Corrective Action Plans

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Finding 2025-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Medical Records Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to reinforce provider responsibilities related to documentation and record retention. As part of the annual communication ...
Finding 2025-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Medical Records Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to reinforce provider responsibilities related to documentation and record retention. As part of the annual communication plan, MDHHS issues provider alerts twice per year to remind providers of the MDHHS record retention policy and post payment review process. The most recent provider alert was issued on January 5, 2026, and communicated to providers the importance of maintaining appropriate documentation for services provided. The provider was not responsive to MDHHS’s request for documentation for the exception identified. As a result, MDHHS voided the associated claim on February 11, 2026, recouped the full payment, and notified the provider of the action taken. Anticipated Completion Date Completed Responsible Individual(s) Alexis Bond, MDHHS
Finding 2025-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action In March 2025, MDHHS implemented an interface fix to resolve multiple system issues and eliminate limitations that contributed to r...
Finding 2025-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action In March 2025, MDHHS implemented an interface fix to resolve multiple system issues and eliminate limitations that contributed to retroactive disenrollment. MDHHS has also submitted a work request for a system enhancement within Bridges to prevent recurrence of retroactive eligibility removals and improve the accuracy of eligibility across systems. In addition, MDHHS will evaluate additional potential processes to identify and resolve discrepancies between eligibility and enrollment data across systems, thereby reducing the risk of improper payments. Anticipated Completion Date MDHHS will determine an anticipated completion date after the work request has been prioritized. Responsible Individual(s) Jamy Hengesbach, MDHHS
Finding 2025-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates and distributes a monthly hospitalization report to adult services supervisors, who then distribute to adult services ...
Finding 2025-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates and distributes a monthly hospitalization report to adult services supervisors, who then distribute to adult services workers as part of the post-payment review process. During February 2025, MDHHS issued an Adult Services Notification to managers and directors reminding local office management of the expectation to thoroughly monitor and review the hospitalization reports to ensure timely and accurate action is taken by adult services workers. MDHHS also reissued the Home Help Recoupment Process training and procedural resources during February 2025 to adult services workers who manage Home Help cases to ensure process steps are consistently followed. In addition, during February 2026, MDHHS issued recoupments for the two clients identified by the Office of the Auditor General as part of the audit finding. During June 2025, MDHHS enhanced the monthly hospitalization report to improve data accuracy for identified service overlaps and ensure timely recovery of payments. However, MDHHS identified timing differences between the report run dates and the weekly schedule updates of CHAMPS hospitalization data that could result in incomplete hospitalization data within the monthly monitoring report. To ensure all relevant records are captured and promptly recover payments to clients hospitalized while receiving Home Help Program services who no longer met eligibility requirements, the timing of the report has been modified. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown, MDHHS
Finding 2025-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing the overpayments, as well as deve...
Finding 2025-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing the overpayments, as well as developing mitigation strategies to temporarily address the overpayment concerns while more permanent system solutions are developed. As part of the Departmental Work Intake Process, MDHHS submitted work requests for prioritization to implement larger system changes that will resolve the remaining synchronization issues. Anticipated Completion Date MDHHS will determine an anticipated completion date after the work requests have been prioritized. Responsible Individual(s) Jamy Hengesbach, MDHHS
Finding 2025-037 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Transitional Medicaid Eligibility Management Views MDHHS agrees that renewals for certain beneficiaries within the 16,682 of the total 375,345 beneficiaries receiving transitional medical assistance (TMA) during the audit period wer...
Finding 2025-037 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Transitional Medicaid Eligibility Management Views MDHHS agrees that renewals for certain beneficiaries within the 16,682 of the total 375,345 beneficiaries receiving transitional medical assistance (TMA) during the audit period were not processed in a timely manner. MDHHS also notes that if a beneficiary was misclassified in an incorrect aid category but remained eligible to transition to another Medicaid aid category, no improper payments would have occurred. During the audit testing period, MDHHS had a limited timeframe to conduct manual validation making it infeasible to determine whether improper classifications were associated with all 16,682 beneficiaries identified. Planned Corrective Action As part of the regular eligibility redetermination process, MDHHS has already ended TMA for approximately 14,300 of the 16,682 beneficiaries cited as of January 2026. MDHHS will continue to complete a full review of the remaining beneficiaries to confirm the current eligibility status of these beneficiaries and assess whether they should remain in TMA, transition to another Medicaid aid category, or have their coverage closed if they are no longer eligible. While some individuals may no longer meet TMA criteria, many may be eligible for other Medicaid coverage, and this will be assessed through the follow-up review. MDHHS will complete the review, and establish an ongoing process to monitor redetermination metrics, by September 2026. In December 2025, MDHHS enhanced MI Reports functionality for redetermination reports used to manage the eligibility renewal process to improve timely processing of redeterminations. Also, MDHHS evaluated system functionality related to the timeliness of TMA renewals and identified that the system currently creates one alert for beneficiaries with multiple program renewals. To ensure TMA renewals are processed on a timely basis, MDHHS is collaborating with the Bridges technical team to implement a system enhancement that will generate a separate TMA-specific redetermination alert. This enhancement is expected to be implemented by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Jamy Hengesbach, MDHHS Mariah Schaefer, MDHHS
Finding 2025-036 Medicaid Cluster, ALN 93,775, 93.777, and 93.778 - MiAIMS User Access Management Views MDHHS agrees with the finding. Planned Corrective Action The MDHHS Access Management Section will continue to perform the monthly Michigan Adult Integrated Management System (MiAIMS)-to-DSA user r...
Finding 2025-036 Medicaid Cluster, ALN 93,775, 93.777, and 93.778 - MiAIMS User Access Management Views MDHHS agrees with the finding. Planned Corrective Action The MDHHS Access Management Section will continue to perform the monthly Michigan Adult Integrated Management System (MiAIMS)-to-DSA user reconciliation, resolve discrepancies, and provide LOSCs with a summary of results. As part of strengthening access controls, the MDHHS Access Management Section discontinued the practice of issuing advance notices prior to access termination, which previously allowed additional time for the user to complete recertification. Going forward, any active MiAIMS user who does not have a corresponding approved DSA request will have their access terminated as part of the monthly reconciliation process. Anticipated Completion Date Completed Responsible Individual(s) Cynthia Farrell, MDHHS Tim Kwast, MDHHS
Finding 2025-033 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MiLEAP agrees with the finding. Planned Corrective Action To improve compliance and inspection timeliness, MiLEAP will take the following key steps: • Enhanced regional oversight: The Chil...
Finding 2025-033 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MiLEAP agrees with the finding. Planned Corrective Action To improve compliance and inspection timeliness, MiLEAP will take the following key steps: • Enhanced regional oversight: The Child Care Licensing Bureau (CCLB) will utilize monitoring features within the Child Care Hub Information Records Portal (CCHIRP) to proactively track inspection due dates and identify providers approaching annual inspection deadlines. Consultants, lead workers, and area managers will utilize automated reporting dashboards and task notifications to monitor upcoming inspections and overdue activities in real time. CCLB will establish standardized supervisory review procedures by November 30, 2026, requiring regional management to review inspection completion status on a monthly basis to ensure timely intervention when inspections are at risk of exceeding the required timeframe. In addition, CCLB leadership will monitor statewide inspection completion rates, overdue inspections, and regional trends through recurring data reviews to identify systemic issues and implement timely corrective actions. • Ongoing Technology and Process Improvements: CCLB will continue enhancing the functionality and oversight capabilities within CCHIRP to ensure the system supports current, efficient, and effective inspection processes. Ongoing system improvements will focus on strengthening workflow management, maintaining up-to-date task guidance and tracking mechanisms, and improving the accuracy and visibility of inspection timelines and required activities. Anticipated Completion Date Ongoing Responsible Individual(s) Courtney Adams, MiLEAP Scott Bettys, MiLEAP Erika Bigelow, MiLEAP Monica Sturdivant, MiLEAP
Finding 2025-063 Special Education Cluster (IDEA), ALN 84.027 and 84.173 Management Views MDE disagrees with the finding. MDE maintains that its current monitoring approach satisfies federal requirements. The MDE Office of Special Education’s (OSE) monitoring framework is consistent with the risk-ba...
Finding 2025-063 Special Education Cluster (IDEA), ALN 84.027 and 84.173 Management Views MDE disagrees with the finding. MDE maintains that its current monitoring approach satisfies federal requirements. The MDE Office of Special Education’s (OSE) monitoring framework is consistent with the risk-based requirements of the Uniform Guidance (2 CFR 200.332). The Uniform Guidance does not require routine review of underlying supporting documentation for every subrecipient in every monitoring cycle. Rather, source documentation review is one available monitoring tool, which MDE OSE uses, when warranted, based on risk, audit results, identified concerns, or other relevant information. MDE OSE’s monitoring activities include budget review and approval, budget-to-actual analysis, review of expenditure activity, direct engagement and technical assistance with subrecipients, review of single audit reports, issuance of management decisions (when applicable), and enhanced review procedures for higher-risk subrecipients. These activities collectively provide reasonable assurance that funds are used for authorized purposes and in compliance with applicable requirements. MDE OSE also notes that subrecipient single audits have not routinely identified questioned costs or significant noncompliance, which supports the effectiveness of the existing monitoring framework. Planned Corrective Action MDE disagrees with the finding and does not believe corrective action is required to resolve noncompliance. However, MDE OSE will update its internal monitoring procedures to document the circumstances under which expenditure sampling may be performed for medium- and low-risk subrecipients to enhance clarity of MDE OSE procedures. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Sean McLaughlin, MDE
Finding 2025-027 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Salesforce Security Management and Access Controls Management Views MSF agrees that Salesforce was not written as an exception in the identified policy but disagrees that there is a control deficiency. MSF maintains eff...
Finding 2025-027 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Salesforce Security Management and Access Controls Management Views MSF agrees that Salesforce was not written as an exception in the identified policy but disagrees that there is a control deficiency. MSF maintains effective controls within its control environment that effectively mitigate risks associated with exempting Salesforce from the identified policy and provide reasonable assurance MSF is managing federal awards in compliance with federal statutes, regulations, and the terms and conditions of federal awards. Planned Corrective Action Based on the factors that led MSF to exempt Salesforce from SECU.01.020.01 (Access Control Standard), including risk assessments and MSF’s existing control environment, Salesforce will be included in the policy as a written exception. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Alex Fox, MSF Ian McCorvie, MSF Calvin Myers, MSF William Chaffee, MSF
Finding 2025-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a post payment review process for the final respite payments issued through the Medical S...
Finding 2025-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a post payment review process for the final respite payments issued through the Medical Services Administration Manual Payment System during fiscal year 2025 and finalized the review during fiscal year 2026, noting no improper payments. As all respite payments concluded at the end of fiscal year 2025, this review is no longer applicable moving forward. Anticipated Completion Date Completed Responsible Individual(s) Crystal Kline, MDHHS
Finding 2025-025 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees that security management and access controls should be fully established for the Public Transportation Management System (PTMS). Planned Correcti...
Finding 2025-025 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees that security management and access controls should be fully established for the Public Transportation Management System (PTMS). Planned Corrective Action Because PTMS is a legacy system that is being retired, MDOT will not re-create historical user data that was deleted due to a system limitation. Rather, MDOT EIM and the MDOT Office of Passenger Transportation (OPT) will collaborate and provide oversight to ensure that the new system, the Public Transportation Information Management System (PTIMS), which is scheduled for full implementation August 31, 2026, has fully established security management and access controls and that there is pertinent documentation regarding users’ roles. Also, EIM and OPT will continue to ensure that PTMS, and PTIMS after its implementation, user access is reviewed at least annually in accordance with SOM Technical Standard 1340.00.040.01 (Audit and Accountability Standard). Under the existing process, the designated system security administrators obtain, verify, and document the written approval for all identified users, and access is modified/removed timely and as appropriate based on responses received or removed when no response is received. Anticipated Completion Date September 2026 Responsible Individual(s) Sandy Lovell, MDOT Gina Huhn, MDOT Jean Ruestman, MDOT Kyle Nelson, MDOT Andy Esch, MDOT
Finding 2025-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - MiSSG Security Management and Access Controls Management Views MiLEAP agrees with the finding. Planned Corrective Action For part a., for the exceptions noted in the finding, MiLEAP had the contractors complete the acce...
Finding 2025-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - MiSSG Security Management and Access Controls Management Views MiLEAP agrees with the finding. Planned Corrective Action For part a., for the exceptions noted in the finding, MiLEAP had the contractors complete the access forms and has approved their access. MiLEAP also updated its procedures to ensure that contractors complete the Michigan Student Aid Scholarships and Grants (MiSSG) access forms before access is granted to the system. For part b., MiLEAP updated its procedures to ensure that it maintains sufficient documentation of its recertification review of internal users. Anticipated Completion Date Completed Responsible Individual(s) Diann Cosme, MiLEAP
Finding 2025-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - EGrAMS Security Management and Access Controls Management Views LEO agrees with the finding. Planned Corrective Action For part a., LEO has a process to maintain documentation and support for internal users. For externa...
Finding 2025-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - EGrAMS Security Management and Access Controls Management Views LEO agrees with the finding. Planned Corrective Action For part a., LEO has a process to maintain documentation and support for internal users. For external users, LEO will ask the vendor to upgrade the system so it logs every external user activation, including the approving LEO staff member’s name and the timestamp, rather than overwriting previous external user activation records. For part b., LEO established a user reconciliation process in March 2026 that will be managed by the LEO Grants Division. For part c., LEO will change its policy requiring the disablement of user accounts inactive for over 60 days to comply with SOM Technical Standard 1340.00.020.01 (Access Control Standard). LEO will work with DTMB to complete a system security plan so user accounts will be automatically deactivated after 60 days of inactivity. LEO will also explore options to address the issue of EGrAMS users who typically only access the system every 90 days to complete required system reports. Anticipated Completion Date a. December 31, 2026 b. Completed c. December 31, 2026 Responsible Individual(s) Jason Hamblin, LEO
Finding 2025-022 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Concur Security Management and Access Controls Management Views The Michigan Strategic Fund (MSF) agrees that Concur was not written as an exception in the identified policy but disagrees that there is a control deficie...
Finding 2025-022 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Concur Security Management and Access Controls Management Views The Michigan Strategic Fund (MSF) agrees that Concur was not written as an exception in the identified policy but disagrees that there is a control deficiency. MSF maintains effective controls within its control environment that effectively mitigate risks associated with exempting Concur from the identified policy and provide reasonable assurance MSF is managing federal awards in compliance with federal statutes, regulations, and the terms and conditions of federal awards. Planned Corrective Action Based on the factors that led MSF to exempt Concur from SECU.01.020.01 (Access Control Standard), including risk assessments and MSF’s existing control environment, Concur will be included in the policy as a written exception. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Alex Fox, MSF Ian McCorvie, MSF Calvin Myers, MSF William Chaffee, MSF
Finding 2025-021 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees it did not fully establish effective security management and access controls over the American Association of State Highway and Transportat...
Finding 2025-021 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees it did not fully establish effective security management and access controls over the American Association of State Highway and Transportation Officials software (AASHTOWare) users. Planned Corrective Action For part a., the MDOT Office of Enterprise Information Management (EIM), Bureau of Field Services-Construction Field Services Division, and Bureau of Development-Design Division will collaborate and provide oversight to ensure that internal user access for AASHTOWare is reviewed at least annually. MDOT will implement an improved process, which will be facilitated by the designated system security administrators, to ensure an internal user review at least annually. For part b., MDOT worked with DTMB in May 2026 to correct and enhance the auto-disabler function of the AASHTOWare program. In addition, MDOT will continue to monitor this functionality as part of its improved access control process to ensure users who have not accessed AASHTOWare within 365 days for internal user accounts and 18 months for external user accounts are disabled timely. Anticipated Completion Date a. September 30, 2026 b. Completed Responsible Individual(s) Mark Shulick, MDOT Dan Burns, MDOT Kristin Schuster, MDOT Dee Parker, MDOT Lindsey Renner, MDOT Jason Gutting, MDOT Kyle Nelson, MDOT Andy Esch, MDOT
Corrective Action Plan Finding No.: 2025 - 004 Condition: During testing of expenditures claimed under the Education Stabilization Fund program we identified $41,157 of expenditures that were included in a reimbursement request were not supported by allowable program expenditures. Subsequent to the ...
Corrective Action Plan Finding No.: 2025 - 004 Condition: During testing of expenditures claimed under the Education Stabilization Fund program we identified $41,157 of expenditures that were included in a reimbursement request were not supported by allowable program expenditures. Subsequent to the reimbursement request and receipt of grant funds, the checks issued as payment to vendors were voided as the vendors did not provide goods or services. These expenditures were determined to be unsupported and resulted in questioned costs. Plan: Administration will not create and hold checks for goods and services not yet rendered under a grant award, as this can lead to unsupported expenditures, should the goods or services not be provided or the checks are voided and not timely reported. The encumbrance process will be used appropriately, and payments will be made once the goods or services have been rendered. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Dr. Rena Whitten, Superintendent
#2025-005 FINDING: Payroll Testing Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will continue to review payroll prior to payroll being paid. The Payroll/Accountant will double check all timesheets before entering and double check payrate against c...
#2025-005 FINDING: Payroll Testing Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will continue to review payroll prior to payroll being paid. The Payroll/Accountant will double check all timesheets before entering and double check payrate against contract amount. Anticipated Completion Date: Ongoing
Finding 2025-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – June 30, 2026 Management agrees with the finding. Remediation: Fairview has correc...
Finding 2025-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – June 30, 2026 Management agrees with the finding. Remediation: Fairview has corrected the payroll reimbursement request for the inaccurate payroll charges identified in the finding. To prevent recurrence, Fairview will enhance controls over payroll review processes to ensure accuracy prior to submission. These enhancements include reinforcing review expectations with project directors and including detailed review procedures for validating pay rate and wage calculations prior to reimbursement submissions. Management believes these actions will improve the accuracy of payroll charges and ensure compliance with federal program requirements.
INVOICE CODING - Criteria: Costs are necessary and reasonable for the performance of the federal award and allocable under the principles of 2 CFR 200, Subpart E. Condition: One invoice charged to the grant in the amount of $1,955 should have been allocated to a different grant. Context: Internal co...
INVOICE CODING - Criteria: Costs are necessary and reasonable for the performance of the federal award and allocable under the principles of 2 CFR 200, Subpart E. Condition: One invoice charged to the grant in the amount of $1,955 should have been allocated to a different grant. Context: Internal control review procedures did not correctly identify that the invoice was charged to the incorrect grant. Effect: Cost was charged to the wrong grant. Cause: Error in invoice coding. Recommendation: Review procedures should be enhanced to ensure approved costs are charged to the appropriate grant. Corrective Action: This mistake of grant attribution was subsequently corrected completely. The issue was attributable to a manual process that has been replaced by electronic processing. The electronic procurement system significantly reduces and in most cases eliminates data entry and manual translation between procurement and posting to a particular grant. Adequate review and oversight processes are in place and this issue does not reflect a systemic failure. Responsible Party: Claudine Lurvey, VP of Finances.
Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and...
Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should expand its financial reporting review procedures to require the documented review and approval of all performance reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: During the fiscal year, the Organization properly implemented procedures that require the documented review of the monthly financial reports, including the corresponding indirect cost calculations. The Organization will expand these policies and procedures to require the documented review and approval of all performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.
Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00...
Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should establish and maintain written internal control procedures that cover the required five components of internal control for each area of compliance for each of its federal programs. The Organization should educate all employees working with federal programs of the Organization’s procedures and monitor compliance with them. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.
Corrective Action: All vouchers require Town Manager and Finance Director to approve and sign all vouchers prior to payment. Efforts are in place to make this a high priority even in busy times. The number of transactions processed greatly increased relative to Federal dollars, but the Town is commi...
Corrective Action: All vouchers require Town Manager and Finance Director to approve and sign all vouchers prior to payment. Efforts are in place to make this a high priority even in busy times. The number of transactions processed greatly increased relative to Federal dollars, but the Town is committed to internal controls. Anticipated Completion Date: Immediately Contact Person: Elizabeth Draper and Brian Rosso
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient t...
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient to Douglas County who is the recipient of the funds. Eide Bailly LLP identified that the Town did not have documented or consistently applied internal controls to ensure compliance with the County’s subrecipient guidance requiring the submission of formal special reports for ALN 21.027. Responsible Individuals: Mark Henderson, Assistant Director of Castle Rock Water Corrective Action Plan: Staff will complete quarterly reports including project progress and estimated project infrastructure costs. The reports will be reviewed by management prior to submission to the recipient of the Federal Funds (Douglas County). Anticipated Completion Date: Ongoing during the period that the Town is a subrecipient of these funds for the project.
Findings (2025-001, 2025-002, 2025-003) Finding: Advance Funds- In accordance with 45 CFR 75.305(b)(1) [refer to “Prepaid Rent” above]. Of the 24 cash advances received, one advance was held for six working days, which is in excess of “immediate cash needs” as outlined in the Uniform Guidance and th...
Findings (2025-001, 2025-002, 2025-003) Finding: Advance Funds- In accordance with 45 CFR 75.305(b)(1) [refer to “Prepaid Rent” above]. Of the 24 cash advances received, one advance was held for six working days, which is in excess of “immediate cash needs” as outlined in the Uniform Guidance and the policy historically observed by the Organization of 72 working hours. Auditor Recommendation: Advance Funds- We recommend that management design and implement formal, written internal control procedures to ensure compliance with cash management requirements. Specifically, management should implement a supervisory review to ensure federal funds are limited to minimum amounts needed for immediate cash requirements as indicated in the Uniform Guidance. Corrective Action: Advance Funds- Internal controls have been updated and there is an additional level for reviewing requests. The Executive Director is provided a list of all funds available after each draw down and the amounts drawn down are matched to the GL and GFR. This responsibility will be transferred to the Deputy Director once the new Fiscal Manager is in place. There is a schedule for the date the funds are allowed to be requested that fall within the 72-hour window posted in the Finance office and the Executive Director is notified before any requests are processed. The current Finance officer is meeting every 2 weeks for training with NDRN and policies, Uniform Guidance, MIP processes, and federal grants are reviewed in these meetings. Timeline: Advance Funds- TA with NDRN: Every 2 weeks starting April 22, 2026. Fiscal Manager: Posting for the position will be up by end of June 2026. 72-Hour Listing: Created and posted 6/1/26 Finding: Payroll Expenses- During our testing of allowable costs, 2 of the 20 time sheets selected did not contain approval signatures. Auditor Recommendation: Payroll Expenses- We recommend that management update its internal control policies to establish formal backup/interim approval authorities. When primary supervisors are out of the office on vacation or leave, a designated alternative official must be authorized to review and approve timesheets timely to ensure the continuity of internal controls. Corrective Action: Payroll Expenses- Payroll review: Payroll packets are reviewed during and after the payroll process to ensure all timesheets are approved and signed off by both the Executive Director and Board of Directors when appropriate. Executive Director’s timesheets and authorizations are presented to the Board of Directors when signing checks for review and approval. Procedures have been updated to include a secondary review of the timesheets at the end of each payroll cycle. Timeline: Payroll Expenses- Payroll review: After every payroll beginning 4/23/26 Finding: Prepaid Rent- As of September 30, 2025, a total of 14 months of rent payments were recognized in the general ledger and had been drawn from the PAIMI program. Total questioned costs related to these prepaid transactions, prepaid at year end, totaled $3,855.80. Auditor Recommendation: Prepaid Rent- We recommend that management design and implement formal, written internal control procedures to ensure compliance with cash management requirements. Specifically, management should implement a supervisory review of all general ledger disbursements against grant draws to ensure federal funds are limited to minimum amounts needed for immediate cash requirements. Corrective Action: Prepaid Rent- We received permission and were encouraged by our federal funders to pre-pay rent. We will not be pre-paying rent going forward. The Executive Director meets weekly with both PADD and PAIMI program managers to review processes. Timeline: Prepaid Rent- PADD and PAIMI program manager meetings: ongoing since before audit. Finding: Program Income- Our testing of allowable costs under the PADD grant identified two specific transactions where expenditures were fully reimbursed by federal funds despite being offset by program income and/or being erroneously drawn. Because these transactions relate to the same journal entry recognized in the general ledger, these are considered isolated instances. Auditor Recommendation: Program Income- We recommend that management design and implement formal, written internal control procedures to identify, track, and account for all program income generated by PADD grant activities within the general ledger. Corrective Action: Program Income- We received confirmation from the federal partners that we should spend the $16,165 legal fees from 2023, in April 2026. Those funds were not drawn down during PPE 4/30/26 and 5/15/26. Timeline: Program Income- $9104 was used to cover the PADD draw down for 4/30/26. No additional funds were drawn down. The remaining $7061 was used to cover part of the funds requested for 5/15/26. Additional funds were requested during the 5/15/26 draw down to cover remaining expenses. Nevada Disability and Law Center 2820 W Charleston Blvd, Suite 11 Las Vegas, NV 89102 EIN: 88-0327392 Jessica Crain, Deputy Director (Jessica@ndalc.org) (702) 257-8150 ext. 7122 phone (702) 257-8170 fax
Findings (2025-001, 2025-002, 2025-003) Finding: Advance Funds- In accordance with 45 CFR 75.305(b)(1) [refer to “Prepaid Rent” above]. Of the 24 cash advances received, one advance was held for six working days, which is in excess of “immediate cash needs” as outlined in the Uniform Guidance and th...
Findings (2025-001, 2025-002, 2025-003) Finding: Advance Funds- In accordance with 45 CFR 75.305(b)(1) [refer to “Prepaid Rent” above]. Of the 24 cash advances received, one advance was held for six working days, which is in excess of “immediate cash needs” as outlined in the Uniform Guidance and the policy historically observed by the Organization of 72 working hours. Auditor Recommendation: Advance Funds- We recommend that management design and implement formal, written internal control procedures to ensure compliance with cash management requirements. Specifically, management should implement a supervisory review to ensure federal funds are limited to minimum amounts needed for immediate cash requirements as indicated in the Uniform Guidance. Corrective Action: Advance Funds- Internal controls have been updated and there is an additional level for reviewing requests. The Executive Director is provided a list of all funds available after each draw down and the amounts drawn down are matched to the GL and GFR. This responsibility will be transferred to the Deputy Director once the new Fiscal Manager is in place. There is a schedule for the date the funds are allowed to be requested that fall within the 72-hour window posted in the Finance office and the Executive Director is notified before any requests are processed. The current Finance officer is meeting every 2 weeks for training with NDRN and policies, Uniform Guidance, MIP processes, and federal grants are reviewed in these meetings. Timeline: Advance Funds- TA with NDRN: Every 2 weeks starting April 22, 2026. Fiscal Manager: Posting for the position will be up by end of June 2026. 72-Hour Listing: Created and posted 6/1/26 Finding: Payroll Expenses- During our testing of allowable costs, 2 of the 20 time sheets selected did not contain approval signatures. Auditor Recommendation: Payroll Expenses- We recommend that management update its internal control policies to establish formal backup/interim approval authorities. When primary supervisors are out of the office on vacation or leave, a designated alternative official must be authorized to review and approve timesheets timely to ensure the continuity of internal controls. Corrective Action: Payroll Expenses- Payroll review: Payroll packets are reviewed during and after the payroll process to ensure all timesheets are approved and signed off by both the Executive Director and Board of Directors when appropriate. Executive Director’s timesheets and authorizations are presented to the Board of Directors when signing checks for review and approval. Procedures have been updated to include a secondary review of the timesheets at the end of each payroll cycle. Timeline: Payroll Expenses- Payroll review: After every payroll beginning 4/23/26 Finding: Prepaid Rent- As of September 30, 2025, a total of 14 months of rent payments were recognized in the general ledger and had been drawn from the PAIMI program. Total questioned costs related to these prepaid transactions, prepaid at year end, totaled $3,855.80. Auditor Recommendation: Prepaid Rent- We recommend that management design and implement formal, written internal control procedures to ensure compliance with cash management requirements. Specifically, management should implement a supervisory review of all general ledger disbursements against grant draws to ensure federal funds are limited to minimum amounts needed for immediate cash requirements. Corrective Action: Prepaid Rent- We received permission and were encouraged by our federal funders to pre-pay rent. We will not be pre-paying rent going forward. The Executive Director meets weekly with both PADD and PAIMI program managers to review processes. Timeline: Prepaid Rent- PADD and PAIMI program manager meetings: ongoing since before audit. Finding: Program Income- Our testing of allowable costs under the PADD grant identified two specific transactions where expenditures were fully reimbursed by federal funds despite being offset by program income and/or being erroneously drawn. Because these transactions relate to the same journal entry recognized in the general ledger, these are considered isolated instances. Auditor Recommendation: Program Income- We recommend that management design and implement formal, written internal control procedures to identify, track, and account for all program income generated by PADD grant activities within the general ledger. Corrective Action: Program Income- We received confirmation from the federal partners that we should spend the $16,165 legal fees from 2023, in April 2026. Those funds were not drawn down during PPE 4/30/26 and 5/15/26. Timeline: Program Income- $9104 was used to cover the PADD draw down for 4/30/26. No additional funds were drawn down. The remaining $7061 was used to cover part of the funds requested for 5/15/26. Additional funds were requested during the 5/15/26 draw down to cover remaining expenses. Nevada Disability and Law Center 2820 W Charleston Blvd, Suite 11 Las Vegas, NV 89102 EIN: 88-0327392 Jessica Crain, Deputy Director (Jessica@ndalc.org) (702) 257-8150 ext. 7122 phone (702) 257-8170 fax
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