Corrective Action Plans

Finding 567845 (2024-049)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs

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

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

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Finding 567839 (2024-048)

Significant Deficiency 2024

State of Michigan

MI

Eligibility Questioned Costs Special Tests & Provisions

Finding 2024-048 Temporary Assistance for Needy Families, ALN 93.558 - Child Support Non-Cooperation Management Views MDHHS disagrees with part a. of the finding. MDHHS’s eligibility system, Bridges, was functioning as intended for the two cases identified because each case was in a non-ongoing mod...

Finding 2024-048 Temporary Assistance for Needy Families, ALN 93.558 - Child Support Non-Cooperation Management Views MDHHS disagrees with part a. of the finding. MDHHS’s eligibility system, Bridges, was functioning as intended for the two cases identified because each case was in a non-ongoing mode at the time the automated interface occurred. A case is placed into this status if the client circumstances have changed for any MDHHS program within Bridges and the case requires a redetermination. TANF policy cannot mandate Bridges to change the non-ongoing mode because each impacted program is required to be certified prior to changing the status. MDHHS policy does not mandate a specific length of time that a case can be in a non-ongoing status. The results of the redetermination can impact the client’s non-cooperation status and therefore the client should not be sanctioned until the certification by all programs is complete. For one of the cases, the client was appropriately sanctioned after the case review was complete and for the other case, the client was determined to be in compliance once the case was removed from the non-ongoing status mode. MDHHS agrees with part b. of the finding. Planned Corrective Action For part a., MDHHS disagrees with the finding and does not intend to take further action. For part b., MDHHS ESA policy staff will work with the MDHHS Bridges technical team to determine if there was a technical aspect that contributed to the inappropriate sanction and identify a solution by September 30, 2025. If potential system modifications are needed, MDHHS will follow the Departmental Work Intake Process for prioritization and determine an anticipated completion date for implementation. Anticipated Completion Date a. Not applicable b. MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solution identified. Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schulze, MDHHS Brian Sanborn, MDHHS

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Finding 567837 (2024-046)

Significant Deficiency 2024

State of Michigan

MI

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

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

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

View Audit 360209 Questioned Costs: $1

Finding 567836 (2024-045)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Eligibility Questioned Costs § 200.516

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

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

View Audit 360209 Questioned Costs: $1

Finding 567835 (2024-044)

Significant Deficiency 2024

State of Michigan

MI

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

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

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

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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 567762 (2024-017)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs

Finding 2024-017 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Managed Care Periodic Audits Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS formally added the Encounter Data Validation (EDV) protocol to its Ex...

Finding 2024-017 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Managed Care Periodic Audits Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS formally added the Encounter Data Validation (EDV) protocol to its External Quality Review Organization (EQRO) contracts as of October 1, 2022. The EQRO identified three EDV protocol elements to review for the managed care entities including information systems, administrative profiles, and medical records. During fiscal year 2023, EQRO completed the comprehensive information systems review that analyzed MDHHS’s information systems infrastructure and an administrative profile review that analyzed MDHHS’s electronic encounter data completeness, accuracy, and timeliness. MDHHS published the completed reports for the information system and administrative profile reviews on its website during February and March 2024. During fiscal year 2024, EQRO began the medical records review component, which analyzes the completeness and accuracy of MDHHS’s electronic encounter data by comparing it to the information documented in the corresponding members’ medical records. MDHHS completed the fiscal year 2024 medical records report and published it to MDHHS’s website during March 2025. Anticipated Completion Date Completed Responsible Individual(s) Brad Barron, MDHHS Katarzyna Gruszka, MDHHS

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Finding 567761 (2024-016)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs

Finding 2024-016 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Medical Loss Ratio Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS updated the medical loss ratio (MLR) instructions and comparisons were required...

Finding 2024-016 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Medical Loss Ratio Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS updated the medical loss ratio (MLR) instructions and comparisons were required to be submitted to MDHHS as part of the MLR reporting process for the MHP Comprehensive Health Care Plan (CHCP) during June 2023 and for the Dental Health Plans and MI Choice during April 2024. MDHHS will update MLR instructions for PIHPs to clarify that comparisons are required to be submitted as part of the MLR reporting process. MDHHS will continue to work with the CHCPs, PIHPs, MI Choice, and Dental Health plans to obtain the comparisons as part of the MLR reporting process and will follow established procedures to reject those MLR submissions received that fail to attach a comparison. Anticipated Completion Date September 2025 Responsible Individual(s) Keith White, MDHHS Jackie Sproat, MDHHS

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Finding 567760 (2024-015)

Significant Deficiency 2024

State of Michigan

MI

Reporting Questioned Costs

Finding 2024-015 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Refunding of Federal Share of Overpayments Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS has added additional verification checks t...

Finding 2024-015 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Refunding of Federal Share of Overpayments Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS has added additional verification checks to ensure all overpayment reports are included in each quarter’s financial reports. For part b., MDHHS will document the process of identifying late overpayments and calculating interest. There were no late payments identified during fiscal year 2024 that required an interest calculation. For part c., MDHHS will identify and implement CHAMPS enhancements needed to correct Federal Medical Assistance Percentage calculations. Anticipated Completion Date a. Completed b. September 30, 2025 c. September 30, 2025 Responsible Individual(s) Rebecca Jones, MDHHS

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Finding 567759 (2024-014)

Significant Deficiency 2024

State of Michigan

MI

Eligibility Questioned Costs HUD Housing Programs

Finding 2024-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS amended the Pharmacy Benefits Manager, Prepaid Inpatient Health Plan (PIHP),...

Finding 2024-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS amended the Pharmacy Benefits Manager, Prepaid Inpatient Health Plan (PIHP), MI Choice Waiver Program (MI Choice), Medicaid Health Plan (MHP), and Dental Health Plan entity fiscal year 2025 contracts to require that signatures are obtained on the Provider Screening Information Collection Tool (PSICT) forms and returned timely when contracts and waivers are renewed and extended. Also, MDHHS is in the process of amending the remaining Integrated Care Organization contract to include this requirement. MDHHS will continue to educate the managed care entities and MDHHS contract areas on this process to help ensure compliance. MDHHS expects that signatures will be obtained on the PSICT forms effective September 2025 for the fiscal year 2026 contract cycle and will continue to send an annual reminder to the managed care entities to report any change in ownership to MDHHS within 35 days. In addition, MDHHS continues to review provider agreements as part of its monitoring process conducted for all MI Choice entities. MDHHS’s review of fiscal year 2024 provider agreements for MI Choice entities will be completed by December 31, 2025, and will be ongoing during the Administrative Quality Assurance Review process as outlined in the waiver application that was approved by CMS. MDHHS will continue to send annual reminders to MI Choice entities to submit completed PSICT forms by September 1 each year as required by MI Choice contracts. MDHHS obtained an updated provider agreement for the Home Help provider cited in the finding. Home Help providers are now enrolled in CHAMPS and provider agreements, including updated terms and conditions, are completed electronically. Anticipated Completion Date December 31, 2025 Responsible Individual(s) Heather Hill, MDHHS Kim Heinicke, MDHHS Elaina Brown, MDHHS

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Finding 567757 (2024-012)

Material Weakness 2024

State of Michigan

MI

Eligibility Questioned Costs 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 567756 (2024-011)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Reporting Questioned Costs

Finding 2024-011 MDHHS - FFATA Reporting Management Views MDHHS agrees with the finding. Planned Corrective Action The MDHHS Bureau of Grants and Purchasing followed up with the subrecipients regarding unique entity identifier (UEI) account issues in the System for Award Management (SAM) and once ...

Finding 2024-011 MDHHS - FFATA Reporting Management Views MDHHS agrees with the finding. Planned Corrective Action The MDHHS Bureau of Grants and Purchasing followed up with the subrecipients regarding unique entity identifier (UEI) account issues in the System for Award Management (SAM) and once the issues were resolved, the subaward information was submitted. The MDHHS Federal Reporting Section will continue to help ensure the accuracy of the department’s Grants Received Report that is used by the MDHHS Bureau of Grants and Purchasing to report information in SAM. All data elements required to comply with federal funding requirements, such as the Federal Funding Accountability and Transparency Act (FFATA), have been added to the Grants Received Report. The MDHHS Federal Reporting Section will work with the MDHHS Bureau of Grants and Purchasing to develop a more comprehensive process to identify missing data that has not yet been communicated from the federal awarding agency, program area, or others. In the event data elements are missing from the report, the MDHHS Federal Reporting Section will follow up with the awarding agency, program area, or others to update the missing data elements within 30 days of receipt of the award. The MDHHS Bureau of Budget will confirm that a Program Period Code is included on the request form provided by the program office prior to the entry of grant agreements in the Electronic Grants Administration and Management System (EGrAMS). When reviewing grant agreements in EGrAMS, the MDHHS Bureau of Budget will confirm that pertinent coding elements are included prior to approval. In addition, the MDHHS Bureau of Budget will identify EGrAMS agreements with accounting templates that are not initially coded to federal funding, but contain a program code or task code that subsequently splits costs to a federal funding code, and work with the MDHHS Bureau of Grants and Purchasing to help ensure these agreements are included in the query used to obtain data for FFATA reporting. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Jeanette Hensler, MDHHS Rebecca Jones, MDHHS Erik Eklund, MDHHS

View Audit 360209

Finding 567755 (2024-007)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

Finding 2024-007 CHAMPS Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with potential duplicate records for local office staff to review. In addition, the Community Health A...

Finding 2024-007 CHAMPS Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with potential duplicate records for local office staff to review. In addition, the Community Health Automated Medicaid Processing System (CHAMPS) is currently designed to reject potential duplicate records to prevent duplicate payments for the same individuals that already exist in CHAMPS and places these records on a CHAMPS report for review. These two reports could potentially contain the same duplicate records identified by both CHAMPS and Bridges. As part of the Departmental Work Intake Process for prioritization, MDHHS submitted a work request during January 2023 for a Bridges system modification that would allow data from the Bridges reports to be exported to the Bridges data warehouse and MDHHS is currently working with DTMB to obtain access to the data. MDHHS central office will develop a process to reconcile the rejected records identified on the CHAMPS and Bridges reports and ensure that MDHHS is appropriately reviewing those records and making any necessary corrections. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS

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Finding 567726 (2024-035)

Material Weakness 2024

State of Michigan

MI

Questioned Costs Subrecipient Monitoring Material Weakness

Finding 2024-035 CCDF Cluster, ALN 93.575 and 93.596 - FFATA Reporting Management Views MiLEAP and MDE agree with the finding. Planned Corrective Action MiLEAP will implement a process to ensure it submits subaward information as required by FFATA and federal guidance. Anticipated Completion Da...

Finding 2024-035 CCDF Cluster, ALN 93.575 and 93.596 - FFATA Reporting Management Views MiLEAP and MDE agree with the finding. Planned Corrective Action MiLEAP will implement a process to ensure it submits subaward information as required by FFATA and federal guidance. Anticipated Completion Date September 2025 Responsible Individual(s) Lora MacKay, MiLEAP

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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 567706 (2024-030)

Significant Deficiency 2024

State of Michigan

MI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.302

Finding 2024-030 Rehabilitation Services Vocational Rehabilitation Grants to States, ALN 84.126 - Accuracy of Financial Reports Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division will implement the following: 1. Improvements to documented procedures f...

Finding 2024-030 Rehabilitation Services Vocational Rehabilitation Grants to States, ALN 84.126 - Accuracy of Financial Reports Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division will implement the following: 1. Improvements to documented procedures for the Vocational Rehabilitation Financial Report (RSA-17) preparation to ensure consistency and accuracy of financial report submissions. 2. Specific RSA-17 training for applicable staff and management in order to enhance knowledge of reporting requirements. 3. An additional layer of management review on RSA-17 financial reports prior to submission. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Heidi Parker, LEO Chris Johnson, LEO

View Audit 360209

Finding 567697 (2024-026)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Finding 2024-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Workfront Security Management and Access Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB implemented process improvements in May 2024 related to the tracking and documentation of...

Finding 2024-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Workfront Security Management and Access Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB implemented process improvements in May 2024 related to the tracking and documentation of user access requests to support approval of user access and system roles. The exceptions cited are related to users whose access was granted prior to the improved documentation being implemented. Anticipated Completion Date Completed Responsible Individual(s) Jennifer Edmonds, DTMB

View Audit 360209

Finding 567696 (2024-025)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303

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

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

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Finding 567695 (2024-024)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.303

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

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

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Finding 567694 (2024-023)

Significant Deficiency 2024

State of Michigan

MI

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

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

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

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Finding 567691 (2024-001)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

Finding 2024-001 SIGMA High-Risk Activity Monitoring Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division will implement the following: 1. Updated procedures that ensure completeness of high-risk activity reports by adjusting date parameters of weekly ...

Finding 2024-001 SIGMA High-Risk Activity Monitoring Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division will implement the following: 1. Updated procedures that ensure completeness of high-risk activity reports by adjusting date parameters of weekly reports. 2. A layer of review by management that oversees SIGMA override processes and transactions to ensure appropriateness. 3. A procedure to ensure the adequate retention of management review documents. Anticipated Completion Date August 31, 2025 Responsible Individual(s) Robert Mason, LEO Mary McGrath, LEO

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