Corrective Action Plans

Finding 1186915 (2025-005)

Material Weakness 2025

NH

Questioned Costs Eligibility Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, 84.268 Recommendation: We recommend the University review its SAP policies to ensure they met the minimum requirements and that they are fully implemented. Explanation of disagreement with audit finding...

Student Financial Assistance Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, 84.268 Recommendation: We recommend the University review its SAP policies to ensure they met the minimum requirements and that they are fully implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Historically the Graduate School was responsible for reviewing SAP and notifying Student Financial Services (SFS) if students needed to be warned or suspended. Going forward, SFS will begin reviewing graduate students for SAP to ensure accurate and timely notifications are in place. Additionally, SFS is reviewing the current logic to ensure GPA is accurately reviewed in the baseline SAP process. Student Financial Services 11 Garrison Avenue - Stoke Hall Durham, NH 03824 Name(s) of the contact person(s) responsible for corrective action: Elizabeth Stevens, Director, Student Financial Services, University of New Hampshire Planned completion date for corrective action plan: July 1, 2026

View Audit 394674

Finding 1186892 (2025-001)

Material Weakness 2025

Rockport Housing Authority

MA

HUD Housing Programs Questioned Costs Eligibility

2025-001 - ELIGIBILITY Auditee’s Response and Planned Corrective Action Rockport Housing Authority (RHA) contracted with Newburyport Housing Authority (NHA) to manage the Section 8 program. They will be calculating income, assets and/or medical expenses based on HUD regulation. NHA is staffed with a...

2025-001 - ELIGIBILITY Auditee’s Response and Planned Corrective Action Rockport Housing Authority (RHA) contracted with Newburyport Housing Authority (NHA) to manage the Section 8 program. They will be calculating income, assets and/or medical expenses based on HUD regulation. NHA is staffed with an experienced Section 8 Coordinator. In addition, NHA uses Rent O Meter to provide Rent Reasonableness Reporting that will be entered into PHA Web as a method of recording. Planned Implementation Date of Corrective Action: June 30, 2026 Person Responsible for Corrective Action: Marie Mathas, Executive Director

View Audit 394668

Finding 1186855 (2025-001)

Material Weakness 2025

Argus Manor Association

WA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT S3800-010: Finding Reference Number 2025-001 S3800-030: Statement of Condition: Management designed Control Activities to ensure compliance with the Eligibility requirement with respect to tenant eligibility. Those Control Activities include verification...

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT S3800-010: Finding Reference Number 2025-001 S3800-030: Statement of Condition: Management designed Control Activities to ensure compliance with the Eligibility requirement with respect to tenant eligibility. Those Control Activities include verification and review of tenant files by an independent contractor prior to finalization of tenant income certifications and new tenant move-in files. However, during our testing, we noted four (4) move-in files out of four (4) move-in files tested where tenants were approved for move-in prior to review and approval by the independent contractor, circumventing the control. In addition, there was no evidence of approvals of tenant income certifications in the tenant files prior to billing of rental assistance for eleven (11) out of twelve (12) tenant files tested. S3800-080: Auditor Recommendation: We recommend that the client immediately implement corrective actions to ensure compliance with internal control procedures. Specifically: 1. The compliance specialist should be required to wait for proper approval of tenant eligibility files before processing them. 2. Review and reinforce the approval process through additional training for staff to ensure they understand the critical importance of obtaining necessary approvals before proceeding. 3. Implement stronger oversight and monitoring mechanisms to ensure that files are not processed before approval. S3800-045: Actions Taken or to be Taken: Management has reviewed the policies and procedures with the property manager, who also serves as the compliance specialist. The property manager was instructed that no tenants are to be granted occupancy and no billing of rental assistance based on certifications should be billed until the file has been approved by the independent contractor conducting the compliance review.

View Audit 394602

Finding 1186836 (2025-003)

Material Weakness 2025

Independent School District No.15

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Questioned Costs § 200.318

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER (ALN 10.553, 10.555, AND 10.556) 2025-003 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER (ALN 10.553, 10.555, AND 10.556) 2025-003 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires 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, including maintaining appropriate documentation. Official Responsible – Dawn Duevel, Business Services Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – Dawn Duevel, Business Services Director, will assure appropriate internal controls and procedures are in place to ensure compliance with suspension and debarment requirements.

View Audit 394580

Finding 1186808 (2025-001)

Material Weakness 2025

Hertford Housing Authority

NC

HUD Housing Programs Eligibility Reporting

104 White St Hertford, North Carolina 27944 Corrective Action Plan For the year ended June 30, 2025 Section II – Financial Statement Findings none reported Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Arnesa Holley, Executive Director Corrective ...

104 White St Hertford, North Carolina 27944 Corrective Action Plan For the year ended June 30, 2025 Section II – Financial Statement Findings none reported Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Arnesa Holley, Executive Director Corrective Action: We will implement proper internal control procedures for the Section 8 Project Based Cluster eligibility requirements. Management has established a checklist for applications and will establish checklists for move-ins and move-outs. Proposed Completion Date: Imediately

View Audit 394571

Finding 1186794 (2025-002)

Material Weakness 2025

Charleston County Housing and Redevelopment Authority

SC

HUD Housing Programs Subrecipient Monitoring Eligibility

2025-002 ALN: 14.850 – Public Housing Operating Fund – Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Angela Childers, Chief Executive Officer ...

2025-002 ALN: 14.850 – Public Housing Operating Fund – Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Angela Childers, Chief Executive Officer Projected Completion Date: March 31, 2027

View Audit 394546

Finding 1186782 (2025-002)

Material Weakness 2025

Metropolitan School District of Wabash County

IN

School Nutrition Programs Eligibility Matching / Level of Effort / Earmarking

Management agrees with the finding. MSDWC will continue to review and verify that applications and direct certifications are accurate and are coded correctly in the Skyward SIS/FS system. Corrective action plan has been implemented as this finding impacted fiscal year 2024 but did not recur in fisca...

Management agrees with the finding. MSDWC will continue to review and verify that applications and direct certifications are accurate and are coded correctly in the Skyward SIS/FS system. Corrective action plan has been implemented as this finding impacted fiscal year 2024 but did not recur in fiscal year 2025. The district’s CFO will oversee the corrective action plan, in coordination with the Food Service Director, to monitor the eligibility requirements on an ongoing basis.

View Audit 394538

Finding 1186772 (2025-003)

Material Weakness 2025

Person County

NC

Eligibility Internal Control / Segregation of Duties Questioned Costs

Finding: 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2025-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2025-003 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Finding 2025-003...

Finding: 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2025-002 Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2025-003 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Finding 2025-003 also apply to the State findings. Section III. Federal Award Findings and Questioned Costs Diane Oakley and Jasmine Cash, Medicaid Supervisors We will provide refresher trainings related to online verification sources, income verifications, living arrangement verification, life insurance verifications and applying burial exclusions. Additionally, we made some changes to our documentation procedures. Refresher training and procedure updates were completed by November 13, 2025. Section IV - State Award Findings and Question Costs Corrective Action Plan For the Year Ended June 30, 2025 Section II - Financial Statement Findings Tracy Clayton, Interim Chief Financial Officer To address the FY25 audit finding related to the misclassification of school construction assets financed through County borrowing, the County recorded a prior-period restatement to remove $5,006,090 of Construction in Process from governmental activities for assets properly reported on the School Board’s capital asset schedules, separate from the $607,354 change in accounting principle related to GASB Statement No. 101. To prevent recurrence, the Finance Department will implement procedures requiring documented determination of asset ownership and financial reporting responsibility prior to recording inter-entity capital projects, including confirmation of asset title for school-related projects involving County debt and an annual review of Construction in Process and capital asset balances for proper classification. June 30,2026 Tracy Clayton, Interim Chief Financial Officer The budget overexpenditure in the Insurance Fund resulted from a higher-than-anticipated volume and severity of insurance claims incurred during the fiscal year but reported and processed after year-end and required to be accrued as payables. To prevent recurrence, the Finance Department will enhance year-end claims estimation procedures, including coordination with the County’s insurance administrator to identify incurred-but-not-reported claims, and will monitor Insurance Fund activity throughout the year to assess the need for interim budget amendments. June 30,2026 156

View Audit 394528

Finding 1186746 (2025-001)

Material Weakness 2025

The New Randleman Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Name of Contact Person: Angela Glass, Executive Director. Corrective Action: Management will review the recertification process and plan to monitor recertifications. Proposed Completion Date: Immediately.

View Audit 394489

Finding 1186732 (2025-001)

Material Weakness 2025

Hewlett-Woodmere Union Free School District

NY

Questioned Costs Eligibility Significant Deficiency

Current Year Observations and Recommendations Observation: While the District did ultimately meet the necessary requirements for the eligibility standards using budgeted amounts, the District’s maintenance of effort calculator for eligibility was submitted to NYS Education Department (NYSED) with ce...

Current Year Observations and Recommendations Observation: While the District did ultimately meet the necessary requirements for the eligibility standards using budgeted amounts, the District’s maintenance of effort calculator for eligibility was submitted to NYS Education Department (NYSED) with certain inaccurate information. Recommendation: We recommend the District develop a system to review the maintenance of effort calculator with all supporting documentation before submitting it to NYSED in order to ensure that the information submitted is complete and accurate. District Response: The District will have the MOE reviewed and approved by the Business Administrator and Assistant Superintendent for Business and Operations prior to submission to NYSED to ensure the completeness and accuracy of the information reported. Anticipated Completion Date: June 2027 Persons Responsible for Implementation: Sal Perrotta, Assistant Business Manager, Joseph DiBartolo, Business Administrator, and Richard Snyder, Assistant Superintendent for Business and Operations. Prior Year Observations and Recommendations There were no prior year observations.

View Audit 394455

Finding 1186724 (2025-003)

Material Weakness 2025

Delaware State University

DE

Questioned Costs Eligibility Significant Deficiency

2025-003 Student Financial Assistance Cluster – Federal Assistance Listing No. 84.268 – Eligibility Recommendation: We recommend the University review its policies and procedures related to packaging student aid & ensuring any over awards are monitored timely. Explanation of disagreement with audit ...

2025-003 Student Financial Assistance Cluster – Federal Assistance Listing No. 84.268 – Eligibility Recommendation: We recommend the University review its policies and procedures related to packaging student aid & ensuring any over awards are monitored timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent re-occurrence, the Office of Financial Aid has strengthened their internal controls as follows: A system generated over award monitoring report is not reviewed twice weekly, multiple staff members have been trained on the review and reconciliation process to ensure continuity and oversight, and over award monitoring responsibilities are no longer dependent on a single individual. Upon identification of the issue, corrective action was taken immediately to return the excess funds and ensure the student’s aid package was brought into compliance with federal regulations. Name(s) of the contact person(s) responsible for corrective action: Dorothy Fultz, Associate Director of Federal Programs & Quality Control Planned completion date for corrective action plan: March 2026

View Audit 394441

Finding 1186721 (2025-001)

Material Weakness 2025

Roanoke Rapids Housing Authority

NC

HUD Housing Programs Eligibility Reporting

Section III – Federal Award Findings and Questioned Costs 2025-001 Name of Contact Person: William Bobbitt, Executive Director Corrective Action: We will implement proper internal control procedures for the N/C S/R Section 8 program eligibility requirements. Management has established a checklist fo...

Section III – Federal Award Findings and Questioned Costs 2025-001 Name of Contact Person: William Bobbitt, Executive Director Corrective Action: We will implement proper internal control procedures for the N/C S/R Section 8 program eligibility requirements. Management has established a checklist for applications and will establish checklists for move-ins and move-outs. Proposed Completion Date: Immediately

View Audit 394437

Finding 1186710 (2025-002)

Material Weakness 2025

College Unbound

RI

Student Financial Aid Questioned Costs Eligibility

Finding number: 2025-002 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2025 Corrective Action Plan: College Unbound is expanding capacity, hiring in both the Financial Aid and Accounting departments. We are also hiring a ...

Finding number: 2025-002 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans Assistance listing #: 84.268 Award year: 2025 Corrective Action Plan: College Unbound is expanding capacity, hiring in both the Financial Aid and Accounting departments. We are also hiring a new CFO in the Summer of 2026. With this increased capacity, we will have backups for each process and institute a series of double checks in order to ensure accuracy. Timeline for Implementation of Corrective Action Plan: August 15, 2026 Contact Person: Mark Hartonchik, Interim CFO

View Audit 394416

Finding 1186696 (2025-102)

Material Weakness 2025

Maricopa County

AZ

Questioned Costs Special Tests & Provisions Eligibility

Assistance Listings number and program name: 14.195 Section 8 Project-Based Cluster (Project-Based Rental Assistance (PBRA)) Responsible Entity: Housing Authority of Maricopa County Contact Person(s): Gerald Minott, Executive Director, Housing Authority of Maricopa County. Anticipated completion dat...

Assistance Listings number and program name: 14.195 Section 8 Project-Based Cluster (Project-Based Rental Assistance (PBRA)) Responsible Entity: Housing Authority of Maricopa County Contact Person(s): Gerald Minott, Executive Director, Housing Authority of Maricopa County. Anticipated completion date: April 12, 2026 Concur: The Housing Authority of Maricopa County (HAMC) has set up automatic build in compliance alert in Yardi Voyager that will adopt HUD software requirement tools while also creating a compliance calendar for the fiscal year which should further assist in the prevention of late inspections and recertifications. Going forward the HAMC Compliance Department will be performing biannual internal monitoring tests of up to (25%) of files per site/property/program. As part of HAMC’s push to implement internal control best practices, HAMC will update its internal control policies on electronic income verification deadlines, inspection frequency, required documentation, correction of income verification steps, and file retention rules to provide better clarity. HAMC will also work with the HAMC HR Department staff to implement a zero-tolerance policy for incomplete files which will be reviewed on a yearly basis.

View Audit 394404

Finding 1186677 (2025-003)

Material Weakness 2025

The Primary Care Coalition of Montgomery County, Maryland, Inc.

MD

Subrecipient Monitoring Internal Control / Segregation of Duties Eligibility

Views of Responsible Official: Management agrees with the finding. Management will develop an alert system for Program Directors to use in tracking their sub-awards and sub-contracted engagement values and related amendments. This system will create an alert when a contract value exceeds $30,000 pro...

Views of Responsible Official: Management agrees with the finding. Management will develop an alert system for Program Directors to use in tracking their sub-awards and sub-contracted engagement values and related amendments. This system will create an alert when a contract value exceeds $30,000 prompting the Program Director to file, or work with appropriate staff to file the FFATA.

View Audit 394372

Finding 1186658 (2025-001)

Material Weakness 2025

Western North Carolina Aids Project, Inc.

NC

Questioned Costs Eligibility Significant Deficiency

2025-001 – Eligibility for Housing Assistance Condition: During the testing of tenant files, certain documentation deficiencies were noted as summarized below: 1 – Incorrect Rental Calculation on Client #20 Corrective Action: Section 1 RE: Incorrect Rental Calculation: The incorrect calculation refe...

2025-001 – Eligibility for Housing Assistance Condition: During the testing of tenant files, certain documentation deficiencies were noted as summarized below: 1 – Incorrect Rental Calculation on Client #20 Corrective Action: Section 1 RE: Incorrect Rental Calculation: The incorrect calculation referenced in this finding was due to a typo, which resulted in an incorrect payment. To catch simple human errors such as this in the future, management will update the rent calculation worksheet to include reminders to double check data entry in fields that are easy to transpose. Management will also update the recertification process to add the following additional steps: The Data Technician will also review the rent calculation worksheet and the supporting documentation to ensure the amounts in the supporting document(s) match the entry in the worksheet; the Housing Coordinator will conduct a randomized audit of at least two rent calculation worksheets each month. Evidence of the improvements made by management is reflected by the significant decrease in the number of deficient records compared to the FY2023-24 audit: 2023-24 Total Deficient Eligibility Records: 2024-25 Total Deficient Eligibility Records: WNCAP expects to see continued improvement in subsequent audits.

View Audit 394359

Finding 1186641 (2025-001)

Material Weakness 2025

Sterling College

KS

Student Financial Aid Questioned Costs Eligibility

Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2025 Corrective action Sterling College agrees with the finding. At the time of noncompliance the college was transitioning to a new financial aid system. The compliance eng...

Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2025 Corrective action Sterling College agrees with the finding. At the time of noncompliance the college was transitioning to a new financial aid system. The compliance engine of the new system was set up but there was a gap in the compliance which allowed aid for students who were not enrolled to post without warning. The issue was found by the financial aid administrators and corrected as soon as it was discovered. Upon finding the issues, the financial aid administrators reached out to the IT department for more training on the compliance portion of the software and have worked diligently to update the system and put in place processes that will ensure that aid is canceled for students that are not enrolled. The system also has compliance setup to ensure checks and balances are in place to look for students who are eligible to receive aid and will not post aid for students who are not enrolled even if the aid has not been canceled before the official disbursement date.

View Audit 394339

Finding 1186637 (2025-001)

Material Weakness 2025

Waimanalo Health Center

HI

Special Tests & Provisions Questioned Costs Eligibility

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2025: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2025 Item 2025-001 - Specia...

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2025: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2025 Item 2025-001 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6, 2 H80CS00646-24-01, 1 H8LCS51923-01-00 for 2024 and 2025, 1 H8NCS54043-01- 00 for 2025 - (Significant Deficiency) During our audit, we noted that the Center did not properly determine the sliding fee discount for one eligible patient, based on information provided during the patient registration process. Recommendation We recommend that the Center provide training to all personnel involved in determining patients’ sliding fee discounts. In addition, we recommend that an internal audit of a sample of patient charts be conducted periodically to verify that sliding fee scale discounts or categories are properly and accurately determined based on the information provided by patients. Finally, we recommend that the results of such internal audits be formally documented. Action Taken Management agrees with the finding and will be establishing policies and procedures and conducting training for all personnel involved in determining patients' sliding fee discounts to help ensure the accuracy of the process. Management will also implement an internal audit of a sample of patient charts and will ensure that such audits are properly documented. Effectivity Date: June 30, 2026

View Audit 394336

Finding 1186603 (2025-003)

Material Weakness 2025

Summit Academy Oic

MN

Questioned Costs Student Financial Aid Eligibility

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy implement a process to ensure student is being properly awarded based on their SAI and enrollment status. Explanation of disagreement with audit finding: There is no disagreement with the a...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy implement a process to ensure student is being properly awarded based on their SAI and enrollment status. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Coordinators now have a corrected calculator to use when determining the student’s Pell eligibility based on their SAI. The Financial Aid Manager will also look over the award to ensure proper funding has been put into place. Name(s) of the contact person(s) responsible for corrective action: Rachael Farnell Planned completion date for corrective action plan: 07/01/2025

View Audit 394300

Finding 1186588 (2025-003)

Material Weakness 2025

Housing for Rockdale Elders, Inc.

MA

Eligibility Questioned Costs Subrecipient Monitoring

CORRECTIVE ACTION PLAN March 18, 2026 Housing for Rockdale Elders, Inc. respectfully submits the following corrective action plans for the year ended October 31, 2025: Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street Suite 1200 Braintree MA 02184 Audit period: Nove...

CORRECTIVE ACTION PLAN March 18, 2026 Housing for Rockdale Elders, Inc. respectfully submits the following corrective action plans for the year ended October 31, 2025: Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street Suite 1200 Braintree MA 02184 Audit period: November 1, 2024 - October 31, 2025 The findings from the October 31, 2025 schedule of findings and questioned costs is discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding 2025-003 - Eligibility - Material Weakness Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Action Taken: Management agrees with the finding and is in the process of revising internal controls to address this issue.

View Audit 394285

Finding 1182964 (2025-305)

Material Weakness 2025

State of Wisconsin

WI

Questioned Costs Eligibility Significant Deficiency

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-305: Grants to States for Medicaid – Posting of Managed Care Entity Financial Audits. This is the department’s Corrective Action Plan.  Recommendation (2025-305): Grants to States for Medicaid – P...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-305: Grants to States for Medicaid – Posting of Managed Care Entity Financial Audits. This is the department’s Corrective Action Plan.  Recommendation (2025-305): Grants to States for Medicaid – Posting of Managed Care Entity Financial Audits We recommend the Wisconsin Department of Health Services develop and implement procedures to ensure the results of the periodic audits of managed care organizations are posted to the State’s website in a timely manner. Wisconsin Department of Health Services Planned Corrective Action: DHS will establish a tracking process to post the summary results of the managed care entity financial audits to the State’s website in a timely manner. Anticipated Completion Date: June 30, 2026 Persons responsible for corrective action Grant Cummings, Director Bureau of Rate Setting, Division of Medicaid Services grantr.cummings@dhs.wisconsin.gov

View Audit 394279

Finding 1182963 (2025-304)

Material Weakness 2025

State of Wisconsin

WI

Questioned Costs Eligibility Reporting § 200.302

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-304: Grants to States for Medicaid – Medical Status Code Errors. This is the department’s Corrective Action Plan.  Recommendation (2025-304): Grants to States for Medicaid – Medical Status Code Er...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-304: Grants to States for Medicaid – Medical Status Code Errors. This is the department’s Corrective Action Plan.  Recommendation (2025-304): Grants to States for Medicaid – Medical Status Code Errors. We recommend the Wisconsin Department of Health Services ensure the accuracy of the medical status code by: • Implementing and testing the needed updates to CARES to correct the errors in the assigned medical status code; • Completing an assessment of the effect of the identified errors in the medical status code on accounting entries, required federal reporting, and making any necessary corrections; and • Prepare and maintain documentation of its annual review and assessment. Wisconsin Department of Health Services Planned Corrective Action: The Division of Medicaid Services (DMS) identified issues with Medical Status codes prior to the beginning of the audit. DMS directed the Enrollment & Eligibility System vendor to identify and implement a system correction. Concurrently, the LAB identified the issue as part of their current year audit fieldwork. The correction was included in the February 2026 system update which is expected to address the concerns underlying this finding. Additionally, DMS will complete an assessment of potential effects on required federal reporting and make any adjustments. Anticipated Completion Date: June 30, 2026 Persons responsible for corrective action: Hannah Stephens, Section Manager Bureau of Fiscal Accountability and Management, Division of Medicaid Services, hannah.stephens@dhs.wisconsin.gov

View Audit 394279

Finding 1182961 (2025-301)

Material Weakness 2025

State of Wisconsin

WI

Questioned Costs Cash Management Eligibility

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-301: Grants to States for Medicaid and Children’s Health Insurance Program – Computer Data Matches. This is the department’s Corrective Action Plan.  Recommendation (2025-301): Grants to States fo...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-301: Grants to States for Medicaid and Children’s Health Insurance Program – Computer Data Matches. This is the department’s Corrective Action Plan.  Recommendation (2025-301): Grants to States for Medicaid and Children’s Health Insurance Program – Computer Data Matches. We recommend the Wisconsin Department of Health Services: • Identify and implement procedures to monitor the timeliness with which data match discrepancies are resolved and perform follow-up with local agencies as needed; and • Continue efforts to assess solutions for resolving state wage information collection agency data match discrepancies in a timely manner to determine if system or policy changes are needed. Wisconsin Department of Health Services Planned Corrective Action: Beginning in February 2026, the Medicaid Eligibility Quality Control Unit will include State Wage Information Collection Agency (SWICA) discrepancies in the monthly report that is available to Income Maintenance (IM) agencies through SharePoint. IM workers are expected to address the discrepancies. The Medicaid Eligibility Quality Control Unit will monitor the agencies to ensure they are completing the SWICA work. Prior to receipt of this finding in the fall of 2025, DHS initiated a project to assess the current state of SWICA discrepancy processing, develop solutions to improve the process, and consider automation options. The Bureau of Eligibility Operations and Training and the Bureau of Eligibility Enrollment and Policy are currently weighing several proposed solutions. If it is determined that changes to CARES are required, the project completion will depend on prioritization and coordination of CARES updates. Anticipated Completion Date: November 2027 Persons responsible for corrective action: Jonelle Brom, Director Bureau of Eligibility Operations and Training, Division of Medicaid Services Jonellem.Brom@dhs.wisconsin.gov

View Audit 394279

Finding 1182956 (2025-300)

Material Weakness 2025

State of Wisconsin

WI

Eligibility Questioned Costs Cash Management

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan.  Recommendation (2025-300): Eligibility for the Children’s Health Insurance Program W...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan.  Recommendation (2025-300): Eligibility for the Children’s Health Insurance Program We recommend the Wisconsin Department of Health Services continue its efforts to monitor for Children’s Health Insurance Program participants who exceed the age requirement to ensure they are identified and removed in a timely manner. Wisconsin Department of Health Services Planned Corrective Action: On August 1, 2025, a CARES Coordinator Notice was sent to Income Maintenance agencies to emphasize the Monthly BC CHIP Report, which provides a list of individuals aging out of the program in the following month. Beginning with this notification, agencies were required to work the cases on the list and notify DHS of completion on or before the 10th of each month. Since August 2025, agencies have followed the directives in the notice and are informing DHS when work is completed on each case. Anticipated Completion Date: August 2025 Persons responsible for corrective action: Jonelle Brom, Director Bureau of Eligibility Operations and Training, Division of Medicaid Services Jonellem.Brom@dhs.wisconsin.gov

View Audit 394279

Finding 1182943 (2025-303)

Material Weakness 2025

State of Wisconsin

WI

Internal Control / Segregation of Duties Questioned Costs Procurement, Suspension & Debarment § 200.303

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-303: WIC Supplemental Nutrition Program for Women, Infants, and Children – Service Organization Controls. This is the department’s Corrective Action Plan.  Recommendation (2025-303): WIC Supplemen...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-303: WIC Supplemental Nutrition Program for Women, Infants, and Children – Service Organization Controls. This is the department’s Corrective Action Plan.  Recommendation (2025-303): WIC Supplemental Nutrition Program for Women, Infants, and Children – Service Organization Controls. We recommend the Wisconsin Department of Health Services: • Develop and document procedures to complete an annual assessment of the controls in place by each contractor that provides support and security for an IT system used in administering the WIC Special Supplemental Nutrition Program for Women, Infants, and Children program, including the support provider, the cloud provider, and the EBT provider; • Obtain annually available service organization controls audit reports and perform an annual review that includes an assessment of the identified internal control deficiencies and a determination of whether the relevant complementary user entity controls are implemented; and • Prepare and maintain documentation of its annual review and assessment. Wisconsin Department of Health Services Planned Corrective Action: In partnership with DHS’s Information Security Section (ISS), the WIC Program will develop and document procedures to complete an annual assessment of security controls. The WIC Program will annually request SOC reports from all vendors. ISS will review SOC reports identifying deficiencies and risks and ensuring the user entity controls are addressed. DHS will then prepare and maintain documentation of its annual SOC reviews and assessments. Anticipated Completion Date: June 1, 2026 Persons responsible for corrective action: Kari Malone, Section Manager WIC and Nutrition Section, Division of Public Health kari.malone@dhs.wisconsin.gov

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