Corrective Action Plans

Finding 1168948 (2024-009)

Material Weakness 2024

CA

HUD Housing Programs Eligibility Special Tests & Provisions § 200.303

Recommendation: We recommend the City establish procedures to ensure that the review and approval processes are clearly documented within each tenant file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA w...

Recommendation: We recommend the City establish procedures to ensure that the review and approval processes are clearly documented within each tenant file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA will establish procedures to monitor and ensure proper file review. RBHA has created a new checklist for a supervising team member to review intake files for accuracy, to document approval, and to release the Housing Assistance Payment. RBHA will maintain records of the signed checklist for each tenant file. Name of the contact person responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: January 2026.

View Audit 381471

Finding 1168899 (2024-002)

Material Weakness 2024

Berne Union Local School District

OH

Eligibility School Nutrition Programs Matching / Level of Effort / Earmarking

Effective immediately, Berne Union will require PaySchools to provide its policies and procedures governing the eligibility determination process for free, reduced, and paid meal status. These documents will be reviewed to ensure compliance with federal standards for the Free and Reduced-Price Lunch...

Effective immediately, Berne Union will require PaySchools to provide its policies and procedures governing the eligibility determination process for free, reduced, and paid meal status. These documents will be reviewed to ensure compliance with federal standards for the Free and Reduced-Price Lunch Program.

View Audit 381295

Finding 1168670 (2024-001)

Material Weakness 2024

Tri-County Housing, Inc. Dba Total Concept & Subsidiaries

CO

Questioned Costs Subrecipient Monitoring Eligibility § 200.512

Oversight Agency for Audit Tri-County Housing, Inc. dba Total Concept & Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2024. Name of independent accounting firm: Audit Period: January 1, 2024 through December 31, 2024. The finding from the Dece...

Oversight Agency for Audit Tri-County Housing, Inc. dba Total Concept & Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2024. Name of independent accounting firm: Audit Period: January 1, 2024 through December 31, 2024. The finding from the December 31, 2024 Schedule of Findings and Questioned Costs is discussed below. Finding 2024-1 Comments of the finding and recommendation: Management agrees with the finding. Action taken: We will assign the Executive Director to oversee all federal reporting deadlines and implement a centralized compliance calendar with automated reminders. Internal policies will be updated to require a formal review of reporting documents at least 45 days prior to submission deadlines. Additionally, relevant staff will receive training on Uniform Guidance requirements, and quarterly compliance meetings will be held to monitor progress. These actions are intended to ensure timely and accurate future submissions in accordance with federal regulations. If the oversight agency has questions regarding this plan, please email Steven Cordova, executive director of Tri-County Housing, Inc. dba Total Concept & Subsidiaries at scordova@totalconcept.net. Sincerely yours, Tri-County Housing, Inc. dba Total Concept & Subsidiaries

View Audit 380649

Finding 1168640 (2024-004)

Material Weakness 2024

Community Health Center in Cowley County

KS

Questioned Costs Special Tests & Provisions Eligibility

Community Health Center in Cowley County, Inc. acknowledges the repeat finding regarding application of sliding fee discounts. To address this, we have: • Continued weekly meetings between frontline staff and the billing/revenue department to reinforce policy alignment. • Enhanced and formalized tra...

Community Health Center in Cowley County, Inc. acknowledges the repeat finding regarding application of sliding fee discounts. To address this, we have: • Continued weekly meetings between frontline staff and the billing/revenue department to reinforce policy alignment. • Enhanced and formalized training programs for all staff involved in eligibility screening and discount application. • Updated our Financial and Sliding Fee policies to clarify procedures and eligibility criteria. These actions are part of our ongoing commitment to improving internal controls and ensuring compliance with federal program requirements. Effectiveness will be monitored through periodic audits and staff feedback.

View Audit 380589

Finding 1168606 (2024-002)

Material Weakness 2024

Save, Inc. and Affiliates

MO

Questioned Costs Subrecipient Monitoring Eligibility

Finding 2024-002 Federal Agency U.S. Department of Housing and Urban Development Federal Program Community Project Funding Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedure...

Finding 2024-002 Federal Agency U.S. Department of Housing and Urban Development Federal Program Community Project Funding Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedures to ensure program eligibility and we will review the accuracy / completion of the documentation being processed in our participant files on a periodic basis. Anticipated Completion Date November 30, 2025

View Audit 380509

Finding 1168522 (2024-005)

Material Weakness 2024

The Conservation Innovation Fund

DC

Reporting Subrecipient Monitoring Eligibility § 200.512

Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF made adjustments and improvements in this area during FY 25. CIF’s FY 25 Audit Report will be ...

Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF made adjustments and improvements in this area during FY 25. CIF’s FY 25 Audit Report will be submitted to the FAC prior to the deadline, clearing this finding in the FY 25 Audit Report.

View Audit 380327

Finding 1168521 (2024-004)

Material Weakness 2024

The Conservation Innovation Fund

DC

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF retrained staff on FFATA reporting deadlines and documentation expectations so that if new sub...

Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF retrained staff on FFATA reporting deadlines and documentation expectations so that if new subawards are entered into in FY 26, this requirement will be met in a timely fashion. Details relating to FFATA reporting requirements are documented in the CIF Subaward Management & Subrecipient Monitoring Policy and Procedures.

View Audit 380327

Finding 1168388 (2024-001)

Material Weakness 2024

Casa

NC

Eligibility Internal Control / Segregation of Duties Reporting

CASA 624 W Jones St. Raleigh, North Carolina 27603 CORRECTIVE ACTION PLAN December 9, 2025 Single Audit Clearinghouse 1201 East 10th Street Jeffersonville, Indiana 47132 CASA (the "Organization"), respectfully submits the following Corrective Action Plan for the year ended June 30, 2024. Bernard Rob...

CASA 624 W Jones St. Raleigh, North Carolina 27603 CORRECTIVE ACTION PLAN December 9, 2025 Single Audit Clearinghouse 1201 East 10th Street Jeffersonville, Indiana 47132 CASA (the "Organization"), respectfully submits the following Corrective Action Plan for the year ended June 30, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Greensboro, North Carolina 27410 Audit period: Year ended June 30, 2024 The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs: Section II - Findings relating to the financial statements which are required to be reported in accordance with generally accepted Government Auditing Standards and Section III - Findings and questioned costs relating to the major programs which are required to be reported as defined by the Uniform Guidance [2 CFR 200.516(a)]: Finding 2024-001: U.S. Department of Housing and Urban Development, HOME Investments Partnerships Program Recommendation: Management should implement procedures to track tenant's annual recertification dates to ensure timely recertification; utilize checklists to ensure all required documentation, including income verification, disability and homelessness statuses, utility allowance calculations, background checks, and HOME lease addendums are properly maintained; conduct periodic internal audits of tenant's files; and evaluate staffing capacity of the leasing department. Management's Response and Corrective Action Plan: Management agrees with the recommendation and has already adjusted procedures to track annual recertification dates, supported by checklists to ensure all required documentation is complete and accurate. Periodic internal audits of tenant files will be conducted to maintain compliance. Additionally, a newly hired Senior Director of Operations will have total oversight of this process to ensure all recommendations are followed. Leasing staff continue to complete training to develop their knowledge and abilities. If you have questions regarding this plan, please call Everett McElveen at 919-754-9960. Sincerely yours, Everett McElveen CASA

View Audit 380207

Finding 1168227 (2024-007)

Material Weakness 2024

Heritage University

WA

Student Financial Aid Questioned Costs Eligibility

Planned corrective actions: As a response to concerns about disruptions in processes and the turnover of key staff in several departments, the Enrollment Alliance group that includes director-level staff in Admissions, the Registrar, Financial Aid, Advising, Bursar, and IT began meeting under the fa...

Planned corrective actions: As a response to concerns about disruptions in processes and the turnover of key staff in several departments, the Enrollment Alliance group that includes director-level staff in Admissions, the Registrar, Financial Aid, Advising, Bursar, and IT began meeting under the facilitation of the VP of Student Affairs on January 7, 2025. This group will continue to work on implementing the proper controls to ensure that the determination of student eligibility for Title IV aid is appropriate and has supporting documentation. Name of Responsible Party: 1. Nancy Benavides,Financial Aid Director 2. Corey Hodge, VP for Student Affairs 3. Joanne Fernandez, Controller 4. Marla Withers, Assistant Controller 5. Sagrario Armenta Jimenez, CFO 6. Dr. Christopher Gilmer, President Anticipated completion date: 6/30/2026

View Audit 380015

Finding 1168207 (2024-005)

Material Weakness 2024

Detroit Health Care for the Homeless Dba Advantage Health Centers

MI

Questioned Costs Eligibility HUD Housing Programs § 200.303

AHC has revised its patient intake procedures to ensure that all required documentation is collected and verified at the point of service. An electronic eligibility checklist has been integrated into the EHR, and staff have been trained to collect alternative income documentation where appropriate. ...

AHC has revised its patient intake procedures to ensure that all required documentation is collected and verified at the point of service. An electronic eligibility checklist has been integrated into the EHR, and staff have been trained to collect alternative income documentation where appropriate. Monthly audits of ten patient files per site are conducted, and exceptions are logged and resolved within ten business days. Policies and procedures have been updated to reflect documentation and compliance standards. Ongoing monitoring and periodic staff retraining continue to support program integrity and compliance with federal requirements. Moving forward, responsibility for managing the sliding fee discount process will transition from front-desk personnel to the Revenue Cycle department to ensure stronger oversight and accountability.

View Audit 380010

Finding 1168188 (2024-007)

Material Weakness 2024

County of Humboldt

CA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

Condition: During the review of 60 sampled cases, 2 cases were found where redeterminations were performed outside the required 12-month window, indicating non-compliance with federal renewal timing requirements. And one of the two cases were deemed ineligible during the re-evaluation. Recommendatio...

Condition: During the review of 60 sampled cases, 2 cases were found where redeterminations were performed outside the required 12-month window, indicating non-compliance with federal renewal timing requirements. And one of the two cases were deemed ineligible during the re-evaluation. Recommendation: CLA recommends that the County implement or reinforce tracking procedures, such as a monitoring checklist, to ensure lead and supervisor reviews are completed and accountability is maintained. Additionally, CLA recommends that the County conduct targeted refresher training for staff and supervisors on renewal timelines and review protocols to strengthen procedural compliance and minimize errors. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Retrain supervisory staff and line-staff regarding the importance of timely redetermination. Increase reporting, especially exceptions reporting, on the status of outstanding redeterminations. Commitment to continued periodic trainings. Name(s) of the contact person(s) responsible for corrective action: Connie Beck Planned completion date for corrective action plan: Fiscal year ended June 30, 2026

View Audit 379965

Finding 1167141 (2024-007)

Material Weakness 2024

Rural Ulster Preservation Company, Inc.

NY

Eligibility Significant Deficiency

Unexpected staffing challenges contributed to the late inspections. Action taken to date by the Vice President of Program Services. 1. Staffing Structure Strengthened: o A new Program Director has been hired and is fully trained in all HOPWA program requirements, including inspection procedures. o A...

Unexpected staffing challenges contributed to the late inspections. Action taken to date by the Vice President of Program Services. 1. Staffing Structure Strengthened: o A new Program Director has been hired and is fully trained in all HOPWA program requirements, including inspection procedures. o Additional staff members have now been trained to conduct HOPWA inspections to always ensure operational coverage. 2. Cross-Training of Staff: o Multiple team members, including the Director and program service staff, are cross-trained and able to step in to complete inspections if the assigned case manager is unavailable due to illness, emergency leave, or other unforeseeable circumstances. 3. Backup Coverage Plan Implemented: o A formal backup coverage system is now in place. In the event of staff absence, either the Program Director or another trained staff member will complete the scheduled inspection to avoid any delay. o Coverage responsibilities also include providing client support and ensuring continuity of services when primary staff are out. 4. Scheduling and Monitoring: o Inspection schedules are now reviewed monthly (between case mgr. and director) to ensure upcoming deadlines are clearly identified, monitored, and met. Outcome Expected: These corrective measures ensure that all annual HOPWA inspections will be completed on time, regardless of staffing changes or unforeseen absences. The increased number of trained staff and the implementation of a clear backup plan reduce the risk of future delays and strengthen program compliance.

View Audit 378189

Finding 1167125 (2024-010)

Material Weakness 2024

Pacific Forum International

HI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.512

Finding: Significant deficiency in internal control for late submission of data control form and Single Audit report package. Corrective action: Pacific Forum has authorized its outsourced accounting service to take on a larger role in fulfilling auditor requests to ensure the information submitted ...

Finding: Significant deficiency in internal control for late submission of data control form and Single Audit report package. Corrective action: Pacific Forum has authorized its outsourced accounting service to take on a larger role in fulfilling auditor requests to ensure the information submitted is accurate and complete. PFI has also consolidated financial management policies and other required documentation in a secure cloud network. PFI has also adopted more features available through Bill.com, which has enhanced documentation of expenditures and management reviews. Procedures for filing documents and utilizing financial management procedures available through Bill.com will be integrated into PFI financial management policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director

View Audit 378170

Finding 1167123 (2024-008)

Material Weakness 2024

Pacific Forum International

HI

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.213

Finding: Material weakness in internal control over documenting suspension and debarment reviews for vendors receiving federal funds Corrective action: PFI has adopted a policy to document the screening of all vendors receiving federal funds via the suspension and debarment list provided in SAM.gov....

Finding: Material weakness in internal control over documenting suspension and debarment reviews for vendors receiving federal funds Corrective action: PFI has adopted a policy to document the screening of all vendors receiving federal funds via the suspension and debarment list provided in SAM.gov. These procedures will be incorporated into PFI procurement policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director

View Audit 378170

Finding 1166736 (2024-009)

Material Weakness 2024

GREAT PLAINS VETERANS SERVICES CENTER

MT

Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.303

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There ...

Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will reassign roles to ensure clear separation between allowability determinations and expenditure approvals. If staffing constraints prevent full segregation, management will ensure that the Finance Manager performs secondary reviews. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct periodic internal monitoring with documented review of approvals.

View Audit 377852

Finding 1166558 (2024-012)

Material Weakness 2024

State of California

CA

Internal Control / Segregation of Duties Questioned Costs Eligibility § 200.303

CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including s...

CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including surveys conducted by Accrediting Organizations. CHCQ has already taken steps by reiterating this requirement at a recent statewide management meeting. CHCQ will continue reminding staff of expectations at appropriate meetings and provide additional training as needed to ensure all offices follow consistent procedures when completing the required CMS 1539 forms. Headquarters management will provide oversight and conduct periodic audits to ensure staff complete and sign all CMS 1539 forms according to expectations. Estimated Implementation Date: Fiscal Year 2025-26 Contact: Nate Gilmore, State Surveyors Branch Chief, CHCQ

View Audit 377562

Finding 1166553 (2024-011)

Material Weakness 2024

State of California

CA

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County p...

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Through the reinstatement of county performance standards and Focused Reviews, DHCS can identify and address eligibility concerns, such as the proper use of aid codes, and work with counties through the corrective action plan process to address staff training to ensure correct eligibility determinations for all Medi-Cal programs, including pregnancy programs. Estimated Implementation Date: Fully Implemented Contact: Sarah Crow, Medi-Cal Eligibility Division, Division Chief Harold Higgins, Medi-Cal Eligibility Division, Branch Chief Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 377562

Finding 1166548 (2024-010)

Material Weakness 2024

State of California

CA

Questioned Costs Eligibility Internal Control / Segregation of Duties § 200.303

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County p...

Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Additionally, DHCS resumed the Aid Code Cleanup effort in September 2025, as outlined in MEDIL I 25-19. The purpose of the aid code cleanup effort is to assist counties in identifying records that require eligibility re-evaluation to either transition individuals to the correct Medi-Cal aid code or appropriately discontinue coverage. Through these initiatives, DHCS can identify and address eligibility concerns, such as processing timeliness and proper aid code usage. Estimated Implementation Date: Fully Implemented Contact: Sarah Crow, Medi-Cal Eligibility Division, Division Chief Harold Higgins, Medi-Cal Eligibility Division, Branch Chief Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 377562

Finding 1166539 (2024-004)

Material Weakness 2024

State of California

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility § 200.303

The EDD has policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the employee did not follow the proper procedure to include the penalty...

The EDD has policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the employee did not follow the proper procedure to include the penalty. EDD accepts this oversight and is committed to reviewing its applicable policies and procedures to ensure they are clear, and the penalty requirements are emphasized. Regarding internal controls, EDD leverages a process known as the Field Office Basic Evaluation System (FOBES). This process includes a standardized form that is utilized by leadership to evaluate the quality of their employees’ work on a variety of processes, including overpayment processing. EDD continues to review and modernize the existing assessment form and FOBES process to ensure effectiveness and consistency while evaluating employee compliance with policies and procedures Estimated Implementation Date: Currently Implemented Contact: Diane Underwood, Division Chief, Unemployment Insurance Branch, California Employment Development Department

View Audit 377562

Finding 1165587 (2024-227)

Material Weakness 2024

State of Idaho

ID

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303

Finding 2024-227: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Related to Prior Finding: 2023-211 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that inc...

Finding 2024-227: The review and approval of the annual updates to the Low-Income Home Energy Assistance Program (LIHEAP) benefits matrix were not documented. Related to Prior Finding: 2023-211 Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This process was shared with LSO following receipt of the FY23 review findings. Supporting documents can be provided again as needed. Anticipated Corrective Action Date: 03/06/2025 Responsible for Corrective Action: Kristin Matthews, Programs Bureau Chief, Self Reliance kristin.matthews@dhw.idaho.gov 208-334-5553

View Audit 376229

Finding 1165585 (2024-226)

Material Weakness 2024

State of Idaho

ID

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

Finding 2024-226: The Bureau of Facility Standards within the Department failed to complete timely health and safety surveys for three long-term care facilities. Agency’s View: The Department Agrees with this finding. Corrective Action: During SFY24, Bureau of Facility Standards (BFS) was still comi...

Finding 2024-226: The Bureau of Facility Standards within the Department failed to complete timely health and safety surveys for three long-term care facilities. Agency’s View: The Department Agrees with this finding. Corrective Action: During SFY24, Bureau of Facility Standards (BFS) was still coming out of the COVID response for recertification time frames and actively recruiting new health facility surveyors to ensure proper multidisciplined teams were available to complete the overdue surveys. BFS also contracted with Healthcare Management Solutions, LLC. to supplement overdue recertification surveys. On October 3, 2025, during the government shutdown, we were able to complete the final overdue surveys to be compliant with 15.9 months between surveys. Due to the government shutdown, CMS paused recertification surveys for nursing facilities. This may restrict our ability to maintain the required recertification timeline of 15.9 months. We have recruited and maintained staffing posture but are still actively recruiting to round out of staffing to meet the statutory timelines. Anticipated Corrective Action Date: 10/31/2026 Responsible for Corrective Action: Nate Elkins, Programs Bureau Chief, Licensing & Certification nate.elkins@dhw.idaho.gov 208-364-1874

View Audit 376229

Finding 1165574 (2024-222)

Material Weakness 2024

State of Idaho

ID

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

Finding 2024-222: Four providers lacked documentation to support continued eligibility within the Medicaid program. Related to Prior Finding: 2023-223 Agency’s View: The Department Agrees with this finding. Corrective Action: Medicaid is currently under a Corrective Action Plan with CMS requiring al...

Finding 2024-222: Four providers lacked documentation to support continued eligibility within the Medicaid program. Related to Prior Finding: 2023-223 Agency’s View: The Department Agrees with this finding. Corrective Action: Medicaid is currently under a Corrective Action Plan with CMS requiring all Managed Care providers to enroll with Medicaid. This project is currently underway. The initial date of completion of having all providers enroll was 12/31/2025. However, there were unforeseen system enrollment issues that delayed the project. The go live date is now April 1, 2026. Once all providers are enrolled Medicaid will audit provider rosters throughout the year to ensure those providers are in fact enrolled within Medicaid's system. Anticipated Corrective Action Date: 10/31/2026 Responsible for Corrective Action: Alex Scott, Program Bureau Chief, Medicaid alex.scott@dhw.idaho.gov 208-364-1928

View Audit 376229

Finding 1165565 (2024-219)

Material Weakness 2024

State of Idaho

ID

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

Finding 2024-219: The Medicaid Enterprise System was not properly updated for members deemed ineligible, resulting in capitation payments issued to Managed Care Organizations for ineligible members within the Medicaid program. Related to Prior Finding: N/A Agency’s view: The agency agrees with this ...

Finding 2024-219: The Medicaid Enterprise System was not properly updated for members deemed ineligible, resulting in capitation payments issued to Managed Care Organizations for ineligible members within the Medicaid program. Related to Prior Finding: N/A Agency’s view: The agency agrees with this finding. Corrective Action Plan: Medicaid recognizes that this appears to be an interface issue with Self Reliance, and their inability to send correct eligibility records to Medicaid in certain instances. Medicaid will investigate and work with Self Reliance to mitigate these issues while working through our new system implementations and interfaces. Self-Reliance is looking at the issue to identify root causes and will work closely with MC to determine next steps to implement. System integration is expected in 2028. In the interim, we’ll identify issues and develop implementation strategies by 2027. Strategies will align with system updates and builds for both Self-Reliance and Medicaid. Anticipated Corrective Action Date: 07/31/2026 Responsible for Corrective Action: Matt Clark, Programs Bureau Chief, Medicaid matthew.clark2@dhw.idaho.gov 208-332-7979

View Audit 376229

Finding 1165559 (2024-217)

Material Weakness 2024

State of Idaho

ID

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

Finding 2024-217: The Department lacked documentation to support continued eligibility for providers within the Medicaid program. Agency’s View: The Department Agrees with this Finding Corrective Action: As part of the Provider Enrollment project, the division will audit provider payments starting i...

Finding 2024-217: The Department lacked documentation to support continued eligibility for providers within the Medicaid program. Agency’s View: The Department Agrees with this Finding Corrective Action: As part of the Provider Enrollment project, the division will audit provider payments starting in 2026. The health plans will be required to validate that the providers are fully enrolled with Medicaid prior to enrolling with the health plan in early 2026. These are audits will begin in May 2026 and continue through the end of the year depending on when provider reports are due to Medicaid. This is also part of the Corrective Action Plan mentioned in finding #5. The information required to validate that no payment was made inappropriately is part of the audits that will be conducted this year with the provider rosters. Anticipated Corrective Action Date: 12/31/2026 Responsible for Corrective Action: Alex Scott, Program Bureau Chief, Medicaid alex.scott@dhw.idaho.gov 208-364-1928

View Audit 376229

Finding 1165066 (2024-001)

Material Weakness 2024

Asi - Jackson County, Inc.

MN

HUD Housing Programs Questioned Costs Eligibility

The tenant recertifications will be monitored by the owner to ensure they are being completed in a timely manner.

View Audit 375188

Corrective Action Plans

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