CMS audit compliance just needs rigorous attention, as the Federal Information Security Modernization Act of 2014 (FISMA) mandates that all federal agencies develop corrective action plans known as Plans of Action and Milestones (POA&Ms). A POA&M is a management process that outlines weaknesses and the tasks necessary to alleviate them. Current regulations require POA&Ms to be closed within 180 days, changing them into time-bound commitments. We’ll explore the cms audit process, from understanding the cms audit protocol and cms program audit coverage to translating cms audit results into practical POA&Ms that meet cms audit requirements and cms audit guidelines.
Overview of CMS Audit Requirements
Federal Mandates Driving CMS Audits
Multiple federal statutes are the foundations for CMS audit activities. The Federal Information Security Modernization Act requires federal agencies to conduct annual reviews of information security programs. The Office of Management and Budget provides final oversight of compliance efforts. The Chief Financial Officer Act of 1990 governs annual CFO audits and establishes leadership structures. It strengthens accountability reporting through audited financial statements. OMB Circular A-123, issued under the Federal Managers’ Financial Integrity Act, prescribes processes to assess internal control program effectiveness.
The Medicare Program Integrity Manual has policies and responsibilities for contractors tasked with medical and payment review. Providers receiving payments under Parts A and B of the Social Security Act face audit requirements. These audits verify proper payments based on reasonable costs and detect fraud and abuse instances. They also provide information CMS needs to fulfill its responsibilities. Government Auditing Standards, issued by the Comptroller General in July 1988 and effective for Medicare audits performed on or after January 1, 1989, apply to all audits performed by or for any federal agency. Medicare audits must comply with Statements on Auditing Standards issued by the American Institute of Certified Public Accountants, unless individual standards are excluded by Medicare audit policy.
Scope of CMS Program Audit Coverage
CMS conducts program audits at the parent organization level. Data collected has all MA and PDP contracts between CMS and the controlling legal entity. This approach allows CMS to audit a substantial percentage of enrolled sponsors each year. CMS audited 71% of all Medicare Part C and D sponsors in 2019. The agency announced plans to audit all eligible Medicare Advantage plans each year. It expanded from auditing 60 Medicare Advantage plans to over 550 eligible MA contracts.
Program audits evaluate sponsors in seven distinct program areas based on contract types offered: Compliance Program Effectiveness (CPE), Part D Formulary and Benefit Administration (FA), Part D Coverage Determinations, Appeals, and Grievances (CDAG), Part C Organization Determinations, Appeals, and Grievances (ODAG), SNP Care Coordination (SNPCC), Medicare-Medicaid Plan Service Authorization Requests, Appeals and Grievances (MMP-SARAG), and Medicare-Medicaid Plan Care Coordination (MMPCC). Audits for sponsors that include an MMP employ Center for Medicare Program Audit Protocols plus two MMP-specific protocols. These protocols ensure compliance with three-way contract requirements.
Enforcement consequences carry substantial financial weight. CMS issued civil monetary penalties totaling more than $1.6 million in 2019, with an average penalty of just over $200,000. Unfavorable audit determinations can result in immediate civil monetary penalties and intermediate sanctions. These sanctions include suspension of payment, enrollment and marketing activities. They can also lead to for-cause contract terminations.
CMS Audit Guidelines and Standards
The National Institute of Standards and Technology develops standards and policies that agencies employ to ensure systems, applications and networks remain secure. NIST SP 800-53 outlines suggested security controls for FISMA compliance, while FIPS Publication 199 prescribes categorization levels for security and risk requirements. Standards for security controls are documented in the CMS Acceptable Risk Safeguards at CMS.
Independent auditors conduct CMS audits under guidelines established by the Government Accountability Office and HHS’s Office of Inspector General. The audit process consists of four distinct phases: Audit Engagement and Universe Submission, Audit Field Work, Audit Reporting, and Validation and Close-Out. CMS reviews sampled cases over a three-week period during Phase II, primarily via webinars. It conducts compliance-program effectiveness assessments supported by onsite visits. Phase III categorizes findings as Immediate Corrective Action Required, Corrective Action Required, Observations, or Invalid Data Submission. CMS assigns points to generate an overall audit score.
Types of Deficiencies Found in CMS Audits
Audit findings reveal patterns of non-compliance in both information security and program operations. CMS conducted 39 total program audits of 36 parent organizations in 2024. These audits covered 494 MA contracts and represented 87.6% of all beneficiaries enrolled in an MA plan. The audits exposed deficiencies that ranged from technical system failures to fundamental policy gaps. CMS imposed civil monetary penalties on 14 sponsors for 18 different violations that totaled over $292 million.
Technical Control Deficiencies
System audits assess CMS’s information technology infrastructure, applications, data management, policies and procedures. Auditors collect artifacts from systems and compare them to recognized standards and federal laws that have been established. Technical deficiencies emerge mainly from improper system configurations and inadequate tracking mechanisms. The most important technical failure involved sponsors who did not track Maximum Out-of-Pocket limits the right way. This caused beneficiaries to pay more in cost-sharing than allowed. CMS determined that a sponsor violated these provisions and failed to track enrollee out-of-pocket spending. The sponsor charged enrollees more than annual out-of-pocket limits, which led to the largest penalty of $2 million.
Recent audits revealed that sponsors failed to update systems the right way. This led to incorrect provider payments and cost-sharing amounts. Formulary administration deficiencies included sponsors who limited access to covered Part D drugs in ways they should not have. They applied unapproved edits, effectuated authorizations the wrong way, or processed enrollment and eligibility in an improper manner. Electronic prior authorization configuration logic processed redetermination requests as initial requests when ePA cases were submitted with different National Provider Identifiers.
Management and Operational Weaknesses
Compliance issues at the operational level came from oversight structures that did not work well. CMS determined that certain sponsors did not track, address and correct compliance issues related to functions that delegated entities performed. Internal routine monitoring processes did not detect untimely notifications to enrollees when delegated entities misinterpreted regulatory requirements. Compliance departments were often unaware of internal audit results. Organizational turnover disrupted oversight activities.
Operational delays made compliance problems worse. Processing delays were common, with themes related to new system implementations, increased workloads and staffing shortages. Coverage requests were misclassified or dismissed in ways they should not have been. This led to enrollee delays in accessing medications. To name just one example, coverage requests were processed as grievances because staff did not recognize complaints about medication access or cost as coverage requests.
Policy and Procedure Gaps
Documentation deficiencies created barriers to beneficiary advocacy. Decision notifications were incorrect or incomplete and prevented enrollees and providers from advocating for services the right way. CMS found that certain sponsors did not communicate an adverse coverage determination in a clear way. They also did not specify a beneficiary’s rights when challenging the decision. Dismissal notification templates did not contain the enrollee’s right to request the sponsor vacate its dismissal.
Care coordination policies lacked substance. Individualized care plans did not address all results from enrollee health risk assessments or include measurable outcomes. Results from the HRA were not carried over to the ICP as a starting point to prioritize care and develop goals. Sponsors relied on risk stratification systems that categorize enrollees according to health status rather than using individualized HRA results. This meant they did not determine which conditions should be included in the ICP based on individual assessments.
System-Level vs Program-Level Issues
Deficiency severity determines the scope of remediation efforts. System-level issues affect specific applications or processes. To cite an instance, see when claims were rejected at the point of sale because of outdated enrollee eligibility files and incorrect prior authorization edits. Program-level deficiencies represent failures that affect multiple areas at the same time. Beneficiaries were restricted to a single strength or dosage form when sponsors effectuated approved medications in their systems in ways they should not have been. This restriction increases the provider’s burden and requires submission of new coverage requests for the same medication.
Understanding the CMS Audit Protocol
The Medicare Parts C and D Oversight and Enforcement Group administers the audit strategy to oversee Part C and Part D programs, conducting audits of Medicare Advantage Organizations, Prescription Drug Plans, and Section 1876 Cost Plans. CMS solicits feedback on the audit process from industry stakeholders through various mediums on an annual basis and uses this input to update audit operations and explore new program areas requiring oversight. The routine program audit process breaks into four distinct phases that organizations must traverse.
Original Assessment and Planning
The Audit Engagement and Universe Submission phase spans a six-week period before field work. The Auditor-in-Charge conducts a courtesy call to the sponsoring organization’s Medicare Compliance Officer during this original phase and follows up with an audit engagement letter sent via the Health Plan Management System. The engagement letter contains instructions to download audit documents from HPMS and has an Audit Submission Checklist identifying all universe requests and deliverables.
CMS conducts a follow-up call within two business days of the engagement letter date to address questions about the engagement letter and outline next steps. CMS then conducts universe follow-up calls for each audited program area within five business days to answer questions regarding data requests and supplemental documentation files. Sponsoring organizations must also provide a Pre-Audit Issue Summary within five business days, listing all disclosed issues of noncompliance relevant to program areas being audited.
Universe submission occurs within 15 business days of the engagement letter date. CMS then conducts a universe assessment through desk review to ensure completeness and acceptable data formatting. CMS schedules webinars with sponsoring organizations for universe integrity testing to verify data accuracy within five business days of receiving universes.
Evidence Collection Methods
Auditors collect evidence through structured artifact requests that demonstrate security control implementations. The independent assessor executes assessment procedures using three distinct methods. Artifacts provided by the Information System Security Officer support assessment activities and respond to requests for documentation or system access for technical testing.
Security Assessment Plans document the scope by identifying security controls under assessment, describing assessment procedures to determine effectiveness, and outlining the assessment environment, team and responsibilities. The planning phase requires the ISSO to provide current System Security and Privacy Plans along with hardware listings, architecture diagrams and data flow diagrams.
Audit Testing Procedures
Program audit field work occurs over a two to three-week period and we conducted it via webinar. Assessment execution employs three methods: interviews with relevant stakeholders to confirm security control implementations, examination of documentation and artifacts demonstrating implementations, and tests using manual procedures or automated tools like vulnerability scans and penetration tests.
Sponsoring organizations present supporting documentation while CMS assesses sample cases live in the organization’s systems to determine compliance. Root cause analyzes must be submitted within two business days of CMS requests for any noncompliance identified. Impact analyzes follow within 10 business days, identifying all parties affected by noncompliance issues from the request date through the universe period start date.
Final Audit Report Generation
The Auditor-in-Charge issues a draft audit report at the conclusion of field work identifying all potential conditions noted during the audit, delivered via HPMS at least one hour before the exit conference. CMS prepares a draft audit report that has condition classification and an audit score, targeting issuance within 60 calendar days from the exit conference date. Sponsoring organizations receive 10 business days to respond with comments to the draft report. The final report identifies the audit scope and purpose, details findings and provides recommendations to remediate any identified issues.
Introduction to Plans of Action and Milestones
Definition and Purpose of POA&Ms
Organizations must document security weaknesses systematically once audit reports identify them. A Plan of Action and Milestones identifies tasks that need accomplishment and details resources required to accomplish plan elements. It establishes milestones for meeting tasks and sets scheduled milestone completion dates. The CMS Information Security POA&M Procedure provides management and Business Owners with information and instructions they need to develop, maintain, and report weaknesses in information security as they relate to specific information systems.
POA&Ms function as corrective action plans. They track system weaknesses and allow System Owners and ISSOs to create resolution plans over time. They provide details about personnel, technology, and funding required to accomplish plan elements. Milestones for correcting weaknesses and scheduled completion dates are also included. The POA&M process improves CMS’ knowing how to identify, assess, prioritize, and monitor progress of corrective actions that pertain to information security weaknesses found within programs and systems.
The benefits extend beyond simple tracking. POA&Ms serve as dynamic management tools useful for ongoing efforts that address programmatic and system-specific vulnerabilities. Remediation of security weaknesses that works becomes vital to building a mature and sound information security program. POA&Ms also function as historical data sources for management reporting and business intelligence that pertains to costs, effort, and time required to reduce security weaknesses. This capability allows analyzes at both system and program levels for operating divisions and the enterprise.
Regulatory Requirements for POA&Ms
OMB requires tying POA&Ms to the budgeting process to review the soundness of investments. Each POA&M weakness must be linked to the capital planning and investment control process. Unique project identifiers make this connection. The UPI, contained in the Exhibit 300 or 53, is submitted to OMB to request and justify funding that develops or maintains systems. OMB requires related POA&Ms to be cross-referenced through answers to questions when completing section II.B of an Exhibit 300 for major investments.
Evidence of proper POA&M implementation and use represents a critical element in assessment of information security program performance by CMS OIG, DHHS, OMB, and Congress. So OMB requires agencies to submit annual FISMA reports that summarize the previous year’s progress in establishing and maintaining information security programs. An IG evaluation of CMS’ POA&M process is included.
Relationship Between Audit Findings and POA&Ms
All findings and weaknesses must be documented in a POA&M, reported to HHS, and remediated within specific timelines after positive identification. CMS requires POA&Ms to be updated at least monthly and to be accurate at the beginning of each month. The POA&M process begins when a weakness is identified in a CMS FISMA system. The System/Business Owner and Authorizing Official work together and are responsible for reducing the risk posed by weaknesses. The ISSO and Cyber Risk Advisor provide support.
POA&Ms provide documented evidence of corrections like scan results. This makes them significant for remediation and mitigation efforts based on results of ongoing monitoring activities, assessment of risk, and outstanding items. All weaknesses that represent risk to system security or privacy must be corrected. Required mitigation efforts are captured in POA&Ms.
Developing POA&Ms from CMS Audit Results
Transforming audit findings into structured remediation plans requires systematic analysis and documentation. POA&Ms are created and tracked in the CMS FISMA Controls Tracking System (CFACTS), where organizations convert identified weaknesses into practical corrective measures.
Translating Findings into Practical Items
After an assessment or audit, you receive a report showing potential areas of concern. The auditor documents findings using the CMS Assessment and Audit Template (CAAT) and explains where systems perform as expected and where you need to strengthen them. Start by discussing potential threats or vulnerabilities with your integrated project team to understand the implications.
You need an impact assessment to analyze threats and vulnerabilities, with consultation from your integrated project team and vendor supports. Several methodologies apply during this phase. Root Cause Analysis helps uncover actual causes rather than just symptoms of findings. Root cause analysis reviews policy, procedures, people, technology, and resources relevant to identified security weaknesses. Inadequacies in one or more areas are the mechanisms behind most findings.
Setting Realistic Remediation Timelines
The estimated completion date should be based on realistic timelines that allow you to get resources and complete associated steps. Completion dates should derive from prioritization decisions and resource availability. Careful prioritization will give critically important weaknesses the resources they need within time periods proportionate to associated risks.
You need to determine the scheduled date based on realistic estimates of time needed to allocate required resources, implement corrective actions, and complete all associated milestones. Accurate completion estimates represent a critical task that requires consultation with System Owners, responsible system engineers, Authorizing Officials, or other stakeholders.
Defining Measurable Milestones
The Corrective Action Plan forms the POA&M foundation and describes identified weaknesses, associated milestones, and resources needed. Milestones must provide specific descriptions of steps your team will take to reduce findings. Each finding must have at least one corresponding milestone with an estimated completion date and resource requirements.
Make sure your milestones are specific, measurable, assignable, realistic, and time-related. The number of milestones per weakness must correspond to steps or corrective actions you need to address and resolve weaknesses fully.
Estimating Costs and Resources
Determine specific funding and personnel resources needed to reduce each finding. Existing resources allocated to programs or systems are enough in most cases, but you may need to request additional funding or personnel occasionally.
If existing government personnel are assigned to correct weaknesses and no new funding is required, identify the time needed to complete corrective actions and note performance by current staff. Resource estimates must be based on total resources needed to fulfill all milestones for weakness correction.
Assigning Responsible Parties
You must identify a designated Point of Contact for each weakness and its milestones, responsible for proper execution of the Corrective Action Plan. Individual responsibility for CAP execution varies depending on organization, system, milestones, and weaknesses. This POC resource is key to identifying milestone owners and making sure milestones are worked toward eventual remediation or acceptable reduction.
CMS POA&M Reporting Structure
OMB mandated a POA&M format to provide a consistent baseline of required and standardized information. This structure improves stakeholders’ knowing how to locate information and organize details to analyze. Each program or system-level POA&M uses the same required fields containing information about weaknesses and associated remediation activities at CMS.
Mandatory POA&M Data Fields
Each POA&M weakness receives a unique identifier to track from quarter to quarter. The numbering schema consists of the associated system name, the quarter and fiscal year when the weakness was first recorded, and a sequence number. Program weakness identifiers use the program name instead of a system name.
The weakness description requires four minimum elements defined in GAO Yellow Book Government Auditing Standards:
- Criteria – which portion of the applicable control assessment procedure was not met
- Condition – the observed situation as it existed during assessment
- Cause – the probable reason this condition exists
- Effect – the potential or real effect of failing to meet the requirement
A Point of Contact must be identified and documented for each reported weakness. The POC represents the position or role responsible for resolving the weakness, such as Component ISSO or Business Owner. Using specific POC names is not recommended since personnel in these positions may change.
Weakness Severity and Risk Ratings
The Criticality field selects appropriate priority from available options. Higher numbers signify greater CMS priority for remediation. If the weakness Risk Category is High, select Reportable Condition from the dropdown. If the weakness Risk Category is Moderate or Low, select Other Weakness.
Corrective Action Plan Details
Resources required estimates must be based on total resources needed to fulfill all milestones necessary to correct the weakness. The type of funding should be noted in addition to dollar amounts or man hours—new, existing, or reallocated. Zero dollars is not a valid cost estimate because resources are already being spent documenting the weakness.
Milestones provide specific, action-oriented descriptions of tasks stakeholders will take to reduce weaknesses. The number of milestones per weakness must correspond to steps or corrective actions necessary to address and resolve the weakness.
Supporting Documentation Requirements
CMS requires all information in POA&Ms be updated quarterly to ensure accuracy for quick tracking and reporting. CMS must submit POA&M updates once a month by the third business day to HHS to demonstrate mitigation or remediation activities status.
Monitoring Progress and Closing POA&Ms
Quarterly Status Reporting to DHHS
POA&Ms must keep information current at all times. Quarterly status reports communicate overall progress to DHHS and help identify and alleviate weaknesses. CMS updates its POA&M and summary report on an ongoing basis. The agency must be prepared to submit them within seven to fourteen business days before OMB quarterly deadlines when the DHHS Chief Information Security Officer requests. Continuous monitoring requirements mean that CMS submits POA&M updates at least once monthly by the third business day to HHS. These updates show the status of activities to alleviate or remediate issues.
The Division of IT Policies, Procedures and Audits within the Enterprise Architecture & Strategy Group prepares the POA&M Summary Update Report. Business Owners, ISSOs and other stakeholders must work together to determine scheduled completion dates within specified remediation timelines.
Tracking Milestone Completion
All CMS systems need monthly updates. The ISSO keeps POA&Ms on behalf of information system owners through the CFACTS tool and submits updates on each POA&M at least quarterly until resolution. We append comments each month in the Milestone Changes section for milestones. This keeps a complete history of status updates with dated entries. Milestones that face delays and will exceed the scheduled completion date require an Estimated Completion Date with justification that explains the delay. Weaknesses not remediated within scheduled completion dates change status to Delayed.
Validation and Testing of Remediation
OMB’s FISMA reporting guidance recommends that weaknesses be marked Completed only when fully resolved and tested. Testing shows that program vulnerabilities or system controls have been addressed adequately and proven to work. This step must be built into the weakness mitigation process and documented.
POA&M Closure Process and Approvals
Remediation packages contain artifacts that show weakness mitigation. We submit these through CFACTS. The CRA verifies mitigation for all high-risk weaknesses and samples of moderate and low-risk weaknesses. The ISSO closes POA&Ms designated as Low and Moderate, and a CRA spot audits them. Critical and High POA&Ms require CRA closure. Completed weaknesses remain on POA&M reports for one year after closure. OMB advises that weaknesses alleviated for over a year should no longer be reported. CMS ages off any weaknesses Completed for at least 12 months.
Navigating Special Circumstances
Not all POA&Ms follow standard closure procedures. Some weaknesses become infeasible to close using normal cms audit protocol and require alternative approaches.
Internal Justification for Closure
The Business Owner submits justification to the Chief Information Officer or Director of Office of Information Services when findings prove infeasible to close through standard procedures. The Chief Information Security Officer receives formal risk acceptance requests and reviews them. The CISO then provides decisions for internal justification for closure. The CIO delegates authority to the CISO to accept risks with low risk levels.
Risk Acceptance Procedures
Business Owners and project teams sometimes decide to accept risks that cms audit results identify. They must create a Risk Based Decision that explains the reasoning and accepted risk. CMS reviews all RBDs each year to ensure the risk remains acceptable as part of continuous monitoring. Risk acceptance represents a formal decision to accept risk without remediation action. Appropriate authority within the Component documents and approves this decision. The RBD tab in CFACTS manages RBDs.
Waiver Requests for Extended Timelines
Waivers provide formal requests to deviate from specific requirements. Components use them when unforeseen circumstances or resource constraints prevent meeting scheduled completion dates. Waiver requests must include justification for delay and proposed new completion dates. They must also include interim mitigating actions. The status “Delayed” applies when weaknesses continue remediation after original scheduled completion dates. This requires explanation and revised completion dates.
Transferring POA&Ms Between Systems
Transfer of POA&M weaknesses from one FISMA system to another must be traceable and justified. The POA&M must document this transfer. Weaknesses may only be removed due to transfer to another program or system-level POA&M. The 12-month rule also allows removal through retirement.
Tools and Resources for CMS Audit Compliance
Several specialized systems support cms audit compliance efforts at CMS. CFACTS, the CMS FISMA Controls Tracking System, serves as the main governance, risk, and compliance tool where stakeholders identify, track, and manage all system weaknesses and associated POA&Ms to closure. Users request CFACTS access through the Enterprise User Administration using job code CFACTS_User_P. They then notify the CISO mailbox at [email protected] and suggest their role.
CISS Tool for POA&M Management
The CMS Contractor Integrated Security Suite (CISS) allows management and entities to track ongoing security issues and meet FISMA POA&M reporting requirements for all security-related findings. Business Owners can submit Corrective Action Plans to the Enterprise Architecture and Strategy Group manually or use the CISS database tool. Attachment B of the POA&M procedure provides instructions for getting CISS Tool access.
Enterprise Architecture and Strategy Group Support
The Enterprise Architecture and Strategy Group oversees and manages the CMS-wide information security program. EASG develops and manages a detailed POA&M program. The group coordinates and analyzes the POA&M process for improvements and will give the process an assessment of CMS-wide security weaknesses. CMS’ Enterprise Architecture is modeled and managed in an interactive architectural tool called Troux Architect.
System Security Profile Maintenance
System Security Profiles require updates whenever most important changes occur or annually at minimum. Approved versions are saved in CFACTS.
Conclusion
CMS audit compliance represents a critical responsibility that just needs systematic attention and rigorous execution. We covered the foundational elements of audit requirements, from federal mandates and program coverage to the structured four-phase audit protocol. We got into how audit findings translate into POA&Ms, with emphasis on the 180-day closure requirement that turns these plans into time-bound commitments.
POA&M development that works requires realistic timelines and measurable milestones. Accurate resource estimates matter too. The tools we discussed, such as CFACTS and CISS, streamline tracking and reporting. We encourage you to apply these frameworks to strengthen your organization’s compliance posture and meet federal information security standards.
Key Takeaways
Understanding CMS audit compliance is essential for federal agencies, as FISMA mandates require all security weaknesses to be documented in Plans of Action and Milestones (POA&Ms) and closed within 180 days.
• CMS audits 87% of Medicare beneficiaries annually through comprehensive program audits covering seven distinct areas, with penalties reaching over $292 million in 2024 for non-compliance.
• POA&Ms must translate audit findings into actionable remediation plans with specific milestones, realistic timelines, assigned responsible parties, and accurate resource estimates for effective closure.
• Technical deficiencies often stem from system configuration failures while operational weaknesses result from inadequate oversight structures and policy gaps in care coordination.
• The four-phase audit protocol requires systematic preparation including universe submission, evidence collection, testing procedures, and final reporting within structured timelines.
• Specialized tools like CFACTS and CISS streamline POA&M management enabling organizations to track weaknesses, monitor progress, and demonstrate compliance through quarterly reporting to DHHS.
Successful CMS audit compliance depends on understanding the regulatory framework, implementing robust remediation processes, and leveraging available tools to maintain continuous monitoring and timely closure of identified weaknesses.
FAQs
Q1. What exactly is a POA&M in the context of CMS audits? A POA&M (Plan of Action and Milestones) is a structured management document that identifies security weaknesses found during audits and outlines the specific tasks, resources, milestones, and completion dates needed to remediate them. It serves as both a corrective action plan and a tracking tool that helps organizations systematically address vulnerabilities in their information systems and programs.
Q2. What is the primary purpose of creating POA&Ms after a CMS audit? The primary purpose of POA&Ms is to help organizations identify, assess, prioritize, and monitor the progress of corrective efforts for security weaknesses, deficiencies, or vulnerabilities discovered during audits. They transform audit findings into actionable remediation plans with clear accountability, ensuring that identified issues are addressed within required timelines—typically 180 days for CMS compliance.
Q3. What types of deficiencies are commonly found during CMS audits? CMS audits typically uncover four main categories of deficiencies: technical control deficiencies (such as improper system configurations and tracking failures), management and operational weaknesses (including ineffective oversight and processing delays), policy and procedure gaps (like incomplete documentation and inadequate care coordination plans), and both system-level issues affecting specific applications and program-level problems representing systemic failures across multiple areas.
Q4. How does the CMS audit process work from start to finish? The CMS audit process consists of four distinct phases: Initial Assessment and Planning (including universe submission over six weeks), Evidence Collection (through structured artifact requests and documentation review), Audit Testing Procedures (conducted primarily via webinar over two to three weeks), and Final Audit Report Generation (with draft reports issued within 60 days of the exit conference). Organizations must respond to findings and develop POA&Ms for identified weaknesses.
Q5. What tools are available to help manage POA&Ms and ensure CMS audit compliance? CMS provides specialized tools including CFACTS (CMS FISMA Controls Tracking System), which serves as the primary platform for identifying, tracking, and managing system weaknesses and POA&Ms to closure, and CISS (CMS Contractor Integrated Security Suite), which allows organizations to track ongoing security issues and meet FISMA POA&M reporting requirements. The Enterprise Architecture and Strategy Group also provides support for maintaining the CMS-wide information security program.