Corrective Action Plans

Finding 567837 (2024-046)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Allowable Costs / Cost Principles Student Financial Aid § 200.516

Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the bi...

Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the birth certificate was identified and the youth was determined to be Title IV-E eligible. MDHHS will reclassify the funds to the appropriate funding source, allowing the department to claim Title IV-E for the eligible placement. For those cases in which Title IV-E funding is denied initially based on lack of a birth certificate or other documentation of citizenship, the Child Welfare Funding Specialists will continue to monitor the case for updated documentation in order to complete a redetermination of funding. Child Welfare Funding Specialists will be reminded to monitor cases for updated documentation during a Child Welfare Funding conference call in June 2025. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Nancy Berger, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567836 (2024-045)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.516

Finding 2024-045 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine the reason for the incomplet...

Finding 2024-045 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine the reason for the incomplete application by September 30, 2025, and implement a solution to correct the issue, if needed. If potential system modifications are needed, MDHHS will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. MDHHS will also send a memo and template of the application to the local offices to highlight the required questions on the application to help ensure all required questions are appropriately answered. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solution identified. Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schulze, MDHHS Brian Sanborn, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567835 (2024-044)

Significant Deficiency 2024

State of Michigan

MI

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

Finding 2024-044 Temporary Assistance for Needy Families, ALN 93.558 - MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS currently has a process in place to review the user narrative describing the incomp...

Finding 2024-044 Temporary Assistance for Needy Families, ALN 93.558 - MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS currently has a process in place to review the user narrative describing the incompatible role exceptions within the DSA Michigan Statewide Automated Child Welfare Information System (MiSACWIS) request as part of the approval process. MDHHS will continue to work on adding an incompatible role form in the DSA MiSACWIS request with automated routing for appropriate approval. MDHHS anticipates completion of corrective action by October 30, 2025. For part b., MDHHS will evaluate the current DSA timelines for generation of access renewal and access drop requests and implement any necessary changes by September 30, 2025. MDHHS will continue to provide training for LOSCs via quarterly webinars to emphasize the appropriate procedures for granting access, reviewing, and comparing access. All new information related to security access is presented to the LOSCs during the webinars and one-on-one assistance is available as needed for additional support. Anticipated Completion Date a. October 30, 2025 b. September 30, 2025 Responsible Individual(s) Alana Lowe, MDHHS Deon Nelson, MDHHS

View Audit 360209

Finding 567769 (2024-043)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Finding 2024-043 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source for overlaps between fee-for-service and capitation payments is due to retroact...

Finding 2024-043 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source for overlaps between fee-for-service and capitation payments is due to retroactive removal of Medicaid eligibility within Bridges. An upgraded interface fix was implemented during March 2025 to address several issues. This upgraded interface removed the existing limitations to mitigate the occurrence of retroactive disenrollment. Anticipated Completion Date Completed Responsible Individual(s) Latina McCausey, MDHHS Alexis Bond, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567768 (2024-042)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notificatio...

Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notification to adult services staff, communicating that medical needs forms should be uploaded into EDM. MDHHS issued an Adult Services Notification to adult services staff during May 2025 to communicate the exceptions identified and remind them of the medical needs form requirements. MDHHS will develop a procedure to monitor the expiration of medical needs forms using the MiAIMS Plan of Care by August 2025. In addition, MDHHS will research potential options to automate monitoring of the medical needs forms in MiAIMS and determine if any necessary system changes are needed by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Elaina Brown, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567767 (2024-041)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2024-041 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 a monthly hospitalization report and distributes to adult services workers as part of the post-payment review proce...

Finding 2024-041 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 a monthly hospitalization report and distributes to adult services workers as part of the post-payment review process. MDHHS enhanced the report query to improve the data used to identify overlaps in services and timely recover payments. MDHHS implemented the updated query during June 2025. Also, MDHHS issued an Adult Services Notification to managers and directors during February 2025, informing them of the audit finding and 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. In addition, MDHHS 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. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown, MDHHS Michelle Martin, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567766 (2024-040)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2024-040 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 these overpayment issues, as we...

Finding 2024-040 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 these overpayment issues, as well as developing mitigation strategies to temporarily address the overpayment concerns while the more permanent system solutions are developed. MDHHS expects all remaining synchronization issues to be resolved once the remaining larger system changes are implemented in December 2025. Anticipated Completion Date December 31, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567765 (2024-039)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Finding 2024-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Transitional Medicaid Eligibility Management Views MDHHS agrees with the finding. MDHHS recognizes there are opportunities for improvement to ensure renewals are processed on a timely basis for beneficiaries receiving transitional ...

Finding 2024-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Transitional Medicaid Eligibility Management Views MDHHS agrees with the finding. MDHHS recognizes there are opportunities for improvement to ensure renewals are processed on a timely basis for beneficiaries receiving transitional medical assistance (TMA) Medicaid coverage, however due to time constraints, it was not feasible to manually review and validate all 1,802 beneficiaries queried to ensure they should be terminated from TMA. Also, although beneficiaries might not be eligible for TMA, they may be eligible for other Medicaid aid categories, and this will be determined as part of the department’s corrective action. Planned Corrective Action MDHHS implemented a system enhancement during May 2023 that generates redetermination requests one month in advance to allow additional time for processing and help ensure renewals are processed timely. MDHHS is continuing to update the backlog of cases following the end of the PHE, including those identified in the finding, to determine if the beneficiary should remain on Medicaid or if coverage should be terminated, and expects all existing cases will be reviewed and updated by July 2025. MDHHS will evaluate potential underlying system issues related to the timeliness of TMA renewals and will implement system enhancements if necessary by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567764 (2024-038)

Significant Deficiency 2024

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Finding 2024-038 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 reconciles the users in MiAIMS to the users approved within DSA monthly, resolves discrepancies, and...

Finding 2024-038 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 reconciles the users in MiAIMS to the users approved within DSA monthly, resolves discrepancies, and sends an email notification to LOSCs with a summary of the results. Beginning May 2025, the monthly email notification distributed to the LOSCs will emphasize appropriate procedures for granting access, including a reminder to synchronize MiAIMS activations and the DSA final approval to serve as documentation of the activation. By June 2025, MDHHS MiAIMS management and the Access Management Section will begin meeting annually with LOSCs, help desk, and technical staff to review access procedures. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Cynthia Farrell, MDHHS Tim Kwast, MDHHS

View Audit 360209

Finding 567763 (2024-037)

Significant Deficiency 2024

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Finding 2024-037 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - MiAIMS General Controls Management Views For part a., DTMB agrees it had not fully implemented all SOM database specific configurations during the audit period. However, DTMB disagrees these specific configurations created signifi...

Finding 2024-037 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - MiAIMS General Controls Management Views For part a., DTMB agrees it had not fully implemented all SOM database specific configurations during the audit period. However, DTMB disagrees these specific configurations created significant security risks. DTMB has been and continues to follow the manufacturer’s recommendations regarding security configurations. For part b., DTMB agrees with the finding. Planned Corrective Action For part a., DTMB will implement the SOM approved database configurations. For part b., DTMB will review and update internal business processes as needed to ensure privileged Michigan Adult Integrated Management System (MiAIMS) database accounts are reviewed in accordance with SOM Technical Standards. Anticipated Completion Date July 31, 2025 Responsible Individual(s) Nathan Buckwalter, DTMB

View Audit 360209

Finding 567725 (2024-034)

Significant Deficiency 2024

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Special Tests & Provisions

Finding 2024-034 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 took the following key steps: • Increased staffing: In fiscal year 202...

Finding 2024-034 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 took the following key steps: • Increased staffing: In fiscal year 2024, the Child Care Licensing Bureau (CCLB) initiated the hiring of 22 additional licensing consultants across all eight established regions, significantly increasing statewide capacity. All new consultants began their positions by November 2024. Upon hire, they entered a structured training program with the goal of receiving caseload assignments within six months. This strategic staffing expansion has already led to a 30.0 percent reduction in the average caseload per consultant from 88 to 61 facilities aligning more closely with best practice recommendations and enabling more timely inspections. As these new consultants complete training and receive full caseloads, CCLB anticipates an increase in completed onsite inspections, improved timeliness, and enhanced capacity to meet the growing needs of child care providers. • Enhanced regional oversight: In fiscal year 2025, CCLB established lead worker positions in each child care region. These lead workers support area managers in monitoring consultant caseloads and inspection schedules to ensure annual inspections are completed in compliance with federal requirements. • Process improvements through technology: CCLB continues to utilize the Child Care Hub Information Records Portal in a mobile format, improving data access and streamlining on-site inspections. Providers are encouraged to utilize the system during onsite inspections to facilitate faster and more efficient communication and documentation. Anticipated Completion Date Ongoing Responsible Individual(s) Courtney Adams, MiLEAP Scott Bettys, MiLEAP Erika Bigelow, MiLEAP Monica Sturdivant, MiLEAP

View Audit 360209

Finding 567723 (2024-032)

Significant Deficiency 2024

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Special Tests & Provisions

Finding 2024-032 CCDF Cluster, ALN 93.575 and 93.596 - MWBC Child Care System User Access Management Views MiLEAP agrees with the finding. Planned Corrective Action The Michigan Workforce Background Check (MWBC) Child Care System is used to conduct and record the results of criminal history checks...

Finding 2024-032 CCDF Cluster, ALN 93.575 and 93.596 - MWBC Child Care System User Access Management Views MiLEAP agrees with the finding. Planned Corrective Action The Michigan Workforce Background Check (MWBC) Child Care System is used to conduct and record the results of criminal history checks for child care providers and is comprised of multiple modules, including the Consultant Portal and Analyst Portal. Each portal serves distinct functions, carrying varying levels of access to background check information and functionality. MiLEAP acknowledges that internal controls should more explicitly require module-specific documentation. To address this, MiLEAP has reinforced its access control procedures to ensure the Child Care Background Check (CCBC) Access and Security Agreement directs that access requests be sent to the manager of the CCBC unit and explicitly documents the specific portals being requested. The CCBC unit manager is responsible for reviewing and granting access to both the Analyst and Consultant portals based on the user’s role and job duties. MiLEAP has reinforced this policy as of May 2024 with appropriate staff to ensure compliance and improve documentation for each portal. Anticipated Completion Date Completed Responsible Individual(s) Jacob Poynter, MiLEAP Monica Sturdivant, MiLEAP

View Audit 360209

Finding 567696 (2024-025)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.303

Finding 2024-025 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action During fiscal year 2024, MDHHS improved the payment review process prior to manual input into the Medic...

Finding 2024-025 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action During fiscal year 2024, MDHHS improved the payment review process prior to manual input into the Medical Services Administration Manual Payment System (MSAPay) to help ensure there are no improper payments, as demonstrated by no improper payments identified for fiscal year 2024. MDHHS will develop and implement a post payment review process for the final respite payments that were entered into MSAPay during December 2024 and anticipates completion by September 30, 2025. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Crystal Kline, MDHHS Jessica Bowen, MDHHS Elaina Brown, MDHHS

View Audit 360209

Finding 567695 (2024-024)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Cash Management Eligibility § 200.303

Finding 2024-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action The EGLE Water Resources Division’s (WRD) administration staff adjusted their review process in April 20...

Finding 2024-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action The EGLE Water Resources Division’s (WRD) administration staff adjusted their review process in April 2024 to comply with overall EGLE guidance that all reimbursement requests should be reviewed by a program representative and financial representative to ensure payments are made for activities authorized by the grant agreement. However, WRD had not fully completed the retroactive review of payments for fiscal year 2024. This has since been corrected and all retroactive reviews to ensure compliance with program technical specifications were completed as of May 1, 2025. Anticipated Completion Date Completed Responsible Individual(s) Phil Argiroff, EGLE Amy Hicks, EGLE

View Audit 360209

Finding 567694 (2024-023)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding 2024-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT EIM and Office of Passenger Transportation will collaborate and provide oversight to ensure ...

Finding 2024-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT EIM and Office of Passenger Transportation will collaborate and provide oversight to ensure that Public Transportation Management System (PTMS) user access is reviewed semiannually for privileged accounts and annually for all other accounts. MDOT will implement an improved process which will include obtaining, verifying, and documenting the written approval for all identified users by the designated System Security Administrators. Access will be modified/removed, as appropriate, based on responses or removed for non-responders prior to the end of each six-month period for privileged users and each fiscal year for all other users. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Sandy Lovell, MDOT Gina Huhn, MDOT Jean Ruestman, MDOT Kyle Nelson, MDOT Andy Esch, MDOT

View Audit 360209

Finding 567688 (2024-022)

Significant Deficiency 2024

State of Michigan

MI

Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303

Finding 2024-022 Highway Planning and Construction, ALN 20.205 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT’s Office of Enterprise Information Management (EIM), Bureau of Field Services-Construction Field Service...

Finding 2024-022 Highway Planning and Construction, ALN 20.205 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT’s 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 user access for the American Association of State Highway and Transportation Officials software (AASHTOWare) Preconstruction and Construction & Materials modules is reviewed semiannually for privileged accounts and annually for all other accounts. MDOT will implement an improved process, which will be facilitated by the designated System Security Administrators, and access will be modified or removed, as appropriate, prior to the end of each six-month period for privileged users and annually for all other users. Anticipated Completion Date January 1, 2026 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

View Audit 360209

Finding 567666 (2024-019)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

Finding 2024-019 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS discussed the change management documented requirements with the information t...

Finding 2024-019 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS discussed the change management documented requirements with the information technology (IT) contractor during April 2025 to ensure all testing is documented appropriately. MDHHS has updated the Michigan Women, Infants, and Children Information System (MI-WIC) Change Management Controls process to include a review of each change to ensure it has successfully completed all components of the change management process prior to completion of associated release activities. Anticipated Completion Date Completed Responsible Individual(s) Kristina Brady, MDHHS Bagya Kodur, MDHHS

View Audit 360209

Finding 567665 (2024-018)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

Finding 2024-018 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Access Controls Management Views MDHHS and DTMB agree with the finding. Planned Corrective Action DTMB implemented a process in November 2024 to review privileged accounts with direct ...

Finding 2024-018 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Access Controls Management Views MDHHS and DTMB agree with the finding. Planned Corrective Action DTMB implemented a process in November 2024 to review privileged accounts with direct database access semiannually. Anticipated Completion Date Completed Responsible Individual(s) Nathan Buckwalter, DTMB

View Audit 360209

Finding 567640 (2024-001)

Significant Deficiency 2024

Tarrant County Samaritan Housing

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding-001 Allowable Activities – Significant deficiency in internal controls over compliance (HOPWA Payroll Allocation) Management Response The organization recognizes the importance of ensuring that payroll allocations are properly supported by approved documentation. To address this finding, the...

Finding-001 Allowable Activities – Significant deficiency in internal controls over compliance (HOPWA Payroll Allocation) Management Response The organization recognizes the importance of ensuring that payroll allocations are properly supported by approved documentation. To address this finding, the agency has implemented the following corrective actions: • Annual training on grant-specific timekeeping and payroll allocation requirements hasbeen instituted for all employees whose salaries are charged to grants. • Updated Standard Operating Procedures (SOPs) have been issued to program directorsand payroll administrators outlining the necessary approval and documentation processfor payroll allocations. • Supervisory review and certification of payroll allocation reports have been implementedto ensure compliance with approved grant allocations prior to payroll processing. Training sessions will be held on: June 10, 2025 • June 10, 2025 (initial training session for all HOPWA-funded staff) • Refresher training will be scheduled annually each June going forward. Responsible Staff: Controller and Program Directors Implementation Date: June 2, 2025

View Audit 360187 Questioned Costs: $1

Finding 567639 (2024-001)

Material Weakness 2024

Scripps Health and Affiliates

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended S...

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2024 Finding Reference Number: 2024-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of expenditures to support activities allowed or unallowed, allowable costs/cost principles, reporting and special tests and provisions related to amounts reimbursed for the project worksheet as it relates to the FEMA disposition requirements for COVID-19 related supplies. As a result, Management was reimbursed by FEMA for expenditures that were not in compliance with the FEMA disposition requirements which resulted in a questioned costs of $480,606. Corrective Action Plan: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reporting for reimbursement in the FEMA project worksheet comply with the FEMA disposition requirements. Management will work with FEMA to refund the questioned costs and discuss the extent of the additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: June 30, 2025

View Audit 360181 Questioned Costs: $1

Finding 567624 (2024-003)

Significant Deficiency 2024

Metlakatla Indian Community

AK

Questioned Costs Allowable Costs / Cost Principles

Finding 2024-003 Lack of Internal Control over Activities Allowed or Unallowable and Allowable Costs/Cost Principles Name of Contact Person: Alexis Russell, Human Resources Corrective Action: The Human Resources Department will conduct an internal audit of active employee documentation for all maj...

Finding 2024-003 Lack of Internal Control over Activities Allowed or Unallowable and Allowable Costs/Cost Principles Name of Contact Person: Alexis Russell, Human Resources Corrective Action: The Human Resources Department will conduct an internal audit of active employee documentation for all major departments. All active employees within these departments will be required to submit updated voluntary deduction forms. Additionally, department directors will be responsible for submitting and renewing Personnel Action Forms for all employees under their supervision, with all renewals effective no later than October 1st of each year. Proposed Completion Date: The internal audit of documentation for all active employees within major MIC departments will be completed no later than August 31, 2025. All active employees in these departments will be required to submit updated voluntary deduction forms by August 31, 2025. Directors of major MIC departments will be responsible for the submission of Personnel Action Forms for all active employees under their supervision, with all renewals required to be effective no later than October 1, 2025.

View Audit 360172 Questioned Costs: $1

Finding 567595 (2024-001)

Significant Deficiency 2024

Young Mens Christian Association of Boulder Valley

CO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure tha...

Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure that access to records continues to be available.

View Audit 360132

Finding 567412 (2024-005)

Material Weakness 2024

Tullahoma Housing Authority

TN

Questioned Costs Allowable Costs / Cost Principles

2024-005 – ALN 14.872 – Public Housing Capital Fund Program – Allowable Costs Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action pl...

2024-005 – ALN 14.872 – Public Housing Capital Fund Program – Allowable Costs Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action plan is in place to address these weaknesses and deficiencies. Person Responsible for Correction of Finding: Christy Amacher, Executive Director Anticipated Completion Date: September 30, 2025

View Audit 360091 Questioned Costs: $1

Finding 567399 (2024-007)

Material Weakness 2024

Washington Parks Academy

MI

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.303

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • We have brought on a State and Federal Grants Consultant to ensure all required grant related paperwork is completed and saved in a shared location with the Finance Team.

View Audit 360089

Finding 567384 (2024-001)

Significant Deficiency 2024

City of Dallas, Texas

TX

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.305 § 200.516

Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Part...

Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Party: Cynthia Rogers-Ellickson, Director – Housing & Community Development Planned Implementation Date: June 13, 2025

View Audit 360057 Questioned Costs: $1

Corrective Action Plans

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