Corrective Action Plans

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Corrective Action Plan Details Finding Number: 2024-002 Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number 97.036 Federal Emergency Management Agency Passed through Mississippi Emergency Management Agency Responsible Official: Adam Moor...
Corrective Action Plan Details Finding Number: 2024-002 Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number 97.036 Federal Emergency Management Agency Passed through Mississippi Emergency Management Agency Responsible Official: Adam Moore, CFO Finding Detail: Expenses reimbursed from other sources and unsupported expenses were not identified. Appropriate calculations of cost formulas were not utilized for medication reimbursement amounts claimed. Corrective Action Planned: Management concurs with the finding and will implement additional internal controls over the identification of eligible expenditures for the Disaster Grants program. Expenditures identified as potential grant program expenditures will be reviewed by the controller, and final approval of each expense by the chief financial officer to ensure they are eligible expenses and have not been reimbursed by any other sources. We anticipate these additional controls to be in place by September 30. 2025. The Chief Development Officer will oversee the corrective action. Anticipated Completion Date: September 2025
View Audit 360576 Questioned Costs: $1
Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent ...
Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior the submission of the July-September 2025 claim.
View Audit 360487 Questioned Costs: $1
Re: FY23-24 Federal Single Audit Finding (2024-001) Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Perez, Finance Director; Jeff Gilbreath, Executive Director Hawaiʻi Community Lending (HCL) is diligent and ensures all grant requirements are met for Federal, State, and private ...
Re: FY23-24 Federal Single Audit Finding (2024-001) Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Perez, Finance Director; Jeff Gilbreath, Executive Director Hawaiʻi Community Lending (HCL) is diligent and ensures all grant requirements are met for Federal, State, and private funding awards. Due to the transitioning of its Finance Directors upon the start of the FY23-24 audit, the proper procedures to correct the CDFI ERP project account were miscommunicated, and the Schedule of Expenditures for Federal Awards (SEFA) were not reduced to reflect the proper adjustments. The corrective action being taken by HCL leadership is to ensure all loans disbursed and charged to restricted grants are reviewed thoroughly by the Finance Director. The Finance Director will review all eligibility requirements that are met, to include the eligible mapping area, as required and provided by the funder. This thorough review of eligibility will ensure that all loans charged to restricted funding will be properly allocated and charged correctly. In addition to the thorough review mentioned above, HCL will develop procedures to review the SEFA, in detail, which is prepared by a third-party accounting vendor. The procedures will include an extensive review of expenditures by the Finance Director and subsequent review and approval by the Executive Director to ensure all expenses are eligible and allocated properly to our federal grants. Once the SEFA has been fully reviewed and approved by the Finance Director and Executive Director, it will be forwarded to the auditors. Additional staff may be involved in the review and eligibility confirmation process to ensure accuracy. Internal audits of expenditures will also be completed on a quarterly basis. The anticipated completion date of this corrective action plan is June 30, 2025. Mahalo, Jeff Gilbreath Executive Director Hawaiʻi Community Lending
The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25...
The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25. Responsible Contact Person: Julie Luft, NW Social Services Director
South Landry Parish Housing Authority P.O. Drawer E Grand Coteau, LA 70541 Phone: (337) 662-3573 Fax: (337) 662-3583 HOUSING AUTHORITY OF SOUTH LANDRY PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Corrective Action Plan Finding: Finding 2024-001-Re-examination Of Tena...
South Landry Parish Housing Authority P.O. Drawer E Grand Coteau, LA 70541 Phone: (337) 662-3573 Fax: (337) 662-3583 HOUSING AUTHORITY OF SOUTH LANDRY PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Corrective Action Plan Finding: Finding 2024-001-Re-examination Of Tenant Eligibility and Rent Not Timely Done-Special Tests Condition: Tenant eligibility and rent should be examined on an annual basis, as required by federal regulations. Corrective Action Planned: I am Denise Moore, Executive Director and Designated Person to answer this audit finding. We will do as the auditor recommends and timely do the re-exams in the future. Person responsible for corrective action: Denise Moore, Executive Director Telephone: (337) 662-3573 South Landry Parish Housing Authority Fax: (337) 662-3583 P.O. Drawer E Grand Coteau, LA 70541 Anticipated Completion Date: December 31, 2025
Finding 567893 (2024-005)
Significant Deficiency 2024
Hips
DC
Views of Responsible Officials: Prior to receiving this finding in the prior year, HIPS was not in the practice of saving documentation of financial or programmatic reporting submission. Staff responsible for submissions are now documenting submission of reports as of 2024. HIPS Finance Manager has ...
Views of Responsible Officials: Prior to receiving this finding in the prior year, HIPS was not in the practice of saving documentation of financial or programmatic reporting submission. Staff responsible for submissions are now documenting submission of reports as of 2024. HIPS Finance Manager has been tasked with checking all spreadsheet calculations prior to submissions of financial reporting.
Park City has implemented a secure, digital document management protocol requiring that all income verification forms and re-examination documents be scanned and stored within Yardi, our newly adopted digital management system. This transition ensures that all records are accurately maintained, secu...
Park City has implemented a secure, digital document management protocol requiring that all income verification forms and re-examination documents be scanned and stored within Yardi, our newly adopted digital management system. This transition ensures that all records are accurately maintained, securely stored, and readily accessible for audits and inspections. By digitizing these critical documents, we are enhancing regulatory compliance, reducing administrative inefficiencies, and strengthening data integrity. This approach aligns with best practices for record retention and enables swift retrieval of documentation to meet oversight and inspection requirements Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900
A memo relating to HUD and PHA verification requirements has been issued to staff. Utility allowance schedule set up in software has been confirmed for accuracy. Staff has been reminded to ensure appropriate Utility Schedule is applied during processing of transactions. Internal quarterly Qualit...
A memo relating to HUD and PHA verification requirements has been issued to staff. Utility allowance schedule set up in software has been confirmed for accuracy. Staff has been reminded to ensure appropriate Utility Schedule is applied during processing of transactions. Internal quarterly Quality Control reviews are also in place. Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900
View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. We issued a Request for Proposals for a third-party Contractor to perform all recertifications. We intend to award this Contract in July 2025. 2. All Manager...
View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. We issued a Request for Proposals for a third-party Contractor to perform all recertifications. We intend to award this Contract in July 2025. 2. All Managers and assistant Managers will use the third-party Contractor to learn proper recertification and documentation procedures.
Finding 2024-013 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 has been working to ensure correct eligibility classif...
Finding 2024-013 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 has been working to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS is continuing to update cases following the end of the public health emergency (PHE) and expects that all existing cases will be updated by July 2025, as MDHHS completes a mass update and renewals for existing cases. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children’s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 2025 Responsible Individual(s) Brant Cole, MDHHS Logan Dreasky, MDHHS Crystal Kline, MDHHS
Finding 2024-055 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with the B...
Finding 2024-055 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with the BSC analyst team to discuss common errors, answer questions, provide guidance, and on a quarterly basis discuss the results of the State Emergency Relief (SER) case reads. During April 2024, MDHHS SER program policy management and staff began attending BSC leadership meetings to discuss SER case read data findings, policy changes, and communicate common errors found during audits. In addition to updating verification requirements on October 1, 2023, SER program policy management and staff added copay verification requirements on October 1, 2024. MDHHS completed system updates during April 2024 to allow specialists access to directly upload verification documentation to the electronic case file instead of providing the documentation to other areas to process and upload. MDHHS will provide annual training directly to counties that fail to meet the state average for SER case reads relating to verification of the client's income, client contribution payment, and proof of energy crisis. MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support SER processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all ...
Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all specialists that determine eligibility for refugee cash assistance payments by September 30, 2025. MDHHS also will implement ongoing management and peer-to-peer spot checks of cases to ensure that documentation is maintained to support the client’s eligibility beginning October 2025. In addition, MDHHS will determine if technical changes are needed to help ensure the proper documentation is in the electronic case file by December 31, 2025. If potential system modifications are needed, the Bridges technical team will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the determination of whether system modifications are necessary. Responsible Individual(s) Benjamin Cabanaw, LEO Nicole Adams, LEO Bethany Cabanaw, MDHHS Kent Schutz, MDHHS Mariah Schaefer, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567839 (2024-048)
Significant Deficiency 2024
Finding 2024-048 Temporary Assistance for Needy Families, ALN 93.558 - Child Support Non-Cooperation Management Views MDHHS disagrees with part a. of the finding. MDHHS’s eligibility system, Bridges, was functioning as intended for the two cases identified because each case was in a non-ongoing mod...
Finding 2024-048 Temporary Assistance for Needy Families, ALN 93.558 - Child Support Non-Cooperation Management Views MDHHS disagrees with part a. of the finding. MDHHS’s eligibility system, Bridges, was functioning as intended for the two cases identified because each case was in a non-ongoing mode at the time the automated interface occurred. A case is placed into this status if the client circumstances have changed for any MDHHS program within Bridges and the case requires a redetermination. TANF policy cannot mandate Bridges to change the non-ongoing mode because each impacted program is required to be certified prior to changing the status. MDHHS policy does not mandate a specific length of time that a case can be in a non-ongoing status. The results of the redetermination can impact the client’s non-cooperation status and therefore the client should not be sanctioned until the certification by all programs is complete. For one of the cases, the client was appropriately sanctioned after the case review was complete and for the other case, the client was determined to be in compliance once the case was removed from the non-ongoing status mode. MDHHS agrees with part b. of the finding. Planned Corrective Action For part a., MDHHS disagrees with the finding and does not intend to take further action. For part b., MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine if there was a technical aspect that contributed to the inappropriate sanction and identify a solution by September 30, 2025. If potential system modifications are needed, MDHHS will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. Anticipated Completion Date a. Not applicable b. MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solution identified. Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schulze, MDHHS Brian Sanborn, MDHHS
Finding 567837 (2024-046)
Significant Deficiency 2024
Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the bi...
Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the birth certificate was identified and the youth was determined to be Title IV-E eligible. MDHHS will reclassify the funds to the appropriate funding source, allowing the department to claim Title IV-E for the eligible placement. For those cases in which Title IV-E funding is denied initially based on lack of a birth certificate or other documentation of citizenship, the Child Welfare Funding Specialists will continue to monitor the case for updated documentation in order to complete a redetermination of funding. Child Welfare Funding Specialists will be reminded to monitor cases for updated documentation during a Child Welfare Funding conference call in June 2025. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Nancy Berger, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567836 (2024-045)
Significant Deficiency 2024
Finding 2024-045 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine the reason for the incomplet...
Finding 2024-045 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine the reason for the incomplete application by September 30, 2025, and implement a solution to correct the issue, if needed. If potential system modifications are needed, MDHHS will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. MDHHS will also send a memo and template of the application to the local offices to highlight the required questions on the application to help ensure all required questions are appropriately answered. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solution identified. Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schulze, MDHHS Brian Sanborn, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567835 (2024-044)
Significant Deficiency 2024
Finding 2024-044 Temporary Assistance for Needy Families, ALN 93.558 - MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS currently has a process in place to review the user narrative describing the incomp...
Finding 2024-044 Temporary Assistance for Needy Families, ALN 93.558 - MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS currently has a process in place to review the user narrative describing the incompatible role exceptions within the DSA Michigan Statewide Automated Child Welfare Information System (MiSACWIS) request as part of the approval process. MDHHS will continue to work on adding an incompatible role form in the DSA MiSACWIS request with automated routing for appropriate approval. MDHHS anticipates completion of corrective action by October 30, 2025. For part b., MDHHS will evaluate the current DSA timelines for generation of access renewal and access drop requests and implement any necessary changes by September 30, 2025. MDHHS will continue to provide training for LOSCs via quarterly webinars to emphasize the appropriate procedures for granting access, reviewing, and comparing access. All new information related to security access is presented to the LOSCs during the webinars and one-on-one assistance is available as needed for additional support. Anticipated Completion Date a. October 30, 2025 b. September 30, 2025 Responsible Individual(s) Alana Lowe, MDHHS Deon Nelson, MDHHS
Finding 567768 (2024-042)
Significant Deficiency 2024
Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notificatio...
Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notification to adult services staff, communicating that medical needs forms should be uploaded into EDM. MDHHS issued an Adult Services Notification to adult services staff during May 2025 to communicate the exceptions identified and remind them of the medical needs form requirements. MDHHS will develop a procedure to monitor the expiration of medical needs forms using the MiAIMS Plan of Care by August 2025. In addition, MDHHS will research potential options to automate monitoring of the medical needs forms in MiAIMS and determine if any necessary system changes are needed by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Elaina Brown, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567767 (2024-041)
Significant Deficiency 2024
Finding 2024-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates a monthly hospitalization report and distributes to adult services workers as part of the post-payment review proce...
Finding 2024-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates a monthly hospitalization report and distributes to adult services workers as part of the post-payment review process. MDHHS enhanced the report query to improve the data used to identify overlaps in services and timely recover payments. MDHHS implemented the updated query during June 2025. Also, MDHHS issued an Adult Services Notification to managers and directors during February 2025, informing them of the audit finding and reminding local office management of the expectation to thoroughly monitor and review the hospitalization reports to ensure timely and accurate action is taken by adult services workers. In addition, MDHHS reissued the Home Help Recoupment Process training and procedural resources during February 2025 to adult services workers who manage Home Help cases to ensure process steps are consistently followed. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown, MDHHS Michelle Martin, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567766 (2024-040)
Significant Deficiency 2024
Finding 2024-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing these overpayment issues, as we...
Finding 2024-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing these overpayment issues, as well as developing mitigation strategies to temporarily address the overpayment concerns while the more permanent system solutions are developed. MDHHS expects all remaining synchronization issues to be resolved once the remaining larger system changes are implemented in December 2025. Anticipated Completion Date December 31, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567759 (2024-014)
Significant Deficiency 2024
Finding 2024-014 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),...
Finding 2024-014 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), Medicaid Health Plan (MHP), and Dental Health Plan entity fiscal year 2025 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. Also, MDHHS is in the process of amending the remaining Integrated Care Organization contract to include this requirement. MDHHS will continue to educate the managed care entities and MDHHS contract areas on this process to help ensure compliance. MDHHS expects that signatures will be obtained on the PSICT forms effective September 2025 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 review of fiscal year 2024 provider agreements for MI Choice entities will be completed by December 31, 2025, and will be ongoing during the Administrative Quality Assurance Review process as outlined in the waiver application that was approved by CMS. MDHHS will continue to send annual reminders to MI Choice entities to submit completed PSICT forms by September 1 each year as required by MI Choice contracts. MDHHS obtained an updated provider agreement for the Home Help provider cited in the finding. Home Help providers are now enrolled in CHAMPS and provider agreements, including updated terms and conditions, are completed electronically. Anticipated Completion Date December 31, 2025 Responsible Individual(s) Heather Hill, MDHHS Kim Heinicke, MDHHS Elaina Brown, MDHHS
Finding 2024-012 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. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Chil...
Finding 2024-012 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. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Children’s Health Insurance Program (CHIP) cases with MAGI determinations cited in part b. did not have case file documentation supporting the beneficiary eligibility determination. The Centers for Medicare and Medicaid Services (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 and MDHHS disagrees that documentation was not maintained to support the eligibility determination. The SOM MiIntegrate system communicates with various State and federal electronic trusted data sources and sends the 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 electronic 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 system to help secure the data and restrict access as required by federal and state law. Planned Corrective Action To address the exceptions identified that are not related to MAGI-based income verification results, MDHHS has developed mandatory training protocols for eligibility workers and expects to have the first Medicaid audit focused mandatory training implemented by July 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. MDHHS disagrees it did not maintain case file documentation that supports the beneficiary eligibility determination for MAGI cases and does not intend to take further action. Anticipated Completion Date MDHHS will implement the first Medicaid audit focused training by July 2025. Responsible Individual(s) Logan Dreasky, MDHHS Mariah Schaefer, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567755 (2024-007)
Significant Deficiency 2024
Finding 2024-007 CHAMPS Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with potential duplicate records for local office staff to review. In addition, the Community Health A...
Finding 2024-007 CHAMPS Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with potential duplicate records for local office staff to review. In addition, the Community Health Automated Medicaid Processing System (CHAMPS) is currently designed to reject potential duplicate records to prevent duplicate payments for the same individuals that already exist in CHAMPS and places these records on a CHAMPS report for review. These two reports could potentially contain the same duplicate records identified by both CHAMPS and Bridges. As part of the Departmental Work Intake Process for prioritization, MDHHS submitted a work request during January 2023 for a Bridges system modification that would allow data from the Bridges reports to be exported to the Bridges data warehouse and MDHHS is currently working with DTMB to obtain access to the data. MDHHS central office will develop a process to reconcile the rejected records identified on the CHAMPS and Bridges reports and ensure that MDHHS is appropriately reviewing those records and making any necessary corrections. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS
Finding 567695 (2024-024)
Significant Deficiency 2024
Finding 2024-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action The EGLE Water Resources Division’s (WRD) administration staff adjusted their review process in April 20...
Finding 2024-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action The EGLE Water Resources Division’s (WRD) administration staff adjusted their review process in April 2024 to comply with overall EGLE guidance that all reimbursement requests should be reviewed by a program representative and financial representative to ensure payments are made for activities authorized by the grant agreement. However, WRD had not fully completed the retroactive review of payments for fiscal year 2024. This has since been corrected and all retroactive reviews to ensure compliance with program technical specifications were completed as of May 1, 2025. Anticipated Completion Date Completed Responsible Individual(s) Phil Argiroff, EGLE Amy Hicks, EGLE
Finding 567674 (2024-008)
Significant Deficiency 2024
Finding 2024-008 MDE, IT General Controls Management Views DTMB agrees it did not fully implement its user access removal and recertification processes when transitioning responsibilities between employees. Planned Corrective Action DTMB corrected the issues noted and the reassigned employee res...
Finding 2024-008 MDE, IT General Controls Management Views DTMB agrees it did not fully implement its user access removal and recertification processes when transitioning responsibilities between employees. Planned Corrective Action DTMB corrected the issues noted and the reassigned employee resumed DTMB’s existing user access removal and recertification processes in November 2024. Anticipated Completion Date Completed Responsible Individual(s) Rex Menold, DTMB Aaron Dupre, DTMB
Finding 2024-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., d., f., and g. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees that a process is not fully established to monitor the electronic notificat...
Finding 2024-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., d., f., and g. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees 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 effect during fiscal year 2024 to help ensure monitoring of electronic notifications was taking place. Review of IEVS information is fully incorporated into the case read procedure governed by Bridges Administrative Manual 301 and detailed further in desk aids and reading guides. The MDHHS Economic Stability Administration (ESA) provides regular direction and reminders of case read requirements via ESA Memos. For part e., MDHHS disagrees that IEVS information is required to be requested and obtained for modified adjusted gross income (MAGI) based recipients since eligibility is verified upon determination through the MAGI eligibility determination process and then granted for a 12-month continuous eligibility period. Requesting and obtaining IEVS information throughout the eligibility period would be irrelevant since eligibility is continuous. Planned Corrective Action For parts a. and b., MDHHS ESA will continue to provide guidance and trainings to the local office specialists on utilizing the IEVS data timely and appropriately if the data is critical for current eligibility determinations. MDHHS ESA will also continue to review any technical automated solutions of the 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 subsidies recipients funded by Temporary Assistance for Needy Families (TANF). For part f., MDHHS worked with the Social Security Administration (SSA) to resolve a discrepancy in how the file was reported to DTMB by SSA and processed the fiscal year 2024 file during February 2025. For part g., MDHHS worked with the National Technical Information Service (NTIS) to regain access to the data during February 2024 and resume receiving the data monthly. Once access was re-established, NTIS sent a complete base file containing the data for the three months identified and the file exceeded the normal processing limit. MDHHS will work with DTMB to identify potential solutions and will process the complete file base by September 30, 2025. 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 f. Completed g. September 30, 2025 Responsible Individual(s) a., b., and c. Veronica Maxson, MDHHS d. Kathonya Rice, MDHHS e. Logan Dreasky, MDHHS f. Brant Cole, MDHHS g. Brant Cole, MDHHS Nathan Buckwalter, DTMB
View Audit 360209 Questioned Costs: $1
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