Corrective Action Plans

Finding 1218821 (2025-003)

Material Weakness 2025

TX

Questioned Costs Special Tests & Provisions HUD Housing Programs

Authority Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor and has initiated corrective actions to strengthen compliance with Housing Quality Standards (HQS) inspection requirements and related abatement procedures. Management identified that staff...

Authority Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor and has initiated corrective actions to strengthen compliance with Housing Quality Standards (HQS) inspection requirements and related abatement procedures. Management identified that staffing turnover and transition-related training gaps contributed to delays in the timely processing and enforcement of failed inspection reinspections and landlord abatements during the audit period. In response, the Authority has implemented enhanced monitoring and supervisory review procedures over failed inspections and reinspection timelines to ensure compliance with HUD requirements. Management has reinforced staff training related to HQS enforcement, reinspection tracking, and Housing Assistance Payment (HAP) abatement procedures. In addition, the Authority is utilizing system generated tracking reports and management oversight tools to identify failed inspections approaching required corrective action deadlines and to ensure timely follow-up and enforcement actions are completed. The Authority believes these corrective measures will strengthen internal controls over compliance and help ensure continued adherence to HUD Housing Quality Standards requirements and related special tests and provisions compliance requirements. Isaiah Norris, Vice President of the Housing Choice Vouchers Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2026.

View Audit 404911

Finding 1218820 (2025-002)

Material Weakness 2025

Corpus Christi Housing Authority

TX

Questioned Costs Eligibility HUD Housing Programs

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

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

View Audit 404911

Finding 1218814 (2025-003)

Material Weakness 2025

St. Charles Parish Housing Authority

LA

Questioned Costs Procurement, Suspension & Debarment Cash Management § 200.305

Non-compliance with Cash Management Requirements of the Capital Fund Program Corrective Action With the exception of Capital Fund Program grant authorizations budged for Public Housing Program operating assistance, the Authority will expend the unexpended Capital Fund Program grant proceeds held pri...

Non-compliance with Cash Management Requirements of the Capital Fund Program Corrective Action With the exception of Capital Fund Program grant authorizations budged for Public Housing Program operating assistance, the Authority will expend the unexpended Capital Fund Program grant proceeds held prior to drawing down additional funding from Capital Fund Program grants. Jebidiah Jackson, Executive Director, has assumed the responsibility of executing this corrective action as of August 1, 2026.

View Audit 404892

Finding 1218801 (2025-002)

Material Weakness 2025

Ponca Tribe of Nebraska

NE

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

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

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

View Audit 404885

Finding 1218796 (2025-003)

Material Weakness 2025

City of Lowell

MA

Allowable Costs / Cost Principles Period of Performance Questioned Costs § 200.309 § 200.403

Audit Finding Reference: 2025-003 Improve Controls over Period of Performance Planned Corrective Action: The District has strengthened its grant management and closeout procedures to ensure that all expenditures charged to federal awards are incurred, processed, and paid within the applicable period...

Audit Finding Reference: 2025-003 Improve Controls over Period of Performance Planned Corrective Action: The District has strengthened its grant management and closeout procedures to ensure that all expenditures charged to federal awards are incurred, processed, and paid within the applicable period of performance. Specifically, the District will: 1. Implement a formal grant closeout checklist that includes a review of all open purchase orders, encumbrances, unpaid invoices, and outstanding obligations prior to submission of final expenditure reports. 2. Require reconciliation of grant expenditures between the Grants Office, Special Education Department, and Business Office before final grant reports are submitted. 3. Establish periodic reviews of open encumbrances throughout the year to identify outstanding obligations and ensure timely processing of invoices. 4. Designate backup personnel and document grant management procedures to ensure continuity during staffing transitions or vacancies. 5. Require supervisory review and approval of all grant closeout documentation to verify that all allowable expenditures have been recorded and reported appropriately. 6. Provide training to personnel responsible for grant administration and financial reporting regarding federal period-of-performance requirements and grant closeout procedures. Planned Implementation Date of Corrective Action: The revised grant monitoring and closeout procedures have been implemented for all active federal grants and will be fully incoiporated into the District's grant management process beginning with the current fiscal year. Person Responsible for Corrective Action: Grants Manager Signature Derek Pinto, Assistant Superintendent of Finance

View Audit 404883

Finding 1218790 (2025-001)

Material Weakness 2025

City of Lowell

MA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Audit Finding Reference: 2025-001 Maintain Employee's Time and Effort Records Planned Corrective Action: The District will implement and enforce a formal time and effort reporting process for all employees whose salaries are charged to federal programs. The process will include: 1. Identification of...

Audit Finding Reference: 2025-001 Maintain Employee's Time and Effort Records Planned Corrective Action: The District will implement and enforce a formal time and effort reporting process for all employees whose salaries are charged to federal programs. The process will include: 1. Identification of all employees whose compensation is funded, in whole or in part, by federal awards. 2. C.ompletion of required semi-annual certifications or periodic personnel activity reports, as applicable, in accordance with Uniform Guidance requirements. 3. Review and approval of certifications bysupervisory personnel to ensure accuracy and completeness. 4. C.entralized maintenance of all certifications by the Grants Office to ensure records are readily available for audit and monitoring purposes. 5. Development of a compliance calendar with established due dates and reminder notifications for required certifications. 6. Quarterly monitoring bythe Business Office to verifythat all required certifications have been completed, reviewed, and retained. Planned Implementation Date of Corrective Action: The District has begun implementing these procedures and will have the revised process fully operational by 6/30/2026. All required certifications for the current fiscal year will be collected and maintained going forward. Person Responsible for Corrective Action: Grants Manager, Funds Analyst, Deputy Chief Financial Officer Signature Derek Pinto, Assistant Superintendent of Finance

View Audit 404883

Finding 1218776 (2025-002)

Material Weakness 2025

City of Lowell

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.327

Audit Finding Reference: 2025-002 Improve Procurement Procedures Planned Corrective Action: The District will strengthen its procurement procedures for federally funded purchases to ensure compliance with Uniform Guidance requirements. Specifically, the District will: 1. Revise procurement procedure...

Audit Finding Reference: 2025-002 Improve Procurement Procedures Planned Corrective Action: The District will strengthen its procurement procedures for federally funded purchases to ensure compliance with Uniform Guidance requirements. Specifically, the District will: 1. Revise procurement procedures to clearly identify when federal procurement requirements apply in addition to state and local procurement regulations. 2. Develop and implement a federal procurement checklist that must be completed prior to the award of any contract funded in whole or in part with federal grant funds. 3. Work with the Law Department to establish standardized contract templates containing all required federal contract provisions, including the Byrd Anti-Lobbying Amendment when applicable. 4. Require a secondary review bythe Business Office or Grants Management personnel before contract execution to verify compliance with Uniform Guidance procurement standards and required contract clauses. 5. Provide annual training to Business Office staff, grant managers, and other personnel involved in procurement activities regarding federal procurement requirements and contract provisions. 6. Conduct periodic internal reviews of federally funded procurement transactions to ensure ongoing compliance. Planned Implementation Date of Corrective Action: The revised procedures, procurement checklist, and standardized contract templates will be implemented by7 /1/2026. Training will be completed for applicable staff during the current fiscal year and prior to the initiation of future federally funded procurements. Person Responsible for Corrective Action: Assistant Superintendent of Finance Derek Pinto, Assistant Superintendent of Finance

View Audit 404883

Finding 1218753 (2025-002)

Material Weakness 2025

Town of Southbridge, Massachusetts

MA

Procurement, Suspension & Debarment Questioned Costs Significant Deficiency § 200.319

Finding 2025-002 Condition: Two vendors were awarded a contract without a competitive procurement process. The school did not maintain any documentation in the files regarding why a competitive procurement process was not performed. Corrective Action Planned: Southbridge Public Schools is actively c...

Finding 2025-002 Condition: Two vendors were awarded a contract without a competitive procurement process. The school did not maintain any documentation in the files regarding why a competitive procurement process was not performed. Corrective Action Planned: Southbridge Public Schools is actively creating procedures for all procurements in compliance with Massachusetts General Laws and Federal Regulations. This procedure will be in place for any procurements utilizing federal grant funding. Anticipated Completion Date: July 31, 2026 Contact: Matthew Robidoux – Business Manager

View Audit 404856

Finding 1218744 (2025-001)

Material Weakness 2025

Town of Southbridge, Massachusetts

MA

Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.430

Finding 2025-001 Condition: Time and effort certifications were not maintained for grant employees. Corrective Action Planned: Southbridge Public Schools will be creating and implementing procedures for time and effort certifications. The procedure will include use of the form distributed by the Mas...

Finding 2025-001 Condition: Time and effort certifications were not maintained for grant employees. Corrective Action Planned: Southbridge Public Schools will be creating and implementing procedures for time and effort certifications. The procedure will include use of the form distributed by the Massachusetts Department of Elementary and Secondary Education for employees who are paid by a grant and require a time and effort certification. Anticipated Completion Date: July 31, 2026 Contact: Matthew Robidoux – Business Manager

View Audit 404856

Finding 1218738 (2025-001)

Material Weakness 2025

Tallassee City Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures supported by federal funds. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds. Policies and procedures will be im...

Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures supported by federal funds. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior to the submission of the July-September 2026 claim.

View Audit 404835

Finding 1218735 (2025-002)

Material Weakness 2025

Crossett Housing Authority

AR

Questioned Costs Subrecipient Monitoring Cash Management

Views of Responsible Officials and Planned Corrective Actions: The Crossett Housing Authority Director will immediately seek guidance from HUD officials and MRI/Lindsey to remedy this problem.

View Audit 404826

Finding 1218734 (2025-004)

Material Weakness 2025

City of Hill City

MN

Procurement, Suspension & Debarment Questioned Costs Material Weakness

Suspension and Debarment Recommendation: We recommend the City implement a written suspension debarment policy or procedures that comply with the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Th...

Suspension and Debarment Recommendation: We recommend the City implement a written suspension debarment policy or procedures that comply 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 City will adopt a formal suspension and debarment policy. Name of the contact person responsible for corrective action: Tami Meyer Planned completion date for corrective action plan: December 31, 2026

View Audit 404825

Finding 1218716 (2025-061)

Material Weakness 2025

State of Michigan

MI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

Finding 2025-061 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Block Grants for Prevention and Treatment of Substance Abuse, ALN 93.959 Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an A...

Finding 2025-061 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Block Grants for Prevention and Treatment of Substance Abuse, ALN 93.959 Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an API for the submission of FFATA data to the federal system, SAM, to improve both timeliness and accuracy through automation. This API will connect EGrAMS with SAM, enabling backend communication between the systems and allowing SAM to automatically retrieve data directly from EGrAMS. To ensure accurate reporting until the API is established, MDHHS will continue reviewing validation errors when submitting web-based information to SAM and will work with the SAM federal helpline to report federal system issues and identify interim alternatives to submit the required data. Also, MDHHS implemented an enhancement in August 2025 that validates federal funding sources in EGrAMS against their effective dates, reducing coding errors and improving data reliability. In addition, the query used to obtain certain FFATA data elements was modified during fiscal year 2026 to improve accuracy of reporting. Anticipated Completion Date December 31, 2027 Responsible Individual(s) Matt Blackburn, MDHHS Jeanette Hensler, MDHHS Rebecca Jones, MDHHS

View Audit 404775

Finding 1218710 (2025-019)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Internal Control / Segregation of Duties

Finding 2025-019 MARIS Change Management Process Management Views MDHHS agrees that the procedural step of formalizing post implementation validation documentation was not completed for this specific request for change. MDHHS emphasizes that active operational monitoring of the Medicaid Audit Recove...

Finding 2025-019 MARIS Change Management Process Management Views MDHHS agrees that the procedural step of formalizing post implementation validation documentation was not completed for this specific request for change. MDHHS emphasizes that active operational monitoring of the Medicaid Audit Recovery and Investigation System (MARIS) environment occurred post deployment, mitigating the risk of unauthorized or inappropriate changes impacting the system's secure operation. In addition, MDHHS notes that verbal approval for the deployment was provided during a meeting with DTMB, and both parties proceeded with the understanding that the change was authorized. The absence of required written documentation was an administrative oversight stemming from a breakdown in the established interagency communication workflow, where DTMB did not send the standard notification email prompting the business owner's formal sign-off. Planned Corrective Action The MDHHS Office of Inspector General (OIG) formalized a communication protocol with DTMB to ensure the change management documentation lifecycle is completed. During April 2026, DTMB and the OIG implemented the use of Azure DevOps for monitoring scheduled MARIS implementation dates and documenting approvals. Anticipated Completion Date Completed Responsible Individual(s) Casey Barton, MDHHS

View Audit 404775

Finding 1218709 (2025-018)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

Finding 2025-018 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Medical Loss Ratio Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS updated and strengthened its medical loss ratio (MLR) reporting instructions and ...

Finding 2025-018 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Medical Loss Ratio Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS updated and strengthened its medical loss ratio (MLR) reporting instructions and comparison template for the MHP Comprehensive Health Care Plan (CHCP), Dental Health Plans, and MI Choice to ensure clearer expectations and alignment with federal requirements. The CHCP and MI Choice programs cited in the fiscal year 2024 audit did not have any identified issues during the fiscal year 2025 audit, demonstrating the impact of MDHHS’s efforts to improve internal controls and monitoring activities to ensure all submitted MLR reports are completed in accordance with federal regulations. MDHHS updated the MLR reporting instructions and the comparison template for the PIHPs to clarify federal requirements and ensure consistency across all managed care programs and distributed them to the PIHPs during May 2026. MDHHS will strengthen its internal tracking and review process to ensure inclusion of the federally required comparison to audited financial statements in all MLR submissions by September 1, 2026. This verification step, currently in place for PIHPs, will be expanded to all managed care entity types. MDHHS will document this verification and follow up with the managed care entity when the comparison is missing or incomplete to ensure compliance with federal regulations. Anticipated Completion Date September 1, 2026 Responsible Individual(s) Kristen Morningstar, MDHHS Keith White, MDHHS Chris Parker, MDHHS

View Audit 404775

Finding 1218708 (2025-017)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

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

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

View Audit 404775

Finding 1218707 (2025-016)

Material Weakness 2025

State of Michigan

MI

Reporting Questioned Costs

Finding 2025-016 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Refunding of Federal Share of Overpayments Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS will evaluate and enhance the current proces...

Finding 2025-016 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Refunding of Federal Share of Overpayments Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS will evaluate and enhance the current process to ensure all overpayment-related receivables are timely and accurately reported for inclusion in the quarterly statement of expenditures reports (CMS 64 and CMS 21 reports). For part b., MDHHS will implement a review process to verify that all manually entered federal medical assistance percentage (FMAP) rates for CHAMPS receivables are accurate. Additionally, MDHHS will evaluate and enhance current procedures to ensure the date of payment is consistently entered to generate the correct FMAP rate for all overpayments within the Adult Services Authorized Payments system. Anticipated Completion Date September 30, 2027 Responsible Individual(s) Rebecca Jones, MDHHS Darryl Walker, MDHHS Jessica Moy, MDHHS Shemin Blundell, MDHHS Michelle Popowich, MDHHS

View Audit 404775

Finding 1218706 (2025-015)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Subrecipient Monitoring

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

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

View Audit 404775

Finding 1218705 (2025-014)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Cash Management § 200.516

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

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

View Audit 404775

Finding 1218704 (2025-013)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Subrecipient Monitoring § 200.516

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

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

View Audit 404775

Finding 1218703 (2025-011)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Subrecipient Monitoring Material Weakness

Finding 2025-011 MDHHS - FFATA Reporting Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an application programming interface (API) for the submission of the Federal Funding Accountability and Transparency Act (FFATA) data to...

Finding 2025-011 MDHHS - FFATA Reporting Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an application programming interface (API) for the submission of the Federal Funding Accountability and Transparency Act (FFATA) data to the federal system, the System for Award Management (SAM), to improve both timeliness and accuracy through automation. This API will connect the Electronic Grants Administration and Management System (EGrAMS) with SAM, enabling backend communication between the systems and allowing SAM to automatically retrieve data directly from EGrAMS. To ensure accurate reporting until the API is established, MDHHS will continue reviewing validation errors when submitting web-based information to SAM and will work with the SAM federal helpline to report federal system issues and identify interim alternatives to submit the required data. Also, MDHHS implemented an enhancement in August 2025 that validates federal funding sources in EGrAMS against their effective dates, reducing coding errors and improving data reliability. In addition, MDHHS modified the query used to obtain certain FFATA data elements during fiscal year 2026 to improve accuracy of reporting. Anticipated Completion Date December 31, 2027 Responsible Individual(s) Matt Blackburn, MDHHS Jeanette Hensler, MDHHS Rebecca Jones, MDHHS

View Audit 404775

Finding 1218702 (2025-008)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

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

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

View Audit 404775

Finding 1218701 (2025-005)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Subrecipient Monitoring

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

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

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Finding 1218700 (2025-004)

Material Weakness 2025

State of Michigan

MI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

Finding 2025-004 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exceptio...

Finding 2025-004 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals, semi-annual review of privileged users, and annual review for all users. Security management and access control processes will continue to be a standing agenda item for ongoing quarterly training sessions with local office security coordinators (LOSC). For parts a., c., and d., the Access Management Section began implementing a process to conduct quarterly reconciliations of the DSA to the Bridges Integrated Automated Eligibility Determination System (Bridges) during March 2025. Due to the complexity of the reconciliations and time constraints, MDHHS requested the Bridges technical team to develop a consolidated Excel based report to add a level of automation to the process. The report is now available on an ad hoc basis, and the Access Management Section began utilizing it during April 2026 to conduct reviews and provide remediation with the LOSCs and end users. Full automation of the report remains in progress due to significant competing priorities and limited resources. For part b., MDHHS implemented the automated DSA periodic access review process (PAR) during January 2026 to review all users every 90 days, instead of the current 180 days for privileged users. MDHHS updated its policy to require initiation of the PAR in the DSA for all users every 90 days, without exception, to comply with State standards. For part e., MDHHS local office directors, district managers, or designees review a monthly sample of high-risk Bridges transactions to ensure documentation was properly maintained. Beginning September 2024, MDHHS Business Service Centers (BSC) implemented a monitoring process to ensure monthly reviews are completed by the local offices timely and that the documentation is properly maintained. To strengthen compliance, MDHHS will reinforce expectations through manager training and emphasize the requirement to maintain complete records and to sign and date all review reports within 30 days of the report run date. Additional training sessions will be repeated as needed to ensure consistent adherence to documentation and timeliness standards across all local offices. Anticipated Completion Date a., c., and d. Ongoing b. Completed e. September 30, 2026 Responsible Individual(s) a., b., c., and d. Tim Kwast, MDHHS e. Tim Kwast and Veronica Maxson, MDHHS

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Finding 1218699 (2025-003)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties § 200.303

Finding 2025-003 Bridges Interface Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB will establish a process to verify that the total number of processed, exception, and skipped records matches the number of records read from the data source. DTMB will investiga...

Finding 2025-003 Bridges Interface Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB will establish a process to verify that the total number of processed, exception, and skipped records matches the number of records read from the data source. DTMB will investigate discrepancies identified through this validation process and implement appropriate corrective measures to resolve the issues. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Nathan Buckwalter, DTMB

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