Corrective Action Plans

Finding 24854 (2022-001)

Significant Deficiency 2022

LA

Questioned Costs Matching / Level of Effort / Earmarking Special Tests & Provisions

The School District will enhance controls and compliance over all construction projects to secure proper wage rate requirements from contractors and subcontractors when using federal funding.

View Audit 26533 Questioned Costs: $1

Finding 24853 (2022-001)

None 2022

Harvard Supportive Housing, Inc.

MN

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

HARVARD SUPPORTIVE HOUSING, INC. HUD PROJECT NO. 071-HD154 CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Harvard Supportive Housing, Inc. respectfully submits the following corrective action pla...

HARVARD SUPPORTIVE HOUSING, INC. HUD PROJECT NO. 071-HD154 CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Harvard Supportive Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Hinrichs & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT NONE FINDINGS - FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2022-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 The Project failed to comply with the repayment terms of a HUD approved, replacement reserve loan. Recommendation: The Project should deposit $5,606 into the replacement reserve account. Action Taken: The Project agrees with the finding. Management will deposit $5,606 to the replacement reserve account as soon as possible. If the Department of Housing and Urban Development has questions regarding this plan, please call Les Russo at 847-424-5601.

View Audit 25254 Questioned Costs: $1

Finding 24850 (2022-001)

Material Weakness 2022

The Center for Conflict Resolution

IL

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

Finding 2022 ? 001 Fiscal year in which the finding occurred: 2022 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: Chicago Bar Foundation Contact Person(s) Responsible for Corrective Action: Whitney Trumble and Cassandra Lively Contact Phone Number: 312-922-6464 Status ...

Finding 2022 ? 001 Fiscal year in which the finding occurred: 2022 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: Chicago Bar Foundation Contact Person(s) Responsible for Corrective Action: Whitney Trumble and Cassandra Lively Contact Phone Number: 312-922-6464 Status of Audit Finding: At the time of the audit, CCR had not received funds for three months of work as a subgrantee on the large federal grant that is the subject of this plan. The grantor was awaiting the federal contract extension and funds, and so did not have the funds to release. CCR received communication from the grantor that the extension and funds would be available soon, so we prepared a check for a vendor. Then, there was an extensive additional delay in receiving the funds, and CCR did not send the check because the contract had not yet been signed and funds could not be dispersed. The expense had been approved by the grantor and the work was underway during the delay in mailing the check. Corrective Action: As of June 2022, stricter internal controls have been implemented to ensure that any reimbursements listed on a grant invoice have been sent out to the vendor before submitting the report. A more formal review process has been implemented: CCR?s Executive Director will review and approve monthly grant reports via email. She will also review and approve supporting documentation for reach grant report. Approval (sent via email) will be kept with in a digital file with the reporting documentation. An additional internal control has been implemented to ensure that expenditures submitted for reimbursement are within the period of performance for the grant agreement. The Executive Director will monitor the grant expenses against the grant agreement, paying specific attention to the invoices at the end of the grant period, in order to ensure that the invoice is dated prior to the end of the grant agreement or most current amendment.

View Audit 23988

Finding 24848 (2022-001)

Significant Deficiency 2022

Shelby County Health Care Corporation

TN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding No. 2022-001 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned Regional One Health will implement controls and processes to ensure all costs are manually reviewed and approved to ensure allowab...

Finding No. 2022-001 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned Regional One Health will implement controls and processes to ensure all costs are manually reviewed and approved to ensure allowability under the grant and that evidence of review is maintained. 3. Completion date November 1, 2022 4. If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding No. 2022-001 5. The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs Finding No. 2022-001

View Audit 22190

Finding 24846 (2022-002)

Significant Deficiency 2022

Shelby County Health Care Corporation

TN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding No. 2022-002 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned ROH will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is ...

Finding No. 2022-002 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned ROH will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained. 3. Completion date November 1, 2022 4. If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding No. 2022-002 5. The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs Finding No. 2022-002

View Audit 22190

Finding 24845 (2022-002)

Significant Deficiency 2022

Beacon College, Inc.

FL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

2022-002 Higher Education Emergency Relief Fund (HEERF) Reporting Recommendation: We recommend that the College review their reporting policies and procedures to ensure accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Act...

2022-002 Higher Education Emergency Relief Fund (HEERF) Reporting Recommendation: We recommend that the College review their reporting policies and procedures to ensure accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Although the student data for the September 30, 2021 report was gathered timely and accurately, the report was posted on-line three days late and had an error in the quarterly amount awarded. The College will provide a more careful review of all reporting both before and after posting to ensure timeliness and accuracy. Name(s) of the contact person(s) responsible for corrective action: Rich Killion, V.P. of Institutional Advancement; Stephanie Knight, Director of Enrollment Services; Sandi Rysell, Chief Financial Officer Planned completion date for corrective action plan: Completed. If the U.S. Department of Education has questions regarding this plan, please call Dale Herold, Vice President for Admissions and Enrollment Management, Beacon College, 855-220-5376, dherold@beaconcollege.edu.

View Audit 20958

Finding 24843 (2022-001)

Significant Deficiency 2022

Beacon College, Inc.

FL

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

2022-001 Awarding of Direct Loans and Pell Grants Recommendation: We recommend the College evaluate its policies and procedures for identifying transfer credits and other changes made after the initial packaging to ensure that federal awards are revised as needed. Explanation of disagreement with au...

2022-001 Awarding of Direct Loans and Pell Grants Recommendation: We recommend the College evaluate its policies and procedures for identifying transfer credits and other changes made after the initial packaging to ensure that federal awards are revised as needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Beacon is implementing a new comprehensive software system (Jenzabar One) which ? paired with NetPartner and PowerFAIDS ?will better identify changes in student status. The system will also include InfoMaker software which the financial aid office will use to pull information needed to double check for late changes in student eligibility. Full implementation of the new software is now estimated to occur in December 2022. In the interim, enhanced procedures have been put in place by the Financial Aid Office to prevent further issues: a. Requesting an updated anticipated graduation list from the Registrar at the beginning of each term to confirm students are awarded appropriately b. Requesting a final graduation list from the Registrar at the end of each term to identify any students whose graduation plan has been delayed and making immediate adjustments to their aid eligibility, if needed. c. Performing a finalized review of all graduating students prior to the end of the academic year to ensure proper adjustments have been made. d. Requesting updated reports from the Registrar of any student receiving credit for transfer coursework prior to the start of each semester and making adjustments immediately to their aid eligibility; e. Prior to disbursement, a second review of all students is being performed to identify students whose grade-level conflicts with determination level for pending loans f. A final review prior to the end of each term is conducted so late adjustments can be made if needed. Name(s) of the contact person(s) responsible for corrective action: Daphne Parks, Vice President of Processing at FAS; Stephanie Knight, Director of Enrollment Services & Financial Aid, Beacon College; Carrie Santaw, Registrar, Beacon College Planned completion date for corrective action plan: Interim measures ? already implemented. Software implementation is scheduled to go live in December 2022.

View Audit 20958 Questioned Costs: $1

Finding 24792 (2022-020)

Material Weakness 2022

State of Michigan

MI

Cash Management Eligibility Material Weakness § 200.516

Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibil...

Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end date of the PHE, as MDHHS completes renewals for existing cases. MDHHS could not terminate Medicaid benefits during the PHE, and annual renewals have not been completed since the start of the PHE, resulting in most Medicaid cases not being touched until the 14-month unwind period allotted by the Centers for Medicare and Medicaid Services at the end of the PHE. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children?s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 31, 2024 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Erin Emerson, MDHHS

View Audit 20093

Finding 24718 (2022-054)

Material Weakness 2022

State of Michigan

MI

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

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing st...

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing staff training and a memorandum sent out to the local offices. ESA leadership will reach out to the managers of the individual specialists regarding the issues identified and provide additional guidance. Anticipated Completion Date Training will be ongoing. ESA will issue the memorandum and address the specific issues with local office management and specialists by August 31, 2023. Responsible Individual(s) Kenton Schulze, MDHHS Lana Karadsheh, MDHHS Brian Sanborn, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24715 (2022-002)

Material Weakness 2022

Alfred Saliba Family Services Center, Inc.

AL

Matching / Level of Effort / Earmarking Reporting Equipment & Real Property Management § 200.303

Item 2022-002 (Repeat 2021-001) Reporting ? Management?s Response ? Management concurs with the finding. The Agency encountered technical difficulties when attempting to submit the report and is currently seeking the assistance of their representative at Region Four to assist with completing the fil...

Item 2022-002 (Repeat 2021-001) Reporting ? Management?s Response ? Management concurs with the finding. The Agency encountered technical difficulties when attempting to submit the report and is currently seeking the assistance of their representative at Region Four to assist with completing the filing requirement. The grants manager has become aware of the due date for the SF429 and where it is to be submitted and will take full responsibility for the completion and the uploading of this report. Anticipated Completion: September 30, 2023 Responsible Party: Belinda Mitchell, Executive Director

View Audit 21276

Finding 24674 (2022-026)

Significant Deficiency 2022

State of Michigan

MI

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2022-026 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Long-Term Care (LTC) Facility COVID-19 Testing Reimbursements Management Views MDHHS agrees with the finding. ...

Finding 2022-026 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Long-Term Care (LTC) Facility COVID-19 Testing Reimbursements Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will enhance written procedures to reflect the process in place to ensure that LTC facility COVID-19 testing reimbursement requests are reasonable and appropriate. MDHHS will also improve documentation of the procedures performed as part of the current process. Anticipated Completion Date MDHHS expects completion of the written procedures and improved documentation going forward by June 15, 2023. MDHHS expects to process all remaining payments for costs incurred during the PHE by September 30, 2023. Responsible Individual(s) Shannah Havens, MDHHS

View Audit 20093

Finding 24634 (2022-015)

Material Weakness 2022

The City of New York

NY

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2022-015 Department(s) New York City Administration for Children?s Services New York City Human Resources Administration Program(s) Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s) HRA HRA will convene a small workgroup to meet bi-weekly to r...

Finding No. 2022-015 Department(s) New York City Administration for Children?s Services New York City Human Resources Administration Program(s) Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s) HRA HRA will convene a small workgroup to meet bi-weekly to review the details and history of the cases identified to try to isolate the cause of the errors, and once we determine the cause, will work with the necessary parties/stakeholders to develop an approach to avoid the situation from repeating itself. First meeting will be 2nd week of April to identify the appropriate parties to include and come up with meeting goal and agenda. ACS Case No. 1 The audit reviewed a child care case relating to an older Fair Hearing which had not been closed timely per the original State Fair Hearing decision, which had been issued prior to FY22. ACS' Child and Family Well-Being (CFWB) division had previously instituted a new Quality Assurance review of pending Fair Hearing cases and through this QA review had already identified and closed the case. However, the auditors reviewed an earlier State FY22 claim prior to ACS' identification of the case. Per the new QA protocol, CFWB will be reviewing HRA/DSS systems reports on a monthly basis, identify any questioned cases and take appropriate follow-up action. CFWB is also preparing new written guidelines. Case No. 2 In one child care case, ACS was not able to provide eligibility documentation. Further ACS research determined a systems coding inconsistency. ACS procedure is to run reports to identify inconsistencies with programmatic codes and review any flagged cases prior to submission of claims to the State. However, in this instance, the case was not identified in the report. ACS will propose creation of a new exception report with a more refined level of detail to identify any case coding inconsistencies and allow follow up to ensure complete case eligibility support for any flagged cases. ACS will work with HRA/DSS on report development. Anticipated Completion Date HRA Beginning Q2 2023 ? Convene workgroup Beginning Q3 2023 ? Completion date ACS Initiated in FY 2022 ? New quality assurance (QA) review To be completed in FY 2023 ? New written guidelines and refined reporting Person(s) Responsible for Implementation HRA Ramon E. Flores Assistant Deputy Commissioner, Family Independence Administration (FIA) FloresRa@hra.nyc.gov ACS For new QA and guidelines Isabel Villegas Executive Director, Policy & Compliance Division of Child and Family Well-Being (212) 393-5325 For refined reporting Pauline Young Assistant Commissioner for Claiming and Revenue Division of Finance (212) 676-8803

View Audit 22749 Questioned Costs: $1

Finding 24633 (2022-006)

None 2022

The City of New York

NY

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.514

Finding No. 2022-006 Department(s) New York City Department of Health and Mental Hygiene Program(s) Assistance Listing Number 93.069, Public Health Emergency Preparedness Corrective Action(s) DOHMH?s Office of Emergency Preparedness and Response (OEPR) and Division of Finance are in agreement with t...

Finding No. 2022-006 Department(s) New York City Department of Health and Mental Hygiene Program(s) Assistance Listing Number 93.069, Public Health Emergency Preparedness Corrective Action(s) DOHMH?s Office of Emergency Preparedness and Response (OEPR) and Division of Finance are in agreement with the recommendations. Non-compliance with the level of effort requirement occurred because the agency received additional federal funds as part of the American Rescue Plan and utilized those funds to cover city tax levy costs in FY22. This was a one-time offset. In addition to strengthening and maintaining internal controls, DOHMH plans to revisit how maintenance of effort is calculated for the PHEP award, as it is currently calculated using a 15-year-old formula that has not been tweaked to ensure it accurately captures health care preparedness and public health security spending. DOHMH will close out a 5-year project period on the PHEP award in 2024 and plans to revisit the current maintenance of effort formula in advance of applying for the new project period. Anticipated Completion Date June 2024 Person(s) Responsible for Implementation Monica Marquez Assistant Commissioner, OEPR (347) 396-2730 Wai ting Yu Assistant Commissioner, Central Finance (347) 396-6214

View Audit 22749

Finding 24617 (2022-012)

Material Weakness 2022

The City of New York

NY

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2022-012 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) Response: ? HRA agrees that the Agency had challenges in retaining some recertification documentation during the COVI...

Finding No. 2022-012 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) Response: ? HRA agrees that the Agency had challenges in retaining some recertification documentation during the COVID Public Health crisis when staff were working from home and then ultimately leaving the Agency prior to the return to office. ? The identified HOME TBRA tenants had been originally found eligible over five years ago and have been recertified annually every year following. ? This FY22 audit was conducted on the heels of the FY21 audit where the finding was the same and the recommended Corrective Action was the development of a Quality Assurance Checklist due by November 2022 and ongoing. ? HRA agrees to strengthen internal controls and have created and implemented a Quality Assurance Tool that ensure eligibility is accurately assessed, allowable cost is correctly calculated and appropriate evidence (i.e. Recertification Information Form, Proof of Income, Rent Reasonableness Information, Passed Inspection, Landlord Packet, Client Packet, RAC, Tenant Breakdown) that support annual approval is maintained. Also, the payment system already fully requires supervisor approval before annual payments can be set up. Absolutely no payment can go out without supervisor approval. Corrective Actions: ? Strengthen internal governance and future compliance. ? Hire an Executive Director for the TBRA ? Create and implement a Quality Assurance tool that includes information that supports eligibility. ? Provide refresher training for staff involved with TBRA. Anticipated Completion Date May 2023 and ongoing Person(s) Responsible for Implementation Dori Hopkins-Figeroux Director, TBRA (929) 252-6089 Dwana Abraham Assistant Deputy Commissioner (929) 221-6726

View Audit 22749 Questioned Costs: $1

Finding 24615 (2022-008)

None 2022

The City of New York

NY

Special Tests & Provisions Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding No. 2022-008 Department(s) New York City Department of Housing Preservation and Development Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) The Department of Housing Preservation and Development (HPD) continues to maintain processes and...

Finding No. 2022-008 Department(s) New York City Department of Housing Preservation and Development Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) The Department of Housing Preservation and Development (HPD) continues to maintain processes and procedures supporting compliance with Housing Quality (HQ) inspection standards. HPD routinely conducts HQ inspections of HOME Investment Partnership Program assisted rental units and continues to maintain systems to facilitate and promote compliance with HOME inspection requirements; HPD inspects HOME units periodically and follows up on failed inspections routinely. Further, HPD continues to review program requirements and operations to enhance program oversight and ensure the timeliness of repairs. As part of HPD?s ongoing effort to accomplish complete and timely repairs of all HOME units, building owners are notified of failed inspections, and regularly provided with detailed reports identifying non-compliant conditions. HPD also continues to impress upon owners the critical importance of completing timely repairs of all HOME units. Building owners are notified of failed inspections and provided detailed reports regularly, identifying non-compliant conditions. With respect to the finding, HPD recognizes that in six (6) instances, the Certification of Repair was not submitted within the 90-day timeframe. HPD will continue to follow-up with the owner(s) until all required repairs are certified as complete. In addition, HPD will consider, on a case-by-case basis, documenting its rationale for not exercising extreme remedies (such as withdrawal of future funding) for failure to complete repairs within the 90-day cure period. Anticipated Completion Date March 2022 and ongoing Person(s) Responsible for Implementation Arabia Brown Deputy Director, Tax Credit and HOME Compliance (212) 863-8204

View Audit 22749

Finding 24613 (2022-003)

Significant Deficiency 2022

Greene Acres Nursing Home Association, Inc.

AR

Matching / Level of Effort / Earmarking § 200.302 § 200.305

Views of responsible officials and planned corrective actions: Management agrees with this finding and will write policies and procedures for Federal awards.

View Audit 21261

Finding 24611 (2022-001)

Material Weakness 2022

Greene Acres Nursing Home Association, Inc.

AR

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

Views of responsible officials and planned corrective actions: Management agrees with this finding and will ensure proper review is performed and evidenced.

View Audit 21261 Questioned Costs: $1

Finding 24575 (2022-050)

Significant Deficiency 2022

State of Michigan

MI

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

Finding 2022-050 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 of overlaps between fee-for-service and capitation payments is retroactive remov...

Finding 2022-050 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 of overlaps between fee-for-service and capitation payments is retroactive removal of Medicaid eligibility within Bridges. In November 2019, MDHHS formed a multi-disciplinary work group within the Medical Services Administration to address the problems created when eligibility is removed retroactively. An interface fix is being implemented in December 2023 that will address several existing issues. This upgraded interface will remove existing limitations to mitigate the occurrence of retroactive disenrollment. In addition, the work group continues to evaluate whether any additional process and system changes are needed to further mitigate the occurrence of overlapping payments. Anticipated Completion Date The interface fix will be implemented by December 31, 2023, and evaluation of whether additional process and system changes are needed to further mitigate the occurrence of overlapping payments is ongoing. Responsible Individual(s) Alexis Bond, MDHHS Latina McCausey, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24574 (2022-049)

Significant Deficiency 2022

State of Michigan

MI

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

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using E...

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using ESV are based on tasks authorized and completed, and compared to approved authorizations before payment is issued. Also, individual caregiver verifications currently in ESV and Paper Service Verification (PSV) will be replaced with Electronic Visit Verification (EVV), which will help ensure payments are reflective of the services provided. MDHHS will continue to manually review PSVs until EVV is implemented. Anticipated Completion Date December 2024 Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24573 (2022-048)

Significant Deficiency 2022

State of Michigan

MI

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

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is no...

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is now pulling reports by billing date instead of hospitalization dates to capture inpatient stays that are billed late. MDHHS also implemented a new policy on February 1, 2023, that allows payment for Home Help Program (HHP) services on the day an individual is admitted to the hospital. MDHHS changed the HHP payment process to an automated process during April 2022, tying payments to services on the Electronic Service Verification (ESV) prior to payment being made. In addition, MDHHS modified policy to begin recoupment by task instead of by daily rate for services provided on overlapping days. MDHHS provided a recoupment calculator and training for HHP staff to ensure the correct amount is recouped using the revised policy and procedure. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24572 (2022-047)

Significant Deficiency 2022

State of Michigan

MI

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

Finding 2022-047 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 implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger ...

Finding 2022-047 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 implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger updates to CHAMPS. MDHHS is also developing a prior report review process to ensure impacted records that do not get corrected with the CHAMPS retrigger are addressed. Anticipated Completion Date The system solution was implemented as of August 31, 2022. The prior report review process will be implemented by September 30, 2023, and reviews will be ongoing. Responsible Individual(s) Jamy Hengesbach, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24565 (2022-019)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Eligibility Material Weakness § 200.516

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other s...

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. MDHHS conducts mandated training for local office caseworkers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end of the PHE, as allowed by the Centers for Medicare and Medicaid Services. Anticipated Completion Date MDHHS continues to pursue other data sources for income verification and other system enhancements, in addition to determining where training is needed, on an ongoing basis. MDHHS expects to have all existing cases updated by June 2024. Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24510 (2022-046)

Significant Deficiency 2022

State of Michigan

MI

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

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has ...

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has updated its internal policies to clarify how it manages workflow operations, while ensuring CCLB meets federal compliance requirements. In June 2022, the Child Care Organizations Act was amended and the language in Michigan Compiled Law 722.113h was changed to allow for inspections to be conducted in accordance with the State plan. The State plan specifies the annual licensing inspection requirement, at 45 CFR 98.42(b)(2)(i)(B) for unannounced inspections, must be performed ?not less than annually.? According to guidance from the Federal Office of Child Care Region V, this does not mean that inspections must be performed at exact 12-month intervals; therefore, the lead agency has flexibility to schedule the inspections within each calendar year. CCLB has subsequently completed the annually required renewal and/or interim inspections for the licenses identified in the audit sample. The applicable health and safety requirements were reviewed during the inspections conducted. For part b., CCLB is currently creating a new licensing system that will automate letters being sent to licensed child care providers. The new system will generate and store inspection reports directly in the system instead of creating the report in a separate location and then manually moving it to other locations (network drive, SharePoint). This allows the inspection reports to be maintained digitally and be accessible at a later date, while ensuring proper documentation to support renewal inspections is maintained. For part c., in June 2022, CCLB implemented a new process to save all extension letters mailed in PDF format and stored in the current system to be accessed and available upon request. In addition, CCLB will incorporate refresher trainings regarding documentation and storage of inspection reports at its biannual all-staff trainings. The current process of documentation creation and storage will be phased out after the new licensing system is implemented and processes are no longer manually done by CCLB staff. Anticipated Completion Date a. Completed b. October 1, 2023 c. October 1, 2023 Responsible Individual(s) Emily Laidlaw, LARA Lisa Brewer-Walraven, MDE

View Audit 20093 Questioned Costs: $1

Finding 24508 (2022-044)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking § 200.516

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE ...

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE policies and processes. ESA will inform the local office and BSC staff of policy changes or noted trends during PAO?s Bridges Bits and Bytes communications sessions. ESA?s Payment Accuracy Unit completed case reads in December 2022 and, as a result, ESA and MDE finalized a checklist on May 9, 2023, for use by local office staff to help ensure required documentation that supports eligibility is obtained. Also, MDE launched a Child Development and Care case review SharePoint site on May 1, 2023, to share information with MDE and MDHHS staff, reduce errors and promote integrity efforts for the program. Anticipated Completion Date MDHHS assistance and guidance for local office and BSC staff is ongoing. Responsible Individual(s) Mariah Schaefer, MDHHS Gayle Vail, MDHHS Lisa Brewer-Walraven, MDE

View Audit 20093 Questioned Costs: $1

Finding 24488 (2022-043)

Significant Deficiency 2022

State of Michigan

MI

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

Finding 2022-043 Aging Cluster, ALN 93.044, 93.045, and 93.053 - AIS FIRST User Access Management Views Although MDHHS thoroughly reviewed the access forms, MDHHS agrees that the final approval was not documented. Planned Corrective Action MDHHS has instructed staff that all forms must either cont...

Finding 2022-043 Aging Cluster, ALN 93.044, 93.045, and 93.053 - AIS FIRST User Access Management Views Although MDHHS thoroughly reviewed the access forms, MDHHS agrees that the final approval was not documented. Planned Corrective Action MDHHS has instructed staff that all forms must either contain a handwritten or electronic signature. MDHHS will also develop and implement an internal process for staff to ensure all future security forms contain the required approvals. Anticipated Completion Date July 1, 2023 Responsible Individual(s) Jen Hunt, MDHHS Cindy Masterson, MDHHS

View Audit 20093

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