Corrective Action Plans

Finding 568215 (2024-002)

Significant Deficiency 2024

CA

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written ...

Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written policy and implement a documented process for the preparation and review of federal drawdowns, including clear evidence of review such as signoffs or electronic approvals. Responsible Individual: Andres Chavarro, Finance Manager Planned Completion date: 07/01/2025

View Audit 360483

Finding 568214 (2024-001)

Significant Deficiency 2024

Hawaiian Community Assets, Inc.

HI

Reporting Matching / Level of Effort / Earmarking Eligibility § 200.302 § 200.510

Re: FY23-24 Federal Single Audit Finding (2024-001) Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Perez, Finance Director; Jeff Gilbreath, Executive Director Hawaiʻi Community Lending (HCL) is diligent and ensures all grant requirements are met for Federal, State, and private ...

Re: FY23-24 Federal Single Audit Finding (2024-001) Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Perez, Finance Director; Jeff Gilbreath, Executive Director Hawaiʻi Community Lending (HCL) is diligent and ensures all grant requirements are met for Federal, State, and private funding awards. Due to the transitioning of its Finance Directors upon the start of the FY23-24 audit, the proper procedures to correct the CDFI ERP project account were miscommunicated, and the Schedule of Expenditures for Federal Awards (SEFA) were not reduced to reflect the proper adjustments. The corrective action being taken by HCL leadership is to ensure all loans disbursed and charged to restricted grants are reviewed thoroughly by the Finance Director. The Finance Director will review all eligibility requirements that are met, to include the eligible mapping area, as required and provided by the funder. This thorough review of eligibility will ensure that all loans charged to restricted funding will be properly allocated and charged correctly. In addition to the thorough review mentioned above, HCL will develop procedures to review the SEFA, in detail, which is prepared by a third-party accounting vendor. The procedures will include an extensive review of expenditures by the Finance Director and subsequent review and approval by the Executive Director to ensure all expenses are eligible and allocated properly to our federal grants. Once the SEFA has been fully reviewed and approved by the Finance Director and Executive Director, it will be forwarded to the auditors. Additional staff may be involved in the review and eligibility confirmation process to ensure accuracy. Internal audits of expenditures will also be completed on a quarterly basis. The anticipated completion date of this corrective action plan is June 30, 2025. Mahalo, Jeff Gilbreath Executive Director Hawaiʻi Community Lending

View Audit 360478

Finding 568062 (2024-001)

Significant Deficiency 2024

Bastrop County Women's Shelter, Inc. Dba Family Crisis Center

TX

Cash Management Reporting Significant Deficiency § 200.303

1) Effective 3/7/25, reports and requests for reimbursements are being reviewed, signed and dated by the Executive Director prior to submission to ensure the reports and requests for reimbursements are not incomplete or inaccurate; and 2) Financial Policy addressing the Deficiency in Internal Contro...

1) Effective 3/7/25, reports and requests for reimbursements are being reviewed, signed and dated by the Executive Director prior to submission to ensure the reports and requests for reimbursements are not incomplete or inaccurate; and 2) Financial Policy addressing the Deficiency in Internal Controls over Compliance were already in place during the audit period. These policies were reviewed by the Board of Directors on 6/11/25 and found to align with the best practices and compliance requirements. Following the audit, we have also taken steps to reinforce the adherence and ensure consistent implementation across all relevant areas. Responsible Parties: Brandi Senters, Finance Director, will be responsible for implementation, with oversight from Interim Executive Director, Bernie Jackson.

View Audit 360432

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 568024 (2024-002)

Significant Deficiency 2024

MacOn County Samaritan Memorial Hospital

MO

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

FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25...

FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25, as required. Action taken in response to finding: The Hospital will continue to make operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25 . Name of the contact person responsible for corrective action: Carli Taylor, Chief Financial Officer. Planned completion date for corrective action plan: December 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Carli Taylor, Chief Financial Officer at 660.385.8716 .

View Audit 360393

Finding 568008 (2024-002)

Significant Deficiency 2024

Great Lakes Inter-Tribal Council Inc.

WI

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Corrective Actions Taken or Planned: Create procedures by the type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required re...

Corrective Actions Taken or Planned: Create procedures by the type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report should be completed. Procedures will be added to the accounting department procedures and shared with staff as necessary. This is a work in progress and will continue to be adjusted as necessary. Contact person(s) responsible for corrective action: Gina Brown, CFO Anticipated Completion Date: September 2025

View Audit 360368

Finding 567908 (2024-004)

Material Weakness 2024

Disability Rights South Dakota

SD

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

Finding No. 2024-004: Financial Statement Preparation Responsible Individuals: Ona Arnold, Director of Operations and Finance Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2025

View Audit 360252

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 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 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 567757 (2024-012)

Material Weakness 2024

State of Michigan

MI

Questioned Costs Eligibility Subrecipient Monitoring § 200.516

Finding 2024-012 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 identified exceptions for parts a. and c. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Chil...

Finding 2024-012 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 identified exceptions for parts a. and c. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Children’s Health Insurance Program (CHIP) cases with MAGI determinations cited in part b. did not have case file documentation supporting the beneficiary eligibility determination. The Centers for Medicare and Medicaid Services (CMS) has determined that a reasonable compatibility indicator can be used for CMS audit purposes to determine if the attested income information was electronically verified for MAGI cases and MDHHS disagrees that documentation was not maintained to support the eligibility determination. The SOM MiIntegrate system communicates with various State and federal electronic trusted data sources and sends the information from these sources, along with the beneficiaries’ attested income, to the SOM MAGI Rules Engine where the MAGI eligibility determination is made. As part of the MAGI eligibility determination, a reasonable compatibility test is completed to determine if beneficiary/applicant attested income is within a specified percentage of the electronic trusted data sources or if the attested and verified income are below the threshold for the applicable program. The results of the MAGI eligibility determination are sent back to MiIntegrate using an Account Transfer (AT) packet that contains the results. MiIntegrate then communicates the results to the SOM MAGI Viewer and Bridges using an AT packet and Bridges stores the AT packet number only that can be used to view the details of the AT packet within the SOM MAGI Viewer. The version of the AT packet within the MAGI Viewer also contains a reasonable compatibility indicator that documents the outcome of the reasonable compatibility test and supports the SOM MAGI Rules Engine eligibility decision. MDHHS stores the AT packet information, including facts essential to the eligibility determination, within MiIntegrate and the MAGI Viewer instead of Bridges to help protect and secure the federal income tax data and unemployment data used for the determination. The AT packet for each individual determination can be retrieved from the MAGI Viewer using the AT packet number stored in each beneficiary’s case file within Bridges. MDHHS is not aware of any federal regulations that preclude MDHHS from storing this information in a separate system to help secure the data and restrict access as required by federal and state law. Planned Corrective Action To address the exceptions identified that are not related to MAGI-based income verification results, MDHHS has developed mandatory training protocols for eligibility workers and expects to have the first Medicaid audit focused mandatory training implemented by July 2025. 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 within the electronic case file. MDHHS disagrees it did not maintain case file documentation that supports the beneficiary eligibility determination for MAGI cases and does not intend to take further action. Anticipated Completion Date MDHHS will implement the first Medicaid audit focused training by July 2025. Responsible Individual(s) Logan Dreasky, MDHHS Mariah Schaefer, MDHHS

View Audit 360209 Questioned Costs: $1

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 567724 (2024-033)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking § 200.516

Finding 2024-033 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MiLEAP and MDHHS ESA will continue to work together to help ensure compliance with client eligibility requirements by providing guidance on ...

Finding 2024-033 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MiLEAP and MDHHS ESA will continue to work together to help ensure compliance with client eligibility requirements by providing guidance on updated policies, processes, and noted trends to local office and BSC staff. On October 1, 2024, MDHHS ESA distributed an ESA memo to BSCs and local offices requiring a Child Development and Care eligibility checklist to be completed and uploaded to the electronic case file at the time of each Child Development and Care application and redetermination to help ensure the authorized hours of care in Bridges does not exceed the client's documented need for hours of childcare services. The ESA memo also requires local offices that have not yet achieved compliance to review a sample of cases monthly and ensure the Child Development and Care eligibility checklist is properly uploaded to the electronic case file. The BSCs receive the monthly results from the local offices and also monitor progress to help ensure compliance. Anticipated Completion Date Ongoing Responsible Individual(s) Lisa Brewer-Walraven, MiLEAP Mariah Schaefer, MDHHS Gayle Vail, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567723 (2024-032)

Significant Deficiency 2024

State of Michigan

MI

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

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

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

View Audit 360209

Finding 567688 (2024-022)

Significant Deficiency 2024

State of Michigan

MI

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

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

Finding 2024-022 Highway Planning and Construction, ALN 20.205 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT’s Office of Enterprise Information Management (EIM), Bureau of Field Services-Construction Field Services Division, and Bureau of Development-Design Division will collaborate and provide oversight to ensure that user access for the American Association of State Highway and Transportation Officials software (AASHTOWare) Preconstruction and Construction & Materials modules is reviewed semiannually for privileged accounts and annually for all other accounts. MDOT will implement an improved process, which will be facilitated by the designated System Security Administrators, and access will be modified or removed, as appropriate, prior to the end of each six-month period for privileged users and annually for all other users. Anticipated Completion Date January 1, 2026 Responsible Individual(s) Mark Shulick, MDOT Dan Burns, MDOT Kristin Schuster, MDOT Dee Parker, MDOT Lindsey Renner, MDOT Jason Gutting, MDOT Kyle Nelson, MDOT Andy Esch, MDOT

View Audit 360209

Finding 567608 (2024-001)

Material Weakness 2024

The Housing Authority of the City of Aiken, South Carolina

SC

Questioned Costs Matching / Level of Effort / Earmarking

2024-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed, Unallowed The Authority has developed procedures to ensure that restricted funds are repaid to the Low Rent Program and to ensure that further restricted funds are not advanced. Upon notification from the Department of Housi...

2024-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed, Unallowed The Authority has developed procedures to ensure that restricted funds are repaid to the Low Rent Program and to ensure that further restricted funds are not advanced. Upon notification from the Department of Housing and Urban Development to cease and desist of the Authority’s cost sharing agreement, the Authority immediately discontinued the advancement of funds to other programs operated by the Authority. Current management is actively pursuing collection efforts and understands these federal guidelines. Person Responsible for Correction of Finding: Chanosha Lawton, Executive Director Projected Completion Date: June 30, 2025

View Audit 360162 Questioned Costs: $1

Finding 567592 (2024-002)

Significant Deficiency 2024

Alliance Apartments Housing Development Fund Co., Inc.

NY

Cash Management HUD Housing Programs Significant Deficiency

We have requested HUD approval to delay reimbursement of the reserves pending receipt of Budget Based Rent increase. We anticipate that this will be approved.

View Audit 360130

Finding 567564 (2024-003)

Material Weakness 2024

City of New Haven

CT

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding 2024-003: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Coronavirus State and Local Fiscal Recovery Funds Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principl...

Finding 2024-003: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Coronavirus State and Local Fiscal Recovery Funds Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. While the City has a formal policy requiring the purchasing department to perform verification of suspension or debarment over vendors that the City makes contracts with federally funded projects, it does not maintain formal documentation that this procedure occurred. Corrective Actions Taken: 1. Develop Standard Documentation: Create a standardized verification form or checklist for suspension and debarment checks. Include fields for date, method of verification (e.g., SAM.gov search), name of reviewer, and signature. 2. Integrate into Procurement Workflow: Require completion and attachment of the verification form to all federally funded purchase orders and contracts before approval. Embed verification as a required step in MUNIS or other procurement software workflows, if possible. 3. Staff Training: Provide refresher training for purchasing and finance staff on federal compliance requirements, including suspension and debarment procedures. Emphasize the importance of documentation for audit and compliance purposes. Contact: Malinda Figueroa, Purchasing Director, Anticipated Completion Date: December 2025

View Audit 360119

Finding 567562 (2024-004)

Material Weakness 2024

City of New Haven

CT

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding 2024-004: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Lead-Based Paint Hazard Reduction Grant Program Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principle...

Finding 2024-004: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Lead-Based Paint Hazard Reduction Grant Program Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters a covered transaction with an entity at a lower tier, the non-federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. Without documented evidence verifying whether the City was following its policy, the City could not provide evidence of this control being completed for federally funded projects. There were no standard forms or templates that were used to document verification that parties are not suspended or debarred. Corrective Actions Taken: 1. Establish Documentation Protocols: The City is implementing standard templates and procedures for verifying suspension and debarment status, including documentation requirements. 2. System Integration and Workflow Updates: These procedures will be integrated into procurement workflows and reviewed regularly to ensure consistency across all federally funded contracts. 3. Monitoring and Oversight: A designated staff member will perform periodic reviews to confirm verification procedures are being followed and properly documented. Contact: Malinda Figueroa, Purchasing Director, Anticipated Completion Date: December 2025

View Audit 360119

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