Corrective Action Plans

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Action Plan: CCC implemented its corrective action plan immediately upon communication of the original FY24 finding in January 2025. As noted in the status of prior year finding 2024-02, new participants after January 2025 have evidential review of eligibility by a program manager or director and in...
Action Plan: CCC implemented its corrective action plan immediately upon communication of the original FY24 finding in January 2025. As noted in the status of prior year finding 2024-02, new participants after January 2025 have evidential review of eligibility by a program manager or director and internal controls are operating effectively after implementation of the corrective action plan.
The District understands the nature of the weakness and the necessity of oversight and review procedures. The District will review its procedures and continue to implement changes.
The District understands the nature of the weakness and the necessity of oversight and review procedures. The District will review its procedures and continue to implement changes.
PTS will update the capital asset listing to include all of the required information, including the source of funding the property. The Assistant Director of Finance will prepare the listing annually, and the CFO will review for completeness and accuracy before finalizing the list.
PTS will update the capital asset listing to include all of the required information, including the source of funding the property. The Assistant Director of Finance will prepare the listing annually, and the CFO will review for completeness and accuracy before finalizing the list.
The Director of Grants and Assessments will work with the Data Department to refine the process to maintain mobility documentation to ensure appropriate documentation is received and retained for the removal of any students from the cohort.
The Director of Grants and Assessments will work with the Data Department to refine the process to maintain mobility documentation to ensure appropriate documentation is received and retained for the removal of any students from the cohort.
Provider/Employee will submit payroll records/invoices by student services monthly/bi-monthly to the bookkeeper. Once payroll records or invoices are received, the CFO will prepare a spreadsheet that calculates the time/amounts serviced by the non-public school and member school. Once the total hour...
Provider/Employee will submit payroll records/invoices by student services monthly/bi-monthly to the bookkeeper. Once payroll records or invoices are received, the CFO will prepare a spreadsheet that calculates the time/amounts serviced by the non-public school and member school. Once the total hours are calculated, a percentage based on total hours worked for each member school will be used to allocate the provider/employee time for each member school. This documentation will be attached to each reimbursement request.
2025-001 Eligibility Over Title I Program: Title I - Grants to Local Educational Agencies Federal Assistance Listing Number: 84.010 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 25FT1TTI-511375-01A Questioned Costs: $-0- Type of Fin...
2025-001 Eligibility Over Title I Program: Title I - Grants to Local Educational Agencies Federal Assistance Listing Number: 84.010 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 25FT1TTI-511375-01A Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: E. Eligibility Condition/Context: During our testing of school eligibility and funding, we discovered the District did not maintain records that agreed to the low-income student counts as reported to the Arizona Department of Education to properly allocate Title I funding by poverty level. Corrective Action: The District will ensure in future periods that records are maintained to support lowincome students and the allocation of Title I funding as reported to the Arizona Department of Education. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Jenette King, Business Manager
Recovery Services of Northwest Ohio, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 1, 2024-June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently w...
Recovery Services of Northwest Ohio, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 1, 2024-June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. 2025-001 Type of Finding: Significant deficiency identified: The organization is charging payroll costs to grants based on budgeted amounts rather than costs supported by time and effort documentation. Recommendation: Implementation of either a timekeeping system where timecards include documentation of time allocated to each grant or the implementation of a time study process with the lookback procedures to meet the time and effort documentation requirements in accordance with the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The organization will implement time and effort documentation/time study for federal awards and charge grant staff costs based on such documentation. Name(s) of the contact person(s) responsible for corrective action: Jean Groves, CFO, Recovery Services of Northwest Ohio, Inc. 419-782-9920. Planned completion date for corrective action plan: March 15, 2026.
Cognizant or Oversight Agency for Audit: The Autonomous Municipality of Isabela respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Gonzalez. Torres & Co., PSC, San Jose Tower 1250 Ponce de Leon Ave. Suit...
Cognizant or Oversight Agency for Audit: The Autonomous Municipality of Isabela respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Gonzalez. Torres & Co., PSC, San Jose Tower 1250 Ponce de Leon Ave. Suite 801, San Juan, PR 00907-3912 Audit Period: June 30, 2025 The findings form the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT Finding 2025-001: Accounting Records and Reporting System Reportable Condition: See Statement of Condition 2025-001 Recommendation: The Municipality of Isabela should establish procedures and controls to review and modify its current accounting and financial reporting structure in order to obtain reliable financial information on a timely basis. Adjustments and analysis of accounts should be improved to obtain financial statements on time for the decision-making process. The Municipality should establish internal control and procedures in order to maintain an accounting system that contains information pertaining to bank reconciliation and accounts receivables, and related allowances. The Finance Director will delegate the responsibility to perform the monthly bank reconciliations and receivables reports to an employee of the Municipality of Isabela under its supervision. The reconciliation should be signed by the employee of officer and must be checked and signed by the finance director. All differences must be investigated, and the accounts reconciliation must be reconciled to the general ledger. The Centro Isabelino de Medicina Avanzada must strengthen its accounting records for proper follow up and accounting of its receivable’s balances. Corrective Action – Finding 2025-01 During the Fiscal year 2023-2024 and 2024 2025 the Municipality acquired a new accounting system. At this moment, the Finance Department is still working on the implementation of this new accounting system. We expect that when the implementation is completed, it will help the Finance Department to account, in a timely manner, all the financial transactions if the Municipality and to reconcile all the bank accounts in the accounting system. Also, to mitigate this issue, we engaged, annually, with an external consultant to prepare bank reconciliations of the Municipality However, those differences were investigated and record as of June 30, 2025 and also established in the financial statement and in the bank reconciliation as well. In relation to the Centro Isabelino de Medicina Avanzada (CIMA), they’re also implementing a new accounting system. The Municipality will monitor their preparation of bank reconcilations and accounts receivable aging FINDINGS – FEDERAL AWARD Finding 2025-002: Reporting Reportable Condition: See Statement of Condition 2025-002 Recommendation: Due diligence of the supervisory personnel to ensure that reports are submitted on its due date. Corrective Action-Finding 2025-02 The necessary instructions were given to the program staff in order to comply with the reporting requirements established by the federal grant. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please contact us at (787) 872-2100 extension 2301.
Management is cognizant of this limitation and will implement additional procedures where possible.
Management is cognizant of this limitation and will implement additional procedures where possible.
The Authority will attain weekly certified payrolls from contractors as applicable for all federally funded contracts subject to the Davis-Bacon Act. The Authority’s Executive Director, Africa Porter, has assumed the responsibility of executing this corrective action as of April 1, 2026.
The Authority will attain weekly certified payrolls from contractors as applicable for all federally funded contracts subject to the Davis-Bacon Act. The Authority’s Executive Director, Africa Porter, has assumed the responsibility of executing this corrective action as of April 1, 2026.
Name of contact Person: Brittany Naylor, Director of Social Services CorrectiveAction:Thisfinding continues to be cited asanongoingeligibilitydeterminationerrorfrom prioraudits, despite exhaustive efforts to resolve the issue. Lenoir County has worked diligently to address the backlog of exparte rev...
Name of contact Person: Brittany Naylor, Director of Social Services CorrectiveAction:Thisfinding continues to be cited asanongoingeligibilitydeterminationerrorfrom prioraudits, despite exhaustive efforts to resolve the issue. Lenoir County has worked diligently to address the backlog of exparte reviewsand bring all reporting upto date.Based onall availablereports accessibleto ouragency,wehave completedthiseffortand arecurrentonallexpartereviews.Toensureaccuracy,Lenoir Countycontacted theState to confirm whether any additional reports or cases existed that were not reflected in our records. Based on the information provided, there are no outstanding reports listed beyond June 2019. Lenoir County has submitted an additional ticket to determine why these older exparte cases continue to appear as active in the system and to request assistance in resolving this issue. We remain committed to collaborating with the State to identify and address any outstanding exparte reviews that may not be reflected in our current reports. Thisfindingalsodisclosedfourapplicantsand,/orbeneficiariesreceivingassistanceforwhichtherecipientwasnot eligible. This finding consisted of the failure of worker to check all case references to determine eligibility. Lenoir County failed to check and include all financial income on two cases and failed to complete an income budget calculation correctly on one case. The following steps will be added to existing practices to ensure ongoing eligibility compliance. Staff meeting will be held Wednesday, February 18,2026 and the following training materials will be discussed and provided to the Medicaid staff to ensure continued understanding and knowledge of program requirements. MAGI policy manual 3306 - Modified Adjusted Gross Income - will be reviewed and additional guidance provided on how to effectively calculate income correctly to determine eligibility for case actions. Verbally explain and provide MAGI Budgeting: 5% Income Disregard PowerPoint and ensure that staff understand how to apply the deduction correctly to case actions. Verbally explain and provide Reasonable Compatibility PowerPoint and ensure that staff understand when and how to apply reasonable compatibility to case per policy requirements. Providing staff with copies of the Single County Audit findings, the Corrective Action plan and staff expectations to ensure that staff is well informed of the findings and what is expected from the Corrective Action Plan implementation. Staff will be required to complete adding machine calculations and check amounts against NC FAST system calculations to verify correct financial income for case actions. A summary check-off form has been created to ensure that staff are checking NC FAST determinations page to cross reference system eligibility approvals are inline with client case actions. Workers must check household size and compare case composition to ensure correct eligibility results. Supervisor and/or Lead Worker will complete 100% 2nd party reviews on all new hires until each worker receives a 95% or higher accuracy processing rating and will complete a minimum of 5 2nd party reviews for each existing worker to target these key areas of concern until all workers reach and maintain a 95% or higher accuracy processing rating. Staff will correct any findings within three days of receipt of 2nd party review findings. Supervisors and Lead Workers will continue to monitor case actions and provide monthly statistical data detailing case findings. The Supervisor and Lead Worker will provide a list of findings and maintain scheduled monthly meetings with staff to provide feedback and coaching to ensure continued compliance of program requirements. The meetings held will consist of staff unit meetings and/or individual conferences provided by the Supervisors in an effort to effectively catch and manage error trends that have been discovered from 2nd party review findings All documentation will be submitted to the Administrator for review and will be discussed and reviewed with the Supervisors during monthly conference meetings. The Administrator will provide monthly updates on case actions and findings to the Director. Proposed Completion Date: The exparte issue is expected to be resolved when data is received from State, not to exceed timeframeofJune30,2026.Training willbeheldwith MedicaidStaffonWednesday,February18,2026 for other eligibility issues cited. Corrective Action Plan will be implemented immediately after training and significant improvement of all areas cited must be maintained by June 30, 2026.
Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendentwill ensure MDE's approval is tangible before any obligations. We will implement a tool that allows this process to be ...
Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendentwill ensure MDE's approval is tangible before any obligations. We will implement a tool that allows this process to be measured daily. Responsible Parties: Avery Johnson, Business Manager Tiffany Willis, Federal Programs Director Corrective Action Start Date: February 18, 2026
FINDING 2025-006 Finding Subject: Subject: COVID-19 - Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Jamesi Lemon Contact Phone Number and Email Address: jlemon@lakelandlakers.net Views of Responsible Officials: We concur with the finding. Description of ...
FINDING 2025-006 Finding Subject: Subject: COVID-19 - Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Jamesi Lemon Contact Phone Number and Email Address: jlemon@lakelandlakers.net Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Director of Business Operations and Director of Student and Staff Success will meet monthly to plan and effectively monitor the 20% earmark requirement. Records of the meetings will be kept in the grant folder as documentation. Anticipated Completion Date: The projected date of completion is August 31, 2026.
FINDING 2025-003 Finding Subject: Title I, Part A - Special Tests and Provisions - Assessment System Security Contact Person Responsible for Corrective Action: Alexis Grossman Contact Phone Number and Email Address: agrossman@lakelandlakers.net Views of Responsible Officials: We concur with the find...
FINDING 2025-003 Finding Subject: Title I, Part A - Special Tests and Provisions - Assessment System Security Contact Person Responsible for Corrective Action: Alexis Grossman Contact Phone Number and Email Address: agrossman@lakelandlakers.net Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Training for test security is completed electronically. The staff members then sign a paper form stating the training is complete. The form is now scanned and stored both electronically and physically. Anticipated Completion Date: Already completed.
DHS’ Office of Income Maintenance (OIM) Bureau of Operations (BOO): BOO will take the following actions to address the finding: The BOO will work with the EBT Project Office to create a dedicated section in the OIM EBT Procedure Manual to document the exceptions identified during the single audit ea...
DHS’ Office of Income Maintenance (OIM) Bureau of Operations (BOO): BOO will take the following actions to address the finding: The BOO will work with the EBT Project Office to create a dedicated section in the OIM EBT Procedure Manual to document the exceptions identified during the single audit each year. This addition will ensure that all offices are informed of the issues, can review their processes and procedures, and can make any necessary corrections. It will be added by April 1, 2026. The below items will be included: Knowing how to reconcile: • The Roles/Permissions Report from the EBT Card Tracking Database. • The Daily Log Summary and Weekly log report in the EBT Card Tracking Database. Reminders of the following concerns: • EBT card creation should end, and all cards should be logged in the EBT Card Tracking Database, by the close of business each day. No cards should be created after 5 PM. • When to use EBT Card Tracking Paper Logs, and how long to maintain them. • Ensuring that, upon receipt of each shipment of EBT cards and related supplies, the shipping manifest date is stamped. • Mailing locally created EBT cards directly to customers on the same day that the card is created. • Timeframes for completing and submitting the EPPIC EBT Systems Application forms to the OIM EBT Project Office. • Timeframe to deactivate user access in the EBT Card Tracking Database. • Timeframe for when to enter a shipment received into the EBT Card Tracking Database. The BOO, in conjunction with the EBT Project Office, distributes attestation forms to staff each year, typically during the first quarter. Employees are required to sign and return these forms to confirm that they have reviewed the procedure manual. The form for this cycle was sent out in February 2026. Anticipated Completion Date: 04/01/2026 Contact Name: Jeanette Coulston, Staff Assistant to BOO Director OIM Bureau of Program Evaluation (BPE) Division of Corrective Action (DCA): BPE will take the following actions to address the finding: The DCA conducts EBT Card Security reviews at every CAO and District Office that issues EBT cards. These reviews are conducted on a 3-year rotation to ensure compliance with documented policies and procedures. Annually, BPE/DCA EBT Headquarters staff provide training to DCA Income Maintenance Examiners in both field offices, to ensure awareness of any policy or procedure changes, prior to the start of EBT reviews. This training occurred on October 2, 2025. The current rotation schedule spans FFY 2025 through FFY 2027. Anticipated Completion Date: 04/01/2026 Contact Names: Amira Milikin, DCA Director; Bryan Bumpers, EBT Project Officer
The MatrixCare SOC2 report for 2025 was received on Friday February 6, 2026 and was reviewed by the Agency’s Information Technology (IT) Executive. The Agency’s Information Technology Executive/designee will educate the Information Technology Project Manager to request from Matrixcare on an annual b...
The MatrixCare SOC2 report for 2025 was received on Friday February 6, 2026 and was reviewed by the Agency’s Information Technology (IT) Executive. The Agency’s Information Technology Executive/designee will educate the Information Technology Project Manager to request from Matrixcare on an annual basis the SOC2 report and will review compliance criteria such as data security and confidentiality. An Agency Information Technology Resource Account will be developed for the SOC2 report/s to be sent to for review. Future contracts will request the vendor to automatically send SOC2 reports to the established IT Resource Account. Matrixcare security templates for Healthcare Record access have been updated by the Change Management Committee and activated by the Nurse Administrator-Technical for all users to ensure appropriate access. The Agency’s Human Resources Field Operations Manager/designee will educate the State Veterans Home (SVH) Human Resources Assistants of their responsibilities for on-boarding and off-boarding documentation for employee hires, classification changes and separations and of the DMVA’s Onboarding and Offboarding User Guides. The SVH Human Resource Analyst/designee will provide to the SVH Privacy Officer/designee all employee actions monthly to review for appropriate Healthcare Record access, the Bureau of Veterans Homes (BVH) Healthcare Record Management protocol will be updated to reflect this audit. The Agency’s Privacy Officer/designee will review 25% of all employee actions annually during each State Veterans’ Homes’ Facility Performance Assessment (FPA) to verify appropriate Healthcare Record access, the BVH FPA Protocol will be updated to reflect this audit. Anticipated Completion Date: 04/15/2026 Contact Name: Barbara L. Raymond, Director, Bureau of Veterans Homes
Alfred Yaney, Director, Enterprise e-Grants, opened a remedy ticket requesting to have the e-Grants group removed from the list of permitted groups. Screenshots were provided to the auditors as evidence of all the groups that have Admin access to validate the requested group had been removed. Antici...
Alfred Yaney, Director, Enterprise e-Grants, opened a remedy ticket requesting to have the e-Grants group removed from the list of permitted groups. Screenshots were provided to the auditors as evidence of all the groups that have Admin access to validate the requested group had been removed. Anticipated Completion Date: Completed Contact Name: Carolyn McCarthy, Head of Governance, Risk and Compliance
FINDING 2025-005 SPED Procurement and Suspension and Debarment Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of...
FINDING 2025-005 SPED Procurement and Suspension and Debarment Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Accounting Department will start keeping a binder that will include all the Procurement and Suspension and Debarment Certificates pertaining to the vendors in our federal programs that equal or exceed $25,000 for each school year. The A/P Clerk will alert the Treasurer when a certificate is needed, and the Treasurer will first check SAM, and then proceed with collecting a certificate from the vendor if one is not found online. When applicable, we can add a clause or condition to a contract noting this acknowledgement. Anticipated Completion Date: This process will be in place by the end of the current fiscal year, June 30, 2026.
FINDING 2025-003 CNC Eligibility Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Co...
FINDING 2025-003 CNC Eligibility Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Direct Certification downloads will be done once a month by the Cafeteria Director. The Cafeteria Director will sign the report and forward it to the Treasurer for verification and a second signature. The Direct Certification reports will be kept at the central office. Anticipated Completion Date: This process will be in place by the end of the current fiscal year, June 30, 2026.
Trainings have been conducted during the current school year for principals, secretaries, and cooks at all schools on following correct meal patterns and point of service procedures. The current child nutrition director performs random audits and visits at all schools to make sure schools are follow...
Trainings have been conducted during the current school year for principals, secretaries, and cooks at all schools on following correct meal patterns and point of service procedures. The current child nutrition director performs random audits and visits at all schools to make sure schools are following these procedures consistently.
Views of Responsible Officials: The College acknowledges the audit finding that Return of Title IV (R2T4) calculations were not accurately completed for nine of the sixty students sampled, and that Title IV funds were not returned timely for fifteen of the sixty students sampled. During the audit pe...
Views of Responsible Officials: The College acknowledges the audit finding that Return of Title IV (R2T4) calculations were not accurately completed for nine of the sixty students sampled, and that Title IV funds were not returned timely for fifteen of the sixty students sampled. During the audit period, R2T4 tracking and oversight processes were in transition, which resulted in insufficient monitoring of calculation accuracy and timeliness. In addition, for several end-of-term cases involving unofficial withdrawals, the institution could not initiate R2T4 calculation until final grades were posted and an unofficial withdrawal determination was made based on non-passing (F) grades, in accordance with federal regulations governing unofficial withdrawals. The Fall 2024 semester ended on December 21st. The college was closed for the winter break and reopened January 2, 2025. Therefore, the Date of Determination (DOD) was not two days after the end of the semester but in January with the earliest available processing date being January 2, 2025. Corrective Action: The College has implemented enhanced internal controls to ensure compliance with Return of Title IV (R2T4) requirements. Responsibility for monitoring R2T4 calculations and timeliness has been assigned to the Director of Financial Aid and Compliance. A R2T4 tracking log has been established and is reviewed on a weekly basis to ensure that all official withdrawals are identified and processed within the required regulatory timeframe. For unofficial withdrawals, R2T4 calculations are initiated after the end of term once final grades are posted and an unofficial withdrawal date of determination (DOD) is made based on non-passing (F) grades, consistent with federal regulations. End-of-term R2T4 reviews for the fall semester are conducted upon return from winter break after the New Year to ensure complete and accurate academic records are available. Internal staff have received additional training on R2T4 regulatory requirements, timelines, and documentation standards. To ensure operational continuity, a senior specialist has been trained to manage R2T4 processing in the Director's absence. These corrective actions will strengthen internal controls and ensure accurate and timely processing of R2T4 calculations.
Views of Responsible Officials: After consultation with the College’s Information Technology department, management determined that the file was processed and submitted on time. However, the NSLDS discrepancy resulted from a data processing issue during the March 2025 enrollment status download. Spe...
Views of Responsible Officials: After consultation with the College’s Information Technology department, management determined that the file was processed and submitted on time. However, the NSLDS discrepancy resulted from a data processing issue during the March 2025 enrollment status download. Specifically, while the NSLDS file was being generated, staff from another office were simultaneously accessing the same student records. These concurrent activities caused the affected students’ enrollment statuses to default to data from a prior download, resulting in incorrect reporting for the two records of the sixty examined. Corrective action: The College has revised its NSLDS data reporting process to prevent a recurrence of concurrent access. A static, saved population list is now used to generate NSLDS enrollment status downloads, eliminating conflicts caused by concurrent system access. This change ensures that enrollment status data is not impacted and remains consistent at the time of submission. Management believes this corrective action adequately addresses the identified issue, strengthens controls, mitigate this issue for future status change reports, and allows for accurate submission within the required 60-day timeframe.
Corrective action plan: The CAPPS Financials team uses Pathlock to monitor and log privileged user activities. Pathlock maintains documentation of approvals and business justifications. Documentation of recurring privileged access reviews will be maintained as appropriate across all dedicated CAPPS ...
Corrective action plan: The CAPPS Financials team uses Pathlock to monitor and log privileged user activities. Pathlock maintains documentation of approvals and business justifications. Documentation of recurring privileged access reviews will be maintained as appropriate across all dedicated CAPPS Financial modules. IAM team will establish a documented process through which it will coordinate with the CAPPS Financial team to perform quarterly reviews of accounts and audit logs to strengthen privileged access provisioning. The review process will include documented approval, business justification, and periodic revalidation for all elevated roles in CAPPS Financial. Pathlock software is being used to manage single sign-on for granting privileged access to allowed users. With this software, the IAM team can grant access to a user, who would then login as themselves and then switch to the appropriate privileged role. Once the user switches to a privileged role, the Pathlock software maintains the audit log of user activity. Implementation date: February 27, 2026 Responsible persons: Daniel Kellogg, Deputy Chier Information Officer (DCIO), Infrastructure Services Leatha Marr, DCIO & Chief Product Officer, System Applications
Corrective action plan: Long Term Care Regulation will enhance existing internal controls to ensure timely completion and distribution of Form 2567 to the providers. Implementation date: March 31, 2026 Responsible person: Michelle Dionne-Vahalik, Associate Commissioner, Long Term Care Regulations
Corrective action plan: Long Term Care Regulation will enhance existing internal controls to ensure timely completion and distribution of Form 2567 to the providers. Implementation date: March 31, 2026 Responsible person: Michelle Dionne-Vahalik, Associate Commissioner, Long Term Care Regulations
Corrective action plan: HHS Information Security: • Has implemented a centralized governance process to ensure completion of all required biennial risk assessments. • Will establish and maintain oversight, validation, and escalation procedures for overdue assessments to ensure sustained adherence to...
Corrective action plan: HHS Information Security: • Has implemented a centralized governance process to ensure completion of all required biennial risk assessments. • Will establish and maintain oversight, validation, and escalation procedures for overdue assessments to ensure sustained adherence to federal and state requirements. • Will establish an inventory of systems to ensure information owners and custodians are assigned. • Will create an automated compliance dashboard to facilitate monthly reporting to executive leadership. • Will prioritize high-risk Medicaid systems, targeting completion within three months and achieving full compliance with Texas Administrative Code (TAC) 202 requirements within twelve months. The Deputy Chief Information Officers (DCIO) and Chief Product Officers for System Applications, Public Health Applications, and Texas Integrated Eligibility Redesign System (TIERS)/Medicaid Enterprise Systems (MES) will provide support and assistance to the program areas in creating Plan of Actions and Milestones and completing risk assessments for all systems provided in the executive report for their respective areas related to the audit. Implementation date: February 28, 2027 Responsible persons: Anil Koindala, Chief Information Security Officer Leatha Marr, DCIO and Chief Product Officer, System Applications Madhavi Koganti, DCIO and Chief Product Officer, Public Health Applications James Huang, DCIO and Chief Product Officer, TIERS/MES
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