Corrective Action Plans

Finding 1225594 (2025-003)

Material Weakness 2025

KY

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

The Metcalfe County Fiscal Court will establish internal controls over the federal expenditure process when a third-party entity is involved to ensure all compliance and recording requirements are met. Although the Metcalfe County Fiscal Court was in compliance with federal requirements when tested ...

The Metcalfe County Fiscal Court will establish internal controls over the federal expenditure process when a third-party entity is involved to ensure all compliance and recording requirements are met. Although the Metcalfe County Fiscal Court was in compliance with federal requirements when tested by a single audit, having these procedures in place will ensure that all future federal expenditures will remain in compliance.

View Audit 408468

Finding 1225592 (2025-005)

Material Weakness 2025

Princeton Housing Authority

NJ

HUD Housing Programs Questioned Costs Special Tests & Provisions

Authority's Response and Planned Corrective Action Plan: The Authority has recognized the material weakness in the Project Based Rental Assistance program and will implement internal control procedures that will ensure compliance with federal regulations. Tyler Martin, Executive Director, is respons...

Authority's Response and Planned Corrective Action Plan: The Authority has recognized the material weakness in the Project Based Rental Assistance program and will implement internal control procedures that will ensure compliance with federal regulations. Tyler Martin, Executive Director, is responsible for ensuring the deficiencies have been rectified by June 30, 2026.

View Audit 408466

Finding 1225590 (2025-002)

Material Weakness 2025

Princeton Housing Authority

NJ

Questioned Costs Internal Control / Segregation of Duties

Authority's Response and Planned Corrective Action Plan: The Authority agrees with the finding and will strengthen payroll review procedures to ensure compensation is properly authorized, documented, and reconciled to Board-approved salary schedules. Tyler Martin, Executive Director, is responsible ...

Authority's Response and Planned Corrective Action Plan: The Authority agrees with the finding and will strengthen payroll review procedures to ensure compensation is properly authorized, documented, and reconciled to Board-approved salary schedules. Tyler Martin, Executive Director, is responsible for ensuring the deficiencies have been rectified by June 30, 2026.

View Audit 408466

Finding 1225569 (2025-003)

Material Weakness 2025

Governor's Partnership to Protect Connecticut's Workforce, Inc.

CT

Questioned Costs Subrecipient Monitoring § 200.309 § 200.403

The Partnership will implement controls to ensure that program costs are not incurred or charged to federal awards until formal award and budget approval has been received. This will include a required verification step within the finance function prior to cost authorization, documented evidence of ...

The Partnership will implement controls to ensure that program costs are not incurred or charged to federal awards until formal award and budget approval has been received. This will include a required verification step within the finance function prior to cost authorization, documented evidence of approval dates, and staff training on allowability and timing requirements. Existing procedures will be updated to prevent premature charging of expenditures and to ensure ongoing compliance with Uniform Guidance.

View Audit 408447

Finding 1225545 (2025-006)

Material Weakness 2025

Muskegon Heights Public School Academy System

MI

Allowable Costs / Cost Principles Questioned Costs

2025-006 - Documentation and Internal Controls over Disbursements (repeat finding) Auditor Description of Condition and Effect: Evidence of an independent review was not documented on our disbursements selected for testing. As a result of the condition, the Academy is exposed to an increased risk of...

2025-006 - Documentation and Internal Controls over Disbursements (repeat finding) Auditor Description of Condition and Effect: Evidence of an independent review was not documented on our disbursements selected for testing. As a result of the condition, the Academy is exposed to an increased risk of misappropriation, misstated financial statements, or noncompliance. The Academy is at increased risk of unallowable costs being charged to federal programs without being detected by its internal controls. Auditor Recommendation: We recommend that the Academy strengthen its accounts payable process by implementing a formal approval procedure to ensure all invoices are reviewed and authorized by personnel with direct knowledge of the underlying transaction prior to payment. This process should include the following elements: Designated Approvers: Identify specific individuals or roles responsible for reviewing and approving invoices for each department or type of transaction. Documented Approval: Require that each invoice include documented evidence of approval (e.g., signatures or electronic approval) before it is processed for payment. Segregation of Duties: Ensure that the approver is independent of those initiating or processing payments to maintain proper internal controls. Periodic Review: Conduct periodic reviews of accounts payable records to verify compliance with approval procedures and identify any unauthorized payments. Corrective Action: 1. Designate Official Approvers: We will identify specific staff members or roles who have direct knowledge of certain transactions to be the only ones authorized to approve those invoices. 2. Require Proof of Approval: We will implement a strict rule that no invoice is processed for payment unless it has clear, documented evidence of approval, such as a physical signature or a verified electronic sign-off. 3. Maintain Independence in Payments: We will ensure the person approving an invoice is not the individual processing the actual payment. 4. Perform Regular Spot Checks: I will conduct periodic reviews of our accounts payable records to make sure our approval procedures are being followed and to catch any unauthorized payments early. 5. Focus on Federal Compliance: We will meet monthly to monitor disbursements charged to federal programs to ensure all costs are allowable and properly documented, reducing our risk of noncompliance. Responsible Person: LaKisha Loudermill, Superintendent Anticipated Completion Date: June 30, 2026

View Audit 408425

Finding 1225502 (2025-002)

Material Weakness 2025

Lima City School District

OH

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.430 § 200.431

Lima City Schools will prepare and complete the time and effort certifications each school year. Procedures have been put in place to verify that all employees charging salaries and benefits to federal grants will have completed semi-annual certifications, signed and verified.

View Audit 408371

Finding 1225399 (2025-002)

Material Weakness 2025

H.O.P.E. HELPING OURSELVES PREVENT EMERGENCIES

AK

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies...

Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies and procedures for the review and approval of journal entries, adjustments to expenditures, and account reconciliations, to ensure expenditures reported to granting agencies are complete, accurate, allowable, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment -Once we were made aware of this finding through the audit, we began thinking of the most efficient way to document the Board’s knowledge and approvals of journal entries, including adjustments to expenditures and account reconciliations. Root Cause -HOPE is currently revising all policies and procedures. This was HOPE’s first federal single audit, so once we heard of the finding we prioritized revisions of fiscal policies and procedures to address the finding. Action Taken- The first board meeting after learning of this finding will be held on July 27th, 2026. Beginning with that meeting, the Board’s approval of the statement of activity detail, consisting of all charges and journal entries entered into HOPE’s accounting system since the date of the last Board meeting, will be approved via motion and seconded and noted as such in the Board meeting minutes. Most journal entries made during the month are currently entered into the system by HOPE’s CPA. The remaining journal entries are entered by HOPE’s Executive Director. To ensure that the Board is aware of the adjustments made in the system, all journal entries made since the last Board meeting will be approved via a motion and a second as a separate agenda item to ensure that the Board is reviewing these items particularly. All approvals will be noted in the Board meeting minutes. The list of journal entries viewed during the meeting will be initialed by a Board member and kept on file as documentation of internal controls.

View Audit 408352

Finding 1225392 (2025-003)

Material Weakness 2025

Harrington Family Health Center

ME

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was app...

Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was applied Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Billing Team Planned Corrective Action: The Organization revised its sliding fee discount policies, implemented centralized documentation tracking, and enhanced staff training related to eligibility determination and documentation requirements. Monitoring procedures, including periodic supervisory review, were established to ensure compliance. Anticipated Completion Date: Implemented and in progress. Due to the timing of the prior year’s audit completion, the Organization did not have time to complete a full monitoring cycle prior to audit testing.

View Audit 408346

Finding 1225391 (2025-002)

Material Weakness 2025

Harrington Family Health Center

ME

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

Finding: 2025-002 Condition Found: The FAC filing for the fiscal year ended March 31, 2025, was submitted late. Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Board of Directors Planned Corrective Action: Management agrees with the finding. Due to the timin...

Finding: 2025-002 Condition Found: The FAC filing for the fiscal year ended March 31, 2025, was submitted late. Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Board of Directors Planned Corrective Action: Management agrees with the finding. Due to the timing of prior year audit completion and associated late filing, the Organization did not have sufficient time within the current audit period to fully implement and demonstrate the effectiveness of corrective actions related to audit timeliness. As a result, this finding has reoccurred. The Organization has strengthened oversight by formalizing a compliance calendar, assigning clear ownership of Single Audit and Federal Audit Clearinghouse deadlines, and incorporating milestone tracking into finance operations and executive oversight processes. In addition, continued fractional CFO support provides enhanced accountability and monitoring of financial reporting timelines. These actions build upon prior year corrective efforts and are designed to ensure timely and compliant filings going forward. Anticipated Completion Date: FY2026 filing cycle.

View Audit 408346

Finding 1225358 (2025-001)

Material Weakness 2025

American Bird Conservancy

VA

Questioned Costs Reporting Significant Deficiency § 200.328

SF-425 Reporting Planned Corrective Action: American Bird Conservancy will prepare, review and maintain documented comparison of general ledger details to the SF-425 reports prepared. Person Responsible for Corrective Action Plan: Angela Modrick, Vice President of Finance Anticipated Date of Complet...

SF-425 Reporting Planned Corrective Action: American Bird Conservancy will prepare, review and maintain documented comparison of general ledger details to the SF-425 reports prepared. Person Responsible for Corrective Action Plan: Angela Modrick, Vice President of Finance Anticipated Date of Completion: Implemented

View Audit 408337

Finding 1225302 (2025-001)

Material Weakness 2025

Gallaudet University

DC

Questioned Costs Reporting Significant Deficiency

FINDING 2025-001 Internal Control over Compliance and Compliance with Reporting (Significant Deficiency and Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will strengthen its procedures for collecting, maintaining, retaining, and reviewi...

FINDING 2025-001 Internal Control over Compliance and Compliance with Reporting (Significant Deficiency and Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will strengthen its procedures for collecting, maintaining, retaining, and reviewing supporting documentation for performance metrics reported to the U.S. Department of Education. Going forward, every reported metric will be supported by source documentation that is retained, readily accessible, and available for review upon request. The University will implement the following corrective actions: • Develop and document procedures identifying the source documentation required to support each reported performance metric. • Establish a centralized electronic repository for performance-metric documentation. Staff submitting a metric write-up will be required to submit the associated raw data file with it, so the source documentation is captured at the point of submission rather than reconstructed later. • Implement a review process requiring verification of supporting documentation prior to submission of reports. • Provide training to personnel responsible for collecting, compiling, and reporting performance metrics regarding documentation and record-retention requirements. • Periodically review supporting documentation to ensure compliance with Department of Education reporting requirements and federal record-retention standards. Together, these actions will address the documentation gap identified in the finding and establish a sustainable process to support future reporting cycles. Individual(s) Responsible for Corrective Action Plan: Caroline Kobek Pezzarossi, Dean of Curriculum, Outreach, Resources and Effectiveness Khadijat Rashid, Provost Estimated Completion Date: September 30, 2026

View Audit 408332

Finding 1225268 (2025-004)

Material Weakness 2025

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Questioned Costs Special Tests & Provisions

Federal Award Finding 2025-004 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Cash Receipts Finding: The Organization maintained cash balances in excess of federally insured limits in financial institutions that did not meet HUD's minimum GNMA rating requirements. Recomm...

Federal Award Finding 2025-004 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Cash Receipts Finding: The Organization maintained cash balances in excess of federally insured limits in financial institutions that did not meet HUD's minimum GNMA rating requirements. Recommendation: The Organization should transfer excess cash balances to financial institutions that meet HUD's GNMA rating requirements or otherwise structure its cash holdings to ensure compliance with federal insurance limits and HUD custodial requirements. Action Taken: Nevins moved to this financial institution with the first HUD loan in 2015. This is a local bank that actively supports Nevin's mission in the community. Given Nevins’ current financial struggles, the balance in the bank seldom exceeds the $250,000 threshold. In addition, the receiver established its own account with East West Bank and was in the process of fully transitioning the operating account to East West Bank at the end of the fiscal year. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: Not started

View Audit 408309

Finding 1225266 (2025-003)

Material Weakness 2025

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Questioned Costs Special Tests & Provisions

Federal Award Finding 2025-003 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Mortgage Reserve Fund, Equipment Replacement Reserve Fund, and Special Escrows Finding: During the audit period, Henry C. Nevins Home, Inc. did not make all required deposits into the reserve f...

Federal Award Finding 2025-003 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Mortgage Reserve Fund, Equipment Replacement Reserve Fund, and Special Escrows Finding: During the audit period, Henry C. Nevins Home, Inc. did not make all required deposits into the reserve for replacement fund in accordance with the terms of the applicable HUD Regulatory Agreement. The required monthly reserve deposits were either not made or were made in amounts less than those required. Recommendation: We recommend that Henry C. Nevins Home, Inc., in coordination with the court-appointed receiver and HUD, establish procedures to ensure that reserve for replacement deposits are made timely and in accordance with the HUD Regulatory Agreement, or that appropriate waivers or modifications are obtained from HUD where compliance is not currently feasible. Action Taken: Management acknowledges the audit finding related to the failure to make required deposits into the reserve for replacement fund in accordance with the HUD Regulatory Agreement. As disclosed in the notes to the financial statements, during the audit period the Organization was subject to a court-appointed receivership effective September 12, 2025 and is in default under its HUD-insured mortgages. As part of the receivership, control over substantially all cash management and financial decision-making activities was assumed by the court-appointed receiver. Management believes that the conditions giving rise to this finding are directly related to liquidity constraints. Given the complexities of the receivership and regulatory environment, a specific timeline for remediation is not able to be determined. As a result of the loan default, the mortgage was assigned to the U.S. Department of Housing and Urban Development. Since the appointment of the Receiver, responsibility for cash management, financial oversight, and debt service planning has transitioned to the Receiver. The Receiver and the Organization are actively evaluating available options to address the loan default which includes marketing the Organization for a sale. Interim corrective actions include enhanced cashflow monitoring, prioritization of expenses required to continue operations, and ongoing communication with HUD regarding the sale process. Management believes that these actions will address the conditions identified and result in the satisfaction of the HUD loan. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: In process

View Audit 408309

Finding 1225265 (2025-002)

Material Weakness 2025

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Questioned Costs Special Tests & Provisions

Federal Award Finding 2025-002 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Mortgage Status and Reserve for Replacements Finding: During the fiscal year, the Organization experienced ongoing financial distress and declining liquidity, which adversely affected its abili...

Federal Award Finding 2025-002 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Mortgage Status and Reserve for Replacements Finding: During the fiscal year, the Organization experienced ongoing financial distress and declining liquidity, which adversely affected its ability to meet financial obligations as they became due. As a result, mortgage payments, including required principal, interest, mortgage insurance premiums, and escrow deposits, were not made in accordance with the loan and regulatory agreements. As of December 31, 2025, delinquent amounts totaled approximately $978 thousand. Recommendation: The Receiver and the Organization should work with HUD to develop and implement a formal workout or resolution plan, including enhanced cash-flow monitoring and debt service planning, to address the loan default and restore compliance with HUD debt service requirements. Action Taken: Management acknowledges the finding related to the failure to make required debt service payments under the HUD Section 232 and Section 241(a) insured mortgage loan agreements. The Organization experienced significant financial distress and constrained liquidity during the fiscal year, which limited its ability to remit required principal, interest, mortgage insurance premium, and escrow payments as they became due. As a result of the loan default, the mortgage was assigned to the U.S. Department of Housing and Urban Development. With the appointment of a Receiver over the Organization, responsibility for cash management, financial oversight, and debt service planning has transitioned to the Receiver. The Receiver is marketing the facility towards a sale in order to satisfy the outstanding loan balance with HUD. Interim corrective actions include enhanced cash-flow monitoring, prioritization of operational suppliers, and ongoing communication with HUD regarding the project's financial condition and sale status. Management believes that these actions will support progress towards stabilization and marketability of the Organization. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: In process

View Audit 408309

Finding 1225253 (2025-002)

Material Weakness 2025

Sherburne County

MN

Questioned Costs Material Weakness Internal Control / Segregation of Duties

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: S2505MN5ADM - 2025 Award Period: 2025 Type of Finding: • Material Weakness in Internal Control over Compliance Recomme...

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: S2505MN5ADM - 2025 Award Period: 2025 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: CLA recommend that the County implement sufficient internal control procedures to ensure properly documented review of all reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement the recommendation immediately. Name of the contact person responsible for corrective action plan: Loraine Rupp, Sherburne County Auditor-Treasurer Planned completion date for corrective action plan: Already corrected

View Audit 408288

Finding 1225252 (2025-001)

Material Weakness 2025

Sherburne County

MN

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: S2505MN5ADM - 2025 Award Period: 2025 Type of Finding: • Significant Deficiency in Internal Control over Compliance • ...

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: S2505MN5ADM - 2025 Award Period: 2025 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Recommendation: CLA recommend that the County implement sufficient internal control procedures to ensure LCTS payments are made within 30 days of receipt. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement the recommendation immediately. Name of the contact person responsible for corrective action plan: Loraine Rupp, Sherburne County Auditor-Treasurer Planned completion date for corrective action plan: Already corrected

View Audit 408288

Finding 1225243 (2025-001)

Material Weakness 2025

Chinatown Manpower Project, INC

NY

Questioned Costs Reporting

CMP will take the following actions to ensure timely submission in future years: •Submit the 2026 DCF within five (5) business days of receiving the final audit report. •Coordinate earlier with the external audit firm to establish mutually agreed-upon deadlines for key audit deliverables. •Implement...

CMP will take the following actions to ensure timely submission in future years: •Submit the 2026 DCF within five (5) business days of receiving the final audit report. •Coordinate earlier with the external audit firm to establish mutually agreed-upon deadlines for key audit deliverables. •Implement an internal calendar to track critical reporting dates and milestones, beginning with the FY2026 audit cycle. •Assign a dedicated staff member to monitor audit progress and communicate regularly with the audit team to avoid last-minute delays.

View Audit 408285

Finding 1225234 (2025-001)

Material Weakness 2025

Advancing Connecticut Together, Inc. and Subsidiary

CT

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Management has strengthened internal controls over payroll processing and timecard approvals. Effective January 1, 2026, prior to processing each payroll, the Organization downloads a complete file of timesheet hours by employee, hour type, and cost center and compares the data against the contractu...

Management has strengthened internal controls over payroll processing and timecard approvals. Effective January 1, 2026, prior to processing each payroll, the Organization downloads a complete file of timesheet hours by employee, hour type, and cost center and compares the data against the contractual allocation plan. Any exception or deviation identified through this review is routed to the responsible supervisor for resolution before payroll is processed. Supervisors are responsible for correcting and approving timecard errors or documenting confirmation that the timesheet accurately reflects the work performed. This process is designed to ensure that timecards are reviewed, approved, and retained in support of payroll costs charged to federal awards. Management will continue to evaluate this control and implement enhancements as needed as part of its ongoing commitment to continuous quality improvement.

View Audit 408259

Finding 1225066 (2025-071)

Material Weakness 2025

State of Rhode Island

RI

Allowable Costs / Cost Principles Questioned Costs

2025-071a: EOHHS is actively reassessing the current MMIS system configuration and operational processes. In collaboration with Gainwell, a dedicated project is underway to strengthen controls and implement guardrails designed to prevent this from occurring in the future. Several potential solutions...

2025-071a: EOHHS is actively reassessing the current MMIS system configuration and operational processes. In collaboration with Gainwell, a dedicated project is underway to strengthen controls and implement guardrails designed to prevent this from occurring in the future. Several potential solutions are currently being evaluated and developed, with the goal of enhancing the system, oversight, and compliance. 2025-071b: The State is required to provide ongoing oversight and monitoring of CCBHC’s. EOHHS Program Integrity Unit has implemented an audit plan for all CCBHC’s. This plan includes review of historical records as well as on-site visits. Should any findings or questioned costs be identified, EOHHS will determine the appropriate corrective actions and reimburse the federal grantor, as necessary. 2025-071c: Given all CCBHC’s will be audited, any findings identified during an audit or investigation will be evaluated by EOHHS. If EOHHS concludes that a credible allegation of fraud exists, EOHHS will prepare the case record and submit a referral to MFCU for investigation and any subsequent action deemed appropriate. Anticipated Completion Dates: 2025-071a: January 2027 2025-071b: September 2027 2025-071c: Ongoing Contact Persons: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov Lynn Doherty, Managed Care Compliance Officer, Executive Office of Health & Human Services lynn.doherty@ohhs.ri.gov

View Audit 408197

Finding 1225065 (2025-070)

Material Weakness 2025

State of Rhode Island

RI

Allowable Costs / Cost Principles Questioned Costs § 200.303

EOHHS is in agreement with these findings. EOHHS has successfully addressed the deficiencies noted in these findings with updated requirements for this provider type. Community Health Workers have been elevated to high-risk status by Medicaid under “Medicaid Payments and Providers” 210-RICR-20-00-1,...

EOHHS is in agreement with these findings. EOHHS has successfully addressed the deficiencies noted in these findings with updated requirements for this provider type. Community Health Workers have been elevated to high-risk status by Medicaid under “Medicaid Payments and Providers” 210-RICR-20-00-1, which necessitates a National Criminal Background Check through fingerprinting. All enrolled community health worker providers were disenrolled effective December 1, 2025, and required to apply for enrollment under the new, enhanced requirements in the latest Community Health Worker Provider Manual, including the background check and requirement to enroll as a group with a National Provider Identifier (NPI), and as individual rendering providers with an NPI. All current CHW providers are now enrolled with the enhanced screening requirements. Limitations on reimbursement for services have also been successfully implemented, with system edits in place to deny claims billed in noncompliance with the new requirements outlined in the provider manual. Additionally, EOHHS Office of Program Integrity has audited outlier providers (in terms of utilization metrics), identifying overpayments and also collaborating with the MFCU for law enforcement intervention. EOHHS considers finding 2025-070a to be completed based on previous activities. For finding, 2025-070b, EOHHS is finalizing its last CHW audits while the MFCU completes its investigations based on Program Integrity’s referrals. Anticipated Completion Dates: 2025-070a: Complete 2025-070b: Estimate is August 2026 Contact Person: Nicholas James, Implementation Director of Policy and Programs, Executive Office of Health and Human Services nicholas.james@ohhs.ri.gov

View Audit 408197

Finding 1225063 (2025-068)

Material Weakness 2025

State of Rhode Island

RI

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

2025-068a: EOHHS will establish a systemwide audit cycle of this service to ensure the providers are appropriately billing. 2025-068b: EOHHS is actively reassessing the current MMIS system configuration and operational processes. In collaboration with Gainwell Technologies, a dedicated project is un...

2025-068a: EOHHS will establish a systemwide audit cycle of this service to ensure the providers are appropriately billing. 2025-068b: EOHHS is actively reassessing the current MMIS system configuration and operational processes. In collaboration with Gainwell Technologies, a dedicated project is underway to strengthen controls and implement guardrails designed to prevent this from occurring in the future. Several potential solutions are currently being evaluated and developed, with the goal of enhancing the system, oversight, and compliance. 2025-068c: EOHHS is actively reassessing the current provider Billing Manual to ensure the billing requirements for all bundled services is clear and that it is also clear that the unbundling of the rates is not allowed and may cause recoups for the services billed. 2025-068d: EOHHS will establish a systemwide audit cycle of this service to ensure the providers are appropriately billing. Anticipated Completion Date: November 30, 2026 Contact Persons: David McMahon, Assistant Director of Financial Contracts, Executive Office of Health and Human Services david.g.mcmahon@ohhs.ri.gov Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov

View Audit 408197

Finding 1225061 (2025-066)

Material Weakness 2025

State of Rhode Island

RI

Eligibility Reporting Questioned Costs

2025-066a: In order to address repeat income deficiencies from SWICA, Medicaid added The Work Number (TWN) as a new data source in August 2025. Since then, RI Bridges has been modified to first verify earned income against TWN. With this enhancement, Medicaid has seen an improvement in how earned in...

2025-066a: In order to address repeat income deficiencies from SWICA, Medicaid added The Work Number (TWN) as a new data source in August 2025. Since then, RI Bridges has been modified to first verify earned income against TWN. With this enhancement, Medicaid has seen an improvement in how earned income is verified during the post-eligibility verification (PEV) and annual renewal processes. Medicaid has determined the individuals flagged as being enrolled under the expansion pathway beyond their 65th birthday are the result of exceptions to the mass update eligibility process. Medicaid is working with our system vendor to develop a solution that will bypass this exception and terminate expansion eligibility for those turning 65 years old. RI Bridges appropriately identified the individual in question as requiring verification of citizenship status. However, as noted in the expansion age-out response, the mass update eligibility process exceptioned out, leaving the verification as unresolved and requiring manual review. Medicaid is working with our system vendor to develop a solution that will bypass this exception and terminate eligibility. Effective December 2025, the RI Bridges system receives quarterly matches from the SSA Death Master File (DMF). The DMF is automatically sent to the State as part of the quarterly PARIS data matching process. The State has deployed temporary system measures to process the file and automatically terminate Medicaid eligibility for individuals flagged as deceased on the DMF. As per section 71104 of the Working Families Tax Cut (WFTC) legislation, signed by the President on 7/4/25, the State will be deploying a long-term system enhancement to, “at least a quarterly basis, check the DMF to identify if enrolled individuals are deceased. If an individual is identified as deceased on the DMF, then the state must treat this information as factual, disenroll the individual, and discontinue any payments for items or services furnished after the death of the individual.” This enhancement is scheduled for the March 2027 release. In July 2024, federal partners operating the PARIS interstate match informed the State of a hold on PARIS interstate matching files. PARIS lifted the hold in October 2024. In November 2024, the State identified several defects in the PARIS results and suppressed requests for verification. A temporary system enhancement was logged to address the deficiencies and ensure the process was only requesting residency verification from individuals believed to be receiving Medicaid in another State. Long-term enhancements to the PARIS interstate match process are scheduled for late 2027. 2025-066b: Medicaid will continue to work with the Department of Human Services and HealthSource RI to improve reconciliation and quality assurance monitoring of eligibility and operational processes. Including, but not limited to automated quality control checks on batch processes, manual eligibility reviews of quarterly/annual activities, creating specialized reports, improving task logic, and identifying areas of repeat non-compliance to ensure appropriate controls are in place. 2025-066c: Upon notification from the systems team, Medicaid Finance will return any identified ineligible costs to the federal grantor. Anticipated Completion Dates: 2025-066a: Q4 2026 (exception scenarios) and Q4 2027 (PARIS) 2025-066b: Q4 2026 2025-066c: Ongoing Contact Persons: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov

View Audit 408197

Finding 1225059 (2025-064)

Material Weakness 2025

State of Rhode Island

RI

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s T...

A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s TPL data is not good enough to reject encounter claims from the MCO’s. EOHHS continues to work on improving the TPL process specifically cleaning up the TPL data in the MMIS and eligibility system today. Future system enhancements include a direct TPL vendor and new TPL module which should improve TPL accuracy. Anticipated Completion Date: July 31, 2028 Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov

View Audit 408197

Finding 1225056 (2025-061)

Material Weakness 2025

State of Rhode Island

RI

Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment

EOHHS is in agreement with these findings and is in the process of working with Gainwell and its managed care partners to address these discrepancies. The providers that were not properly subjected to EOHHS’s enrollment processes were out of network providers within one of the managed care plans’ na...

EOHHS is in agreement with these findings and is in the process of working with Gainwell and its managed care partners to address these discrepancies. The providers that were not properly subjected to EOHHS’s enrollment processes were out of network providers within one of the managed care plans’ national network provider management system. These providers have been incorrectly included in provider network data as this managed care plan is in the process of end-dating these providers, which will resolve this discrepancy. EOHHS has reorganized Provider Enrollment oversight functions under the Office of Program Integrity (OPI) in alignment with federal standards, and as such will continue to audit and monitor enrollment files to ensure compliance with state and federal requirements. OPI is formalizing a process to swiftly terminate providers who have lost their licensure, as well as randomly auditing enrollment files to ensure proper licensure. Additionally, EOHHS will begin collecting DCYF licensure data as required. Anticipated Completion Date: December 31, 2026 Contact Persons: Nicholas James, Implementation Director of Policy and Programs, Executive Office of Health and Human Services nicholas.james@ohhs.ri.gov Rob Tingle, Chief of Program Analytics, Executive Office of Health and Human Services robert.tingle@ohhs.ri.gov

View Audit 408197

Finding 1225055 (2025-060)

Material Weakness 2025

State of Rhode Island

RI

Special Tests & Provisions Questioned Costs

EOHHS acknowledges the federal reporting requirement specific to the State’s non-emergency medical transportation (NEMT) vendor. The State’s contract with the vendor, more specifically Article I Section 18.13.6, does require the financial reporting necessary to comply with this federal requirement. ...

EOHHS acknowledges the federal reporting requirement specific to the State’s non-emergency medical transportation (NEMT) vendor. The State’s contract with the vendor, more specifically Article I Section 18.13.6, does require the financial reporting necessary to comply with this federal requirement. EOHHS is currently working with vendor and their independent auditor to isolate the necessary financial claims to resolve this deficiency finding for reporting/calendar year 2025. Anticipated Completion Date: EOHHS estimates that the 2025 report will be brought into compliance no later than December 1, 2026. Contact Persons: Storm Lawrence, Chief of Strategic Planning, Monitoring & Evaluation, Executive Office of Health and Human Services storm.lawrence@ohhs.ri.gov Melanie Oxley, Administrator of Medical Services, Division of Healthcare Delivery Contracting, Executive Office of Health and Human Services melanie.j.oxley@ohhs.ri.gov

View Audit 408197

Corrective Action Plans

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