo...

Authority's Response and Planned Corrective Plan: The Authority accepts the auditor’s recommendation. Management acknowledges the importance of maintaining complete and readily available tenant file documentation to support eligibility determinations and ongoing program compliance for the Housing Voucher Cluster. The documents noted as unavailable during the audit relate to file maintenance and documentation retention. Management does not believe the exceptions indicate that the sampled households were ineligible for assistance; however, the Authority recognizes that required documentation must be consistently maintained and available for audit review. In response, the Authority will implement a corrective action plan that includes increased supervisory review of tenant files, enhanced file completion checklists, periodic internal quality control reviews, and additional staff training on required eligibility documentation, including consent forms, lead-based paint documentation, HAP contracts, and tenancy addenda. The Authority will also strengthen monitoring procedures to ensure missing or incomplete documents are identified and corrected timely. Management will assign responsibility for periodic file review to Housing Choice Voucher leadership and will document follow-up actions taken. These procedures are intended to improve internal controls over tenant file maintenance and ensure continued compliance with HUD requirements, Uniform Guidance, and the applicable compliance supplement. Isaiah Norris, Vice President of the Housing Choice Vouchers Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2026.

View Audit 404911

Finding 1218801 (2025-002)

Material Weakness 2025

Ponca Tribe of Nebraska

NE

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

Persons responsible for corrective action: Keith Morrow, Health Services Chief Executive Officer Corrective action planned: Developed and implemented process by which Business Services staff in Health Services review documents provided by non-Ponca Native Americans upon initial request for services ...

Persons responsible for corrective action: Keith Morrow, Health Services Chief Executive Officer Corrective action planned: Developed and implemented process by which Business Services staff in Health Services review documents provided by non-Ponca Native Americans upon initial request for services and on an annual basis to follow to confirm and verify their capacity to receive health services from the Ponca Tribe. Steps have been taken to see the staff verifying are independent from those who initially collect such documents. Additionally, confirmed such process is consistent with existing verification review of Ponca members requesting services. Implementation date: December 1, 2025.

View Audit 404885

Finding 1218708 (2025-017)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding 2025-017 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Screening Management Views MDHHS agrees with the finding. Planned Corrective Action During April 2026, MDHHS notified all relevant program areas of the CHAMPS screening re...

Finding 2025-017 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Screening Management Views MDHHS agrees with the finding. Planned Corrective Action During April 2026, MDHHS notified all relevant program areas of the CHAMPS screening requirement and will provide recurring reminders and updates during monthly program operations meetings. MDHHS is also working across its internal program teams to ensure that plans and providers are aware of this requirement and are completing the required registration. In addition, to strengthen screening of out-of-state Managed Care Organization rendering providers, MDHHS will implement a system enhancement that will enforce CHAMPS registration for out-of-state providers by rejecting encounter claims for providers that are not properly registered. MDHHS anticipates full implementation of this system enhancement by December 31, 2027. Anticipated Completion Date December 31, 2027 Responsible Individual(s) Keith White, MDHHS Chris Parker, MDHHS

View Audit 404775

Finding 1218706 (2025-015)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Subrecipient Monitoring

Finding 2025-015 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS amended the Pharmacy Benefits Manager, Prepaid Inpatient Health Plan (PIHP), MI...

Finding 2025-015 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS amended the Pharmacy Benefits Manager, Prepaid Inpatient Health Plan (PIHP), MI Choice Waiver Program (MI Choice), Integrated Care Organization, Medicaid Health Plan (MHP), and Dental Health Plan contracts to require that signatures are obtained on the Provider Screening Information Collection Tool (PSICT) forms and returned timely when contracts and waivers are renewed and extended. MDHHS obtained all signatures on the PSICT forms effective February 19, 2026, for the fiscal year 2026 contract cycle and will continue to send an annual reminder to the managed care entities to report any change in ownership to MDHHS within 35 days. In addition, MDHHS continues to review provider agreements as part of its monitoring process conducted for all MI Choice entities. MDHHS’s fiscal year 2025 review of fiscal year 2024 provider agreements for MI Choice entities was completed by March 31, 2026, and will be ongoing during the Administrative Quality Assurance Review process as outlined in the waiver application that was approved by CMS. Currently the fiscal year 2026 MI Choice contracts state PSICTs must be submitted by September 1 ahead of the new contract renewal, but this will be amended for fiscal year 2026 and subsequent contracts to indicate the PSICT must be submitted to MDHHS upon contract renewal. MDHHS will continue to remind MI Choice entities to submit the PSICT timely and according to contract requirements. Anticipated Completion Date July 31, 2026 Responsible Individual(s) Heather Hill, MDHHS Kim Heinicke, MDHHS

View Audit 404775

Finding 1218705 (2025-014)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Cash Management § 200.516

Finding 2025-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system update in Bridges to ensure new cas...

Finding 2025-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system update in Bridges to ensure new cases are correctly assigned to either CHIP or Medicaid, and all remaining existing cases were updated during fiscal year 2025, eliminating the need for the quarterly manual reclassification. MDHHS discontinued the manual reclassification process during fiscal year 2026 and transferred the expenditures back to Medicaid for the individuals identified in the finding. Anticipated Completion Date Completed Responsible Individual(s) Brant Cole, MDHHS Crystal Kline, MDHHS

View Audit 404775

Finding 1218704 (2025-013)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Subrecipient Monitoring § 200.516

Finding 2025-013 Medicaid Cluster, ALN 93.775, 93.777 and 93.778 and Children’s Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the identified exceptions for parts a. and c. However, MDHHS disagrees that 2 Medicaid cases and 11 CHIP cases with MAGI d...

Finding 2025-013 Medicaid Cluster, ALN 93.775, 93.777 and 93.778 and Children’s Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the identified exceptions for parts a. and c. However, MDHHS disagrees that 2 Medicaid cases and 11 CHIP cases with MAGI determinations cited in part b. lacked documentation supporting the eligibility determination. CMS has determined that a reasonable compatibility indicator can be used for CMS audit purposes to determine if the attested income information was electronically verified for MAGI cases. For this reason, MDHHS disagrees that documentation was not maintained. The State of Michigan (SOM) MiIntegrate system communicates with various electronic State and federal trusted data sources and sends information from these sources, along with the beneficiaries’ attested income, to the SOM MAGI Rules Engine where the MAGI eligibility determination is made. As part of the MAGI eligibility determination, a reasonable compatibility test is completed to determine if beneficiary/applicant attested income is within a specified percentage of the trusted data sources or if the attested and verified income are below the threshold for the applicable program. The results of the MAGI eligibility determination are sent back to MiIntegrate using an Account Transfer (AT) packet that contains the results. MiIntegrate then communicates the results to the SOM MAGI Viewer and Bridges using an AT packet and Bridges stores the AT packet number only that can be used to view the details of the AT packet within the SOM MAGI Viewer. The version of the AT packet within the MAGI Viewer also contains a reasonable compatibility indicator that documents the outcome of the reasonable compatibility test and supports the SOM MAGI Rules Engine eligibility decision. MDHHS stores the AT packet information, including facts essential to the eligibility determination, within MiIntegrate and the MAGI viewer instead of Bridges to help protect and secure the federal income tax data and unemployment data used for the determination. The AT packet for each individual determination can be retrieved from the MAGI Viewer using the AT packet number stored in each beneficiary’s case file within Bridges. MDHHS is not aware of any federal regulations that preclude MDHHS from storing this information in a separate, secure system to ensure appropriate data protection and access controls required by federal and State laws. Planned Corrective Action To address the exceptions identified that are not related to MAGI-based income verification results, MDHHS developed mandatory training protocols for eligibility specialists, and the first Medicaid audit-focused mandatory training was implemented in June 2025. MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained within the electronic case file. For the exception that did not contain the appropriate coverage termination date, MDHHS reviewed the case and determined that the beneficiary remained eligible to transition to another aid category, and therefore no improper payments occurred. MDHHS will identify the system issue that produced the incorrect termination date and will implement a system fix if necessary. Should such an improvement be identified, it will be submitted through the Departmental Work Intake Process for prioritization and implementation by the Bridges technical team. MDHHS maintains that documentation supporting MAGI eligibility determinations is retained within MiIntegrate and the MAGI Viewer and therefore disagrees that case file documentation was not maintained. As such, no further corrective action is planned. Anticipated Completion Date June 30, 2027 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

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Finding 1218702 (2025-008)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding 2025-008 CHAMPS Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has strengthened its processes to ensure that documentation is maintained for all eligibility records identified with errors and excluded from the Community Health Aut...

Finding 2025-008 CHAMPS Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has strengthened its processes to ensure that documentation is maintained for all eligibility records identified with errors and excluded from the Community Health Automated Medicaid Processing System (CHAMPS) interface processing. Bridges, as the system of record for eligibility, continues to generate reports identifying potential duplicate identification numbers (ID) for local office staff to review and merge the records when they determine the IDs represent the same individual. Until this review and merging process is completed, CHAMPS rejects these potential duplicate records to prevent duplicate beneficiary payments under different CHAMPS Medicaid IDs. In April 2026, MDHHS implemented a weekly query to identify potential duplicate IDs rejected by CHAMPS that were not captured on the standard Bridges reports and therefore require additional review. These records are forwarded to the MDHHS Enrollment Services Section for manual assessment to determine whether they represent new beneficiaries or existing beneficiaries associated with a different CHAMPS Medicaid ID. The Enrollment Services Section then completes the appropriate resolution and ensures the required documentation is maintained. Anticipated Completion Date Completed Responsible Individual(s) Jonathan Bair, MDHHS

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Finding 1218701 (2025-005)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Subrecipient Monitoring

Finding 2025-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., and d. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees with the conclusion that a process is not fully established to monitor the electronic ...

Finding 2025-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., and d. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees with the conclusion that a process is not fully established to monitor the electronic notifications provided to county/district office caseworkers to ensure they utilized the Income Eligibility and Verification System (IEVS) information to determine the recipients’ eligibility. MDHHS had policies and procedures in place during fiscal year 2025 to help ensure monitoring of electronic notifications occurred. Review of IEVS information is fully incorporated into the case read procedure governed by Bridges Administrative Manual 301 and further detailed in accompanying desk aids and reading guides. The MDHHS Economic Stability Administration (ESA) also provides regular direction and reminders regarding case read requirements through ESA memos. For part e., MDHHS disagrees that IEVS information is required to be requested and obtained for Medicaid Cluster Healthy Kids, Healthy Michigan Plan, Children’s Health Insurance Program (CHIP) Healthy Kids, and MiChild modified adjusted gross income (MAGI) based recipients since eligibility is verified upon determination through the MAGI eligibility determination process. MAGI verification rules are contained within federal regulation 42 CFR 435.603, which describes electronic verification through the Federal Data Services Hub, reasonable compatibility standards, and verification at application and renewal. The Centers for Medicare and Medicaid Services (CMS) MAGI Application and Eligibility Process Implementation Guides describe MAGI verification as a streamlined, electronic process using the federal hub and state data sources with no reference to IEVS. The IEVS rules are contained within federal regulations 42 CFR 435.940 through 42 CFR 435.965 and are part of the non-MAGI verification framework. Planned Corrective Action For parts a. and b., MDHHS ESA will continue to provide guidance and training to local office specialists on timely and appropriate use of IEVS when the information is critical to current eligibility determinations. MDHHS ESA will also continue to evaluate potential technical and automated solutions related to IEVS data to help ensure its proper utilization and timeliness. For parts c. and e., MDHHS disagrees with the finding and does not intend to take further action. For part d., MDHHS is collaborating with other work areas to identify potential solutions to establish and implement IEVS interfaces for adoption subsidy recipients funded by the Temporary Assistance for Needy Families (TANF) program. Anticipated Completion Date a. and b. Ongoing c. Not applicable d. MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solutions identified. e. Not applicable Responsible Individual(s) a., b., and c. Veronica Maxson and Mariah Schaefer, MDHHS d. Kathonya Triplett, MDHHS e. Logan Dreasky, MDHHS

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