Corrective Action Plans

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Finding 2025-007 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 A...
Finding 2025-007 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. Also, MDHHS added an incompatible role form in the DSA MiSACWIS request with automated routing for appropriate approval on November 11, 2025. In addition, MDHHS provides ongoing education during the quarterly LOSC webinars, where guidance is shared with the LOSCs on security management and access control topics, such as the correct procedures for processing system access requests. For part b., during April 2025, MDHHS updated the renewal processing start date to 15 days earlier to ensure renewal requests are reviewed prior to the annual recertification date. Anticipated Completion Date Completed Responsible Individual(s) Tim Kwast, MDHHS Alana Lowe, MDHHS
Finding 2025-020 Foster Care Title IV-E, ALN 93.658 and Adoption Assistance, ALN 93.659 - Accuracy of Financial Reports Management Views MDHHS disagrees with the finding. The expenditures noted were recorded through MDHHS’s normal, federally approved Public Assistance Cost Allocation Plan cost alloc...
Finding 2025-020 Foster Care Title IV-E, ALN 93.658 and Adoption Assistance, ALN 93.659 - Accuracy of Financial Reports Management Views MDHHS disagrees with the finding. The expenditures noted were recorded through MDHHS’s normal, federally approved Public Assistance Cost Allocation Plan cost allocation process. As part of this process, certain administrative costs are not identifiable or allocable to federal programs until the allocation is completed. At that point, MDHHS recognizes these costs as expenditures in the CB-496 report in the quarter in which the allocation occurs and the costs are assigned to the grant. Consistent with this approach, MDHHS has historically reported these amounts as current quarter expenditures. MDHHS previously consulted with the U.S. Department of Health and Human Services (HHS) Administration for Children and Families (ACF) on the appropriate use of the prior quarter adjustment column, and MDHHS was verbally instructed to no longer record these administrative costs as adjustments since this is part of the normal cost allocation process. ACF approves the CB-496 reports in the federal system and ensures the final award amount reconciles with the amounts reported. This approval process supports the reporting approach used by MDHHS is both consistent with prior guidance and accepted by ACF through its approval and award process. Planned Corrective Action Although MDHHS disagrees with the finding, MDHHS sought written guidance from ACF and will follow up to obtain clarification on the appropriate reporting of administrative costs. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Rebecca Jones, MDHHS
Finding 2025-006 ADP Security Program Management Views MDHHS and DTMB agree with the finding. Planned Corrective Action For 2 of the 3 systems cited, the Authority to Operate (ATO) was successfully re-established on July 8, 2025, and October 10, 2025, respectively. For the remaining system, MDHHS an...
Finding 2025-006 ADP Security Program Management Views MDHHS and DTMB agree with the finding. Planned Corrective Action For 2 of the 3 systems cited, the Authority to Operate (ATO) was successfully re-established on July 8, 2025, and October 10, 2025, respectively. For the remaining system, MDHHS and DTMB will complete a comprehensive update to the System Security Plan, incorporate all missing control assessments into the risk analysis, and implement the ATO by August 30, 2026. Anticipated Completion Date August 30, 2026 Responsible Individual(s) Nathan Buckwalter, DTMB Heather Frick, DTMB Veronica Maxson, MDHHS Jim Bowen, MDHHS Kasi Hunziger, MDHHS Lyndia Deromedi, MDHHS
Finding 2025-010 MDE, Change Management Process Management Views MDE partially agrees with the finding. MDE agrees that testing results were not fully documented. However, MDE does not agree that post implementation validation could be performed. The scan-vulnerability process could not be performed...
Finding 2025-010 MDE, Change Management Process Management Views MDE partially agrees with the finding. MDE agrees that testing results were not fully documented. However, MDE does not agree that post implementation validation could be performed. The scan-vulnerability process could not be performed in the production environment in this instance without significantly impacting system performance for users, making post implementation validation infeasible. Planned Corrective Action MDE management will review the testing documentation maintained in DevOps for all tickets classified as tasks and associated with change management activities and deployments and will remind staff of the required documentation standards for all DevOps tickets linked to a deployment. Additionally, MDE will evaluate whether an alternative method of validating the scan-vulnerability process in production is feasible. If no alternative method is identified, MDE will document that post implementation validation cannot be performed due to system constraints. Anticipated Completion Date December 31, 2026 Responsible Individual(s) Monica Butler, MDE
Finding 2025-009 MDE, Security Management and Access Controls Management Views MDE agrees with the finding. Planned Corrective Action For part a., management will review the exceptions with the team responsible for processing security forms to reinforce appropriate review and processing. MDE will al...
Finding 2025-009 MDE, Security Management and Access Controls Management Views MDE agrees with the finding. Planned Corrective Action For part a., management will review the exceptions with the team responsible for processing security forms to reinforce appropriate review and processing. MDE will also implement an automated security access request process, which will eliminate any human error as a result of processing forms. For part b., management will refine the NexSys annual recertification process to reduce errors. NexSys staff will improve internal user list reviews and confirm completeness during the upcoming recertification cycle prior to management’s final review. MDE is currently developing an automated process to handle the annual recertification of the Grant Electronic Monitoring System/Michigan Administrative Review System (GEMS/MARS) users and anticipates implementation in September 2026. For part c., MDE updated the procedure for disabling accounts in April 2026 to strengthen and clarify the process to ensure MDE disables inactive user accounts after 18 months. Anticipated Completion Date a. May 2027 b. NexSys: October 2026 GEMS/MARS: September 2026 c. Completed Responsible Individual(s) Monica Butler, MDE Joshua Long, MDE Drew Finkbeiner, MDE
Finding 2025-001 SIGMA High-Risk Activity Monitoring Management Views The Michigan Department of Lifelong Education, Advancement, and Potential (MiLEAP) agrees with the finding. Planned Corrective Action MiLEAP started monitoring its high-risk activity report weekly to ensure users performed only au...
Finding 2025-001 SIGMA High-Risk Activity Monitoring Management Views The Michigan Department of Lifelong Education, Advancement, and Potential (MiLEAP) agrees with the finding. Planned Corrective Action MiLEAP started monitoring its high-risk activity report weekly to ensure users performed only authorized override actions in SIGMA beginning June 20, 2025. Anticipated Completion Date Completed Responsible Individual(s) Lora MacKay, MiLEAP Dawn Lake, MiLEAP Erica Nowland, 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 2025-060 Coronavirus Capital Projects Fund, ALN 21.029 Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division and the LEO Grants Division have identified the deficiencies that led to the audit finding. LEO will correct the internal FFATA reporting pr...
Finding 2025-060 Coronavirus Capital Projects Fund, ALN 21.029 Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division and the LEO Grants Division have identified the deficiencies that led to the audit finding. LEO will correct the internal FFATA reporting process to ensure that new and amended subaward contract information is received by the LEO Finance Division in a timely manner and in accordance with FFATA requirements. LEO will utilize the EGrAMS vendor to update software functionality that will generate an email notification to the LEO Finance Division when a grant agreement is finalized or amended. This notification will ensure communication with the LEO Finance Division occurs in a timely manner and in accordance with FFATA requirements. Anticipated Completion Date June 30, 2026 Responsible Individual(s) Jennifer Duffey, LEO Heidi Parker, LEO
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 2025-022 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 2025-059 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure revenues and program income generated by non-commercial airports were expended for airport capital or operatin...
Finding 2025-059 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure revenues and program income generated by non-commercial airports were expended for airport capital or operating costs, the local airport system, or other local facilities. Planned Corrective Action MDOT will review existing procedures, including the MDOT Office of Aeronautics Project Manager/Engineering Manual and block grant conditions, to assess whether updates are needed and if resources will be prioritized to help ensure monitoring and oversight efforts are performed relating to revenue and program income requirements. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Bryan Budds, MDOT
Finding 2025-058 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure weekly certified payrolls were obtained from contractors. Planned Corrective Action MDOT will provide training...
Finding 2025-058 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure weekly certified payrolls were obtained from contractors. Planned Corrective Action MDOT will provide training and guidance to pertinent staff to help ensure contract compliance and that weekly certified payrolls are obtained from contractors. In addition, MDOT will review existing procedures to assess whether updates are needed. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Bryan Budds, MDOT
Finding 2025-012 SNAP Cluster, ALN 10.551 and 10.561 and Summer Electronic Benefits Transfer Program for Children, ALN 10.646 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is currently evaluating the two System and Organization Con...
Finding 2025-012 SNAP Cluster, ALN 10.551 and 10.561 and Summer Electronic Benefits Transfer Program for Children, ALN 10.646 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is currently evaluating the two System and Organization Controls (SOC) reports and will document the evaluation and determination of whether a review is required. Based on these evaluations, if MDHHS determines reviews are required, MDHHS will document the SOC report reviews by June 30, 2026. Also, MDHHS will assess the current SOC review process and implement any needed improvements to ensure subservice organizations are properly evaluated, formally documented, and that SOC report reviews are submitted within 60 days of receiving each report, by September 30, 2026. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Tony Weber, MDHHS Veronica Maxson, MDHHS Dani Wager, MDHHS Tim Kubu, MDHHS
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
Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program FFAL # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: The Federal requirement related to processing of...
Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program FFAL # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: The Federal requirement related to processing of an application requires the State to provide notice of its decision concerning eligibility and provide timely and adequate notice of the basis for denial or termination of assistance (42 USC 1320c-7(d)). According to the Colorado Department of Health Care Policy and Financing (HCPF), processing standards 8.100.3.D, the County is required to process an initial application for any program not requiring a disability determination no later than 45 days following receipt of application. Our auditors, Eide Bailly, tested eligibility determination and controls over this process for sixty case files. They noted the following in our testing: • Two instances of non-compliance in which the County did not complete the eligibility determination and approve/deny the case within 45 days, and no notice of action was sent to the client within the required timeframe. • Two instances of non-compliance in which it could not be verified whether the notice of action was sent by the County to the client via mail or email Responsible Individuals: Joanne Sprouse, Human Services Director Corrective Action Plan: Summit County Human Services implemented multiple procedures in response to the prior 2024 findings. Those corrective action responses were still in process for the current 2025 period tested and will continue into 2026. During 2025, Summit County Human Services successfully retrained all case managers on application processing protocols, utilizing stateapproved training modules administered through the Staff Development Department. Summit County Human Services strictly follows state-mandated guidelines for processing Medical Assistance applications to ensure that all cases are approved or denied within the 45-day timeframe established by state regulations. To further enhance the accuracy of eligibility determinations for all household members, case managers have also completed the "Case Wrap-Up Training" through CoLearn, an online training platform developed by the State's Staff Development Department. Completion of this training ensures that eligibility determinations are accurate, and that appropriate client correspondence is issued. In 2025 and continuing into 2026, Summit County Human Services has also implemented a weekly review of the county dashboards, specifically the “HCPF Application Timeliness” and “HCPF Renewal Timeliness” dashboards. These dashboards monitor Medicaid application and renewal processing timelines initiated upon receipt by our office. In addition to the dashboard reviews, management meets weekly with the case managers responsible for monitoring the dashboards to identify trends and determine training needs. Furthermore, an additional line was added to the case comment template to ensure review and verification of correct case correspondence issuance. Anticipated Completion Date: Ongoing
#2025-006 FINDING: Reporting Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will reconcile individual program expenditure activity to the completed SF425 report and establish deadlines for filing submissions within the grant agreement timelines. The...
#2025-006 FINDING: Reporting Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will reconcile individual program expenditure activity to the completed SF425 report and establish deadlines for filing submissions within the grant agreement timelines. The Business Manager will follow the recommendation of the auditor. Anticipated Completion Date: Ongoing
#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
Segregation of Duties
Segregation of Duties
Name of Contact Person: Chelsey Traeger, City Clerk
Name of Contact Person: Chelsey Traeger, City Clerk
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Depar...
CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the Agency perform case file reviews on a more representative sample of the total clients served and that adequate documentation be retained of those reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Waylon Welvaert, Finance Manager Planned completion date for corrective action plan: December 31, 2026
ELIGIBILITY DETERMINATION Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minneso...
ELIGIBILITY DETERMINATION Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the Agency implement procedures to ensure the citizenship, asset, and income verification documentation in the casefiles be retained and that it matches the METS eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and show staff proper documentation and entry into METS and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Waylon Welvaert, Finance Manager Planned completion date for corrective action plan: December 31, 2026
3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure all replacement reserve withdrawals are supported with a HUD-signed Form HUD-9250 prior to releasing funds, the rec...
3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure all replacement reserve withdrawals are supported with a HUD-signed Form HUD-9250 prior to releasing funds, the recommendation to repay the $3,970 withdrawal, and the recommendation to obtain HUD approval for the 2024 unauthorized withdrawals of $39,282 or pay the amounts back to the reserve. b. Action(s) Taken or Planned on the Finding Management stated that a correction was processed to return the $3,970 to the replacement reserve account, with the repayment clearing in October 2025. The prior year unauthorized withdrawal remains unresolved, as management does not have the funds to repay the $39,282. Management will also strengthen internal controls to ensure all future withdrawals are fully supported with HUD-signed Form HUD-9250 approvals.
The Crete Public Schools Board of Education and Superintendent continually evaluate the distribution of duties to employees and closely monitor federal program finances. The Chief Financial Officer will continue to separate duties to the greatest extent possible with available staff. The Director of...
The Crete Public Schools Board of Education and Superintendent continually evaluate the distribution of duties to employees and closely monitor federal program finances. The Chief Financial Officer will continue to separate duties to the greatest extent possible with available staff. The Director of Federal Programs will assist in strengthening internal controls by actively participating in the preparation and review of grant expenditures, reimbursement requests, budget-to-actual reports, and supporting documentation to ensure transactions are accurate, properly approved, and comply with federal grant requirements. The Director of Federal Programs will also monitor federal program activities, review exception reports, and provide an additional layer of oversight for federally funded transactions. The District will continue to evaluate opportunities to implement additional compensating controls as staffing and resources permit.
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