Corrective Action Plans

Finding 568845 (2024-005)

Significant Deficiency 2024

County of Berrien

MI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding: 2024-005 – Reporting Auditor Description of Condition and Effect: The County has not performed all of the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting. Specifically, the Project and Expenditure report for the second quarter of 2024 was not filed. However...

Finding: 2024-005 – Reporting Auditor Description of Condition and Effect: The County has not performed all of the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting. Specifically, the Project and Expenditure report for the second quarter of 2024 was not filed. However, these reports were filed for the first, third and fourth quarters of 2024. As a result of this condition, the County did not comply completely with the reporting requirements of the Coronavirus State and Local Fiscal Recovery Funds grant. Auditor Recommendation: We recommend that the County review the reporting requirements for each grant and complete all reporting as required under the terms of the grant agreement. Corrective Action: Management acknowledges the oversight regarding the 2nd quarter reporting and agrees with the condition as noted. The County will provide a reminder to all grant administrators of the policy. An additional confirmation step is under consideration for verification of completion, at the discretion of County Administration, which would require notification to Financial Services personnel that filing activities have occurred. This oversight process change would require additional resources to complete. Contact Person: Brian Dissette, County Administrator/Controller Estimated Completion Date: December 31, 2025

View Audit 360575

Finding 568841 (2024-003)

Material Weakness 2024

Community Health & Social Services Center, Inc.

MI

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management

CHASS management concurs with the audit findings and will put the following corrective action plan in place to mitigate this finding in the future: During the fiscal year, the organization submitted requests for reimbursement of federal grant funds before incurring allowable expenses under the terms...

CHASS management concurs with the audit findings and will put the following corrective action plan in place to mitigate this finding in the future: During the fiscal year, the organization submitted requests for reimbursement of federal grant funds before incurring allowable expenses under the terms of the grant agreement. Moving forward, the new CFO will implement and enforce policies and procedures to ensure that all federal fund requests are supported by documented and allowable expenditures. Staff responsible for grant management will receive training to ensure the organization maintains compliance with all federal funding. All reimbursement requests should be reviewed and approved by the program manager/COO and the new CFO.

View Audit 360573

Finding 568833 (2024-001)

None 2024

Primary Care Medical Services of Poinciana, Inc.

FL

Subrecipient Monitoring Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2024-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. Ant...

MANAGEMENT’S CORRECTIVE ACTION PLAN Finding Number: 2024-001 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Chief Financial Officer

View Audit 360568

Finding 568832 (2024-004)

Material Weakness 2024

Rolette Community Care Center

ND

Allowable Costs / Cost Principles Material Weakness § 200.303

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Applicable Federal Award Number and Year - Period 6 TIN #205330283 Activities Allowed or Unallowed and Allowable Costs/Cost Pri...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Applicable Federal Award Number and Year - Period 6 TIN #205330283 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Finding Summary: There was no formal review or approval of the expenditure spreadsheet used to calculate the expenditures claimed for the federal program outside of the preparer. In addition, we noted the individual transactions were also not reviewed or approved by someone outside of the business office manager. Responsible Individuals: Kathy Morrow, Business Office Manager, Kelly VandeVorste, Interim Administrator Corrective Action Plan: Management will ensure that the information contained in supporting spreadsheets and individual transactions for federal programs is reviewed and approved by someone other than the preparer or the person initiating the transactions. Anticipated Completion Date: December 31, 2025

View Audit 360565

Finding 568817 (2024-002)

Material Weakness 2024

American Farmland Trust

DC

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

AFT remains committed to maintaining an effective system of internal control over financial reporting and compliance. To that end, AFT has taken the following corrective actions to ensure appropriate and timely compliance with FFATA filing requirements. 1. F&A Staff reviewed FFATA Training Resources...

AFT remains committed to maintaining an effective system of internal control over financial reporting and compliance. To that end, AFT has taken the following corrective actions to ensure appropriate and timely compliance with FFATA filing requirements. 1. F&A Staff reviewed FFATA Training Resources and SAM.gov resources o Ongoing Staff Training of F&A staff and staff identified in item 4. 2. Updated AFT’s Subawards Manual. The purpose of the Subawards Manual document is to assist in the preparation, administration, and management of AFT issued subawards. The Subaward Manual identifies the roles and responsibilities of AFT staff throughout the subaward lifecycle. 3. Updated Subaward Template FFATA Reporting Requirements and Data Collection 4. To ensure timely compliance with FFATA reporting requirements o Designated Contract Administrator with responsibility to file FFATA reports in connection with the execution and delivery of any subaward which occurs through our contracts management system o Will designate grant management staff to confirm filing 5. F&A Remediation o F&A is pulling the Schedule of Expenditures of Federal Awards (SEFA) data for FY22, FY23, and FY24 to determine which prime grants may have had subawards o Identify subaward agreements that require FFATA filing If AFT does not have the required information to make FFATA, AFT program, project, and/or finance staff will be tasked with obtaining the information o Make the required FFATA reports on SAM.gov 6. AFT will continue to monitor compliance with the updated procedures and FFATA requirements on a quarterly basis. o Using shared resources, finance will work with the Administrative Coordinator to verify that tracked information for issued subawards resulted in timely filing.

View Audit 360549

Finding 568514 (2024-003)

Significant Deficiency 2024

Bmc Health System, Inc.

MA

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

Audit Report Reference: 2024-003 Program name: Research and Development Completion Date: September 30, 2025 Finding 2024-003 is a repeat finding (2023-001) from fiscal year end September 30, 2023. The Health System implemented change controls and audit of employee permissions per the corrective act...

Audit Report Reference: 2024-003 Program name: Research and Development Completion Date: September 30, 2025 Finding 2024-003 is a repeat finding (2023-001) from fiscal year end September 30, 2023. The Health System implemented change controls and audit of employee permissions per the corrective action plan for 2023-001.The corrective actions for repeat finding 2024-003 addresses documentation of performed controls and training for employees involved in the control activities. Workday Change Review: The HRIS team will continue with a change review audit as they have done in the previous year with a few enhancements to increase auditability. The Sr. HRIS Manager will send official communication to the HRIS team to initiate the end-of-year change review. This email will provide a clear timeline for the audit period with a hard deadline. Once complete, the HR Compliance Manager and/or the Sr. HRIS Manager will issue a written communication to document the completion of the review summary of findings (if any), and corrective actions taken (if applicable). This will remedy the issue of missing approval documentation. The team will also be reeducated around the need to document written approval and testing for changes throughout the year. Workday Security Review: The HRIS team will continue to conduct an audit of security roles and users within Workday to ensure that permissions are updated appropriately. The HRIS Analyst will generate reports for the Sr. HRIS Manager's review, identifying any required changes. The analyst will then make these updates in Workday, followed by a new report for verification. Upon successful verification, the Sr. HRIS Manager will send a formal written communication of the approved changes. Workday Terminations: To address the access provisioning deficiency as it relates to terminating employees, the management team will be re-trained in the importance of adhering to timely terminations of employees in Workday. Person Responsible: Ashley Cesarano - HR Compliance and Workplace Accommodations Manager; Karen Alvarado – Senior Manager HRIS E-mail address: Ashley.Cesarano@bmc.org; Karen.Alvarado@bmc.org

View Audit 360505

Finding 568216 (2024-001)

Significant Deficiency 2024

Tallassee City Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent ...

Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior the submission of the July-September 2025 claim.

View Audit 360487 Questioned Costs: $1

Finding 568028 (2024-004)

Significant Deficiency 2024

Catholic Medical Mission Board, Inc.

NY

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during t...

Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during the audit period. To strengthen documentation access and retention, the Organization has transitioned to NetSuite, where backup documentation for transactions is now stored centrally on the cloud and can be easily accessed by headquarters staff. This change enhances our ability to ensure timely review, approval, and audit readiness, regardless of field conditions. We remain committed to continuous improvement of our internal controls and documentation practices. Responsible Person: Country Finance Directors

View Audit 360404

Finding 567947 (2024-005)

Material Weakness 2024

Low Rent Housing Agency of Fort Madison

IA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.403

As already indicated, income from tenant payments were not being properly applied to the correct revenue streams, all monies received were being coded to dwelling rents and not extra utility and cable charges as applicable. See response to 2024-001. Also, we have raised the fee charged to the tena...

As already indicated, income from tenant payments were not being properly applied to the correct revenue streams, all monies received were being coded to dwelling rents and not extra utility and cable charges as applicable. See response to 2024-001. Also, we have raised the fee charged to the tenants for cable to ensure that the expense is being adequately covered.

View Audit 360281 Questioned Costs: $1

Finding 567892 (2024-004)

Significant Deficiency 2024

Hips

DC

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

Views of Responsible Officials: This deficiency was noted internally even before the auditors flagged it in April 2024. Effective April 2024, the allocation of salaries and wages to different grants was transferred back to the Finance Manager who has more information regarding the grants timing, emp...

Views of Responsible Officials: This deficiency was noted internally even before the auditors flagged it in April 2024. Effective April 2024, the allocation of salaries and wages to different grants was transferred back to the Finance Manager who has more information regarding the grants timing, employees involved, % of time spent et al. In addition, the salaries and wages allocation is now a prerequisite for the invoicing process every month. HIPS have already seen significant improvements in both accuracy in seeking salaries and wages reimbursement as well as in wages reconciliations against paychex reports. COLA adjustments will be recorded more accurately and approval documented. As of 2024, HIPS has also updated our HR policy to provide written documentation by the Operations Manager of COLA increases to each staff member when they are implemented.

View Audit 360239

Finding 567881 (2024-056)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Special Tests & Provisions § 200.303

Finding 2024-056 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - EM Grants Manager Security Management and Access Controls Management Views MSP agrees with the finding. MSP implemented the EM Grants Manager system in November 2023 and did not fully establish pr...

Finding 2024-056 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - EM Grants Manager Security Management and Access Controls Management Views MSP agrees with the finding. MSP implemented the EM Grants Manager system in November 2023 and did not fully establish procedures for maintaining documentation of user access forms, reviewing privileged access, and disabling inactive users due to the number of current disasters and limited staff. Planned Corrective Action For part a., MSP implemented an access approval process in November 2023 to maintain documentation of access request forms within the EM Grants Manager system. For parts b. and c., MSP will create procedures to help ensure the timely completion of privileged user reviews and inactive user deactivation. MSP will perform the required user reviews and deactivate applicable accounts by September 30, 2025. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Penny Burger, MSP

View Audit 360209

Finding 567846 (2024-050)

Material Weakness 2024

State of Michigan

MI

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.516

Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all ...

Finding 2024-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS, in conjunction with LEO, will provide mandatory training for all specialists that determine eligibility for refugee cash assistance payments by September 30, 2025. MDHHS also will implement ongoing management and peer-to-peer spot checks of cases to ensure that documentation is maintained to support the client’s eligibility beginning October 2025. In addition, MDHHS will determine if technical changes are needed to help ensure the proper documentation is in the electronic case file by December 31, 2025. If potential system modifications are needed, the Bridges technical team will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the determination of whether system modifications are necessary. Responsible Individual(s) Benjamin Cabanaw, LEO Nicole Adams, LEO Bethany Cabanaw, MDHHS Kent Schutz, MDHHS Mariah Schaefer, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567845 (2024-049)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance

Finding 2024-049 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. Planned Corrective Action The LEO Office of Global Michigan (OGM) will improve established...

Finding 2024-049 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. Planned Corrective Action The LEO Office of Global Michigan (OGM) will improve established procedures and tracking logs to help ensure compliance with SOM Technical Standard 1340.00.020.01 (Access Control Standard). Specifically, LEO OGM will review user access semiannually for privileged accounts and annually for all other accounts. Also, LEO-IC is in the process of establishing a compliance team that will perform validation of the ongoing reviews. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Ben Cabinaw, LEO Allen Williams, LEO

View Audit 360209

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

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