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Corrective Action Plans

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Finding 1218822 (2025-001)
Material Weakness 2025
Little Rivers Health Care, Inc.
VT
Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring
Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly appli...
Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly applied a sliding fee discount to a patient account, resulting in a discount that was not consistent with the Organization's sliding fee discount policy. Individual(s) Responsible for Corrective Action: Andrew Barter, CEO Planned Corrective Action: The identified error resulted from a contracted third-party billing company applying a sliding fee discount that was inconsistent with Little Rivers Health Care's Sliding Fee Discount Program policy. Upon identification of the finding, the account was reviewed and corrected to ensure the patient received the appropriate discount. To prevent future occurrences, Little Rivers Health Care re-instituted its monthly monitoring and review procedures in May 2026. These monitoring activities had been conducted consistently through the fall of 2025 and include periodic audits of patient accounts receiving sliding fee discounts, verification of discount calculations, and oversight of third-party billing activities. Findings from these reviews are documented, and corrective action is taken promptly when discrepancies are identified. In addition, the contracted billing company has been reminded of the organization's sliding fee discount requirements and expectations for compliance. To provide ongoing oversight and validation of compliance with the Sliding Fee Discount Program, Little Rivers Health Care has also implemented quarterly review meetings involving the Billing Manager, Controller, and Chief Executive Officer. These meetings have been formally scheduled, with the first occurrence set for July 20, 2026. The quarterly reviews will evaluate monitoring results, validate adherence to policy requirements, identify trends or potential risks, and ensure continuous compliance with program requirements. Anticipated Completion Date: May 20, 2026 (Corrective action completed), for reinstatement of monthly monitoring procedures. Quarterly compliance review meetings with the Billing Manager, Controller, and CEO are scheduled to commence on July 20, 2026, and will continue on an ongoing basis as part of the Organization's continuous compliance monitoring process.
View Audit 404913
Finding 1218801 (2025-002)
Material Weakness 2025
Ponca Tribe of Nebraska
NE
Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303
Persons responsible for corrective action: Keith Morrow, Health Services Chief Executive Officer Corrective action planned: Developed and implemented process by which Business Services staff in Health Services review documents provided by non-Ponca Native Americans upon initial request for services ...
Persons responsible for corrective action: Keith Morrow, Health Services Chief Executive Officer Corrective action planned: Developed and implemented process by which Business Services staff in Health Services review documents provided by non-Ponca Native Americans upon initial request for services and on an annual basis to follow to confirm and verify their capacity to receive health services from the Ponca Tribe. Steps have been taken to see the staff verifying are independent from those who initially collect such documents. Additionally, confirmed such process is consistent with existing verification review of Ponca members requesting services. Implementation date: December 1, 2025.
View Audit 404885
Finding 1218790 (2025-001)
Material Weakness 2025
City of Lowell
MA
Allowable Costs / Cost Principles Subrecipient Monitoring Material Weakness
Audit Finding Reference: 2025-001 Maintain Employee's Time and Effort Records Planned Corrective Action: The District will implement and enforce a formal time and effort reporting process for all employees whose salaries are charged to federal programs. The process will include: 1. Identification of...
Audit Finding Reference: 2025-001 Maintain Employee's Time and Effort Records Planned Corrective Action: The District will implement and enforce a formal time and effort reporting process for all employees whose salaries are charged to federal programs. The process will include: 1. Identification of all employees whose compensation is funded, in whole or in part, by federal awards. 2. C.ompletion of required semi-annual certifications or periodic personnel activity reports, as applicable, in accordance with Uniform Guidance requirements. 3. Review and approval of certifications bysupervisory personnel to ensure accuracy and completeness. 4. C.entralized maintenance of all certifications by the Grants Office to ensure records are readily available for audit and monitoring purposes. 5. Development of a compliance calendar with established due dates and reminder notifications for required certifications. 6. Quarterly monitoring bythe Business Office to verifythat all required certifications have been completed, reviewed, and retained. Planned Implementation Date of Corrective Action: The District has begun implementing these procedures and will have the revised process fully operational by 6/30/2026. All required certifications for the current fiscal year will be collected and maintained going forward. Person Responsible for Corrective Action: Grants Manager, Funds Analyst, Deputy Chief Financial Officer Signature Derek Pinto, Assistant Superintendent of Finance
View Audit 404883
Finding 1218776 (2025-002)
Material Weakness 2025
City of Lowell
MA
Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.327
Audit Finding Reference: 2025-002 Improve Procurement Procedures Planned Corrective Action: The District will strengthen its procurement procedures for federally funded purchases to ensure compliance with Uniform Guidance requirements. Specifically, the District will: 1. Revise procurement procedure...
Audit Finding Reference: 2025-002 Improve Procurement Procedures Planned Corrective Action: The District will strengthen its procurement procedures for federally funded purchases to ensure compliance with Uniform Guidance requirements. Specifically, the District will: 1. Revise procurement procedures to clearly identify when federal procurement requirements apply in addition to state and local procurement regulations. 2. Develop and implement a federal procurement checklist that must be completed prior to the award of any contract funded in whole or in part with federal grant funds. 3. Work with the Law Department to establish standardized contract templates containing all required federal contract provisions, including the Byrd Anti-Lobbying Amendment when applicable. 4. Require a secondary review bythe Business Office or Grants Management personnel before contract execution to verify compliance with Uniform Guidance procurement standards and required contract clauses. 5. Provide annual training to Business Office staff, grant managers, and other personnel involved in procurement activities regarding federal procurement requirements and contract provisions. 6. Conduct periodic internal reviews of federally funded procurement transactions to ensure ongoing compliance. Planned Implementation Date of Corrective Action: The revised procedures, procurement checklist, and standardized contract templates will be implemented by7 /1/2026. Training will be completed for applicable staff during the current fiscal year and prior to the initiation of future federally funded procurements. Person Responsible for Corrective Action: Assistant Superintendent of Finance Derek Pinto, Assistant Superintendent of Finance
View Audit 404883
Finding 1218766 (2025-001)
Material Weakness 2025
Nevada School District
AR
Subrecipient Monitoring Internal Control / Segregation of Duties
District management will adopt sound accounting policies and establish and maintain internal control that will initiate, authorize, record, process, and report transactions consistent with management's assertions embodied in the financial statements and that will safeguard District assets.
District management will adopt sound accounting policies and establish and maintain internal control that will initiate, authorize, record, process, and report transactions consistent with management's assertions embodied in the financial statements and that will safeguard District assets.
View Audit 404881
Finding 1218757 (2025-002)
Material Weakness 2025
Pact, Inc.
DC
Subrecipient Monitoring Reporting Internal Control / Segregation of Duties
Corrective Action Plan: Effective January 2026, Pact management implemented a new process that strengthens the internal controls over the FFATA reporting to ensure the required reports are submitted within the required timeframe. The monthly report being run to capture those subaward actions that re...
Corrective Action Plan: Effective January 2026, Pact management implemented a new process that strengthens the internal controls over the FFATA reporting to ensure the required reports are submitted within the required timeframe. The monthly report being run to capture those subaward actions that require FFATA reporting has been changed to encompass 45 days to ensure that no late entries are missed when the reporting is done.
View Audit 404865
Finding 1218756 (2025-001)
Material Weakness 2025
Pact, Inc.
DC
Subrecipient Monitoring Internal Control / Segregation of Duties Procurement, Suspension & Debarment
Corrective Action Plan: Misuse of Funds – Vehicle: Pact updated its Global Vehicle Policy effective November 1, 2025. The updated Global Vehicle Policy reinforces Pact’s zero-tolerance policy. No new reports of vehicle misuse have been received since November 2025, and all the reported cases of misu...
Corrective Action Plan: Misuse of Funds – Vehicle: Pact updated its Global Vehicle Policy effective November 1, 2025. The updated Global Vehicle Policy reinforces Pact’s zero-tolerance policy. No new reports of vehicle misuse have been received since November 2025, and all the reported cases of misuse occurred prior to November 1. Pact’s updated policy complies with all applicable laws and regulations, including the organization’s internal Code of Conduct, while aligning with the objectives and scope of work for the project. Pact’s guidelines specify roles and responsibilities and role assignments; identify authorized places to obtain fuel; where to store vehicle keys; where to park vehicles; and require individuals to enter detailed records regarding the use of the vehicle into a log. Misuse of Funds – Payroll: In alignment with Pact’s core principle of continuous quality improvement, and following substantiation of the misuse in one country office, Pact developed and implemented a corrective action plan. This plan included a comprehensive quality review of existing controls to identify and address any procedural gaps in the timesheet systems to ensure the timesheet systems have a functional auditable approval trail. We have reinforced, including in Senior Management Team meetings with staff, and other trainings supervisors’ responsibility to review and verify hours worked for their staff.
View Audit 404865
Finding 1218735 (2025-002)
Material Weakness 2025
Crossett Housing Authority
AR
Subrecipient Monitoring Cash Management Period of Performance
Views of Responsible Officials and Planned Corrective Actions: The Crossett Housing Authority Director will immediately seek guidance from HUD officials and MRI/Lindsey to remedy this problem.
Views of Responsible Officials and Planned Corrective Actions: The Crossett Housing Authority Director will immediately seek guidance from HUD officials and MRI/Lindsey to remedy this problem.
View Audit 404826
Finding 1218716 (2025-061)
Material Weakness 2025
State of Michigan
MI
Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
Finding 2025-061 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Block Grants for Prevention and Treatment of Substance Abuse, ALN 93.959 Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an A...
Finding 2025-061 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Block Grants for Prevention and Treatment of Substance Abuse, ALN 93.959 Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an API for the submission of FFATA data to the federal system, SAM, to improve both timeliness and accuracy through automation. This API will connect EGrAMS with SAM, enabling backend communication between the systems and allowing SAM to automatically retrieve data directly from EGrAMS. To ensure accurate reporting until the API is established, MDHHS will continue reviewing validation errors when submitting web-based information to SAM and will work with the SAM federal helpline to report federal system issues and identify interim alternatives to submit the required data. Also, MDHHS implemented an enhancement in August 2025 that validates federal funding sources in EGrAMS against their effective dates, reducing coding errors and improving data reliability. In addition, the query used to obtain certain FFATA data elements was modified during fiscal year 2026 to improve accuracy of reporting. Anticipated Completion Date December 31, 2027 Responsible Individual(s) Matt Blackburn, MDHHS Jeanette Hensler, MDHHS Rebecca Jones, MDHHS
View Audit 404775
Finding 1218709 (2025-018)
Material Weakness 2025
State of Michigan
MI
Subrecipient Monitoring Internal Control / Segregation of Duties
Finding 2025-018 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 and strengthened its medical loss ratio (MLR) reporting instructions and ...
Finding 2025-018 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 and strengthened its medical loss ratio (MLR) reporting instructions and comparison template for the MHP Comprehensive Health Care Plan (CHCP), Dental Health Plans, and MI Choice to ensure clearer expectations and alignment with federal requirements. The CHCP and MI Choice programs cited in the fiscal year 2024 audit did not have any identified issues during the fiscal year 2025 audit, demonstrating the impact of MDHHS’s efforts to improve internal controls and monitoring activities to ensure all submitted MLR reports are completed in accordance with federal regulations. MDHHS updated the MLR reporting instructions and the comparison template for the PIHPs to clarify federal requirements and ensure consistency across all managed care programs and distributed them to the PIHPs during May 2026. MDHHS will strengthen its internal tracking and review process to ensure inclusion of the federally required comparison to audited financial statements in all MLR submissions by September 1, 2026. This verification step, currently in place for PIHPs, will be expanded to all managed care entity types. MDHHS will document this verification and follow up with the managed care entity when the comparison is missing or incomplete to ensure compliance with federal regulations. Anticipated Completion Date September 1, 2026 Responsible Individual(s) Kristen Morningstar, MDHHS Keith White, MDHHS Chris Parker, MDHHS
View Audit 404775
Finding 1218706 (2025-015)
Material Weakness 2025
State of Michigan
MI
Eligibility Subrecipient Monitoring HUD Housing Programs
Finding 2025-015 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...
Finding 2025-015 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), Integrated Care Organization, Medicaid Health Plan (MHP), and Dental Health Plan 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. MDHHS obtained all signatures on the PSICT forms effective February 19, 2026, 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 fiscal year 2025 review of fiscal year 2024 provider agreements for MI Choice entities was completed by March 31, 2026, and will be ongoing during the Administrative Quality Assurance Review process as outlined in the waiver application that was approved by CMS. Currently the fiscal year 2026 MI Choice contracts state PSICTs must be submitted by September 1 ahead of the new contract renewal, but this will be amended for fiscal year 2026 and subsequent contracts to indicate the PSICT must be submitted to MDHHS upon contract renewal. MDHHS will continue to remind MI Choice entities to submit the PSICT timely and according to contract requirements. Anticipated Completion Date July 31, 2026 Responsible Individual(s) Heather Hill, MDHHS Kim Heinicke, MDHHS
View Audit 404775
Finding 1218704 (2025-013)
Material Weakness 2025
State of Michigan
MI
Eligibility Subrecipient Monitoring Material Weakness § 200.516
Finding 2025-013 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. However, MDHHS disagrees that 2 Medicaid cases and 11 CHIP cases with MAGI d...
Finding 2025-013 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. However, MDHHS disagrees that 2 Medicaid cases and 11 CHIP cases with MAGI determinations cited in part b. lacked documentation supporting the eligibility determination. 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. For this reason, MDHHS disagrees that documentation was not maintained. The State of Michigan (SOM) MiIntegrate system communicates with various electronic State and federal trusted data sources and sends 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 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, secure system to ensure appropriate data protection and access controls required by federal and State laws. Planned Corrective Action To address the exceptions identified that are not related to MAGI-based income verification results, MDHHS developed mandatory training protocols for eligibility specialists, and the first Medicaid audit-focused mandatory training was implemented in June 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. For the exception that did not contain the appropriate coverage termination date, MDHHS reviewed the case and determined that the beneficiary remained eligible to transition to another aid category, and therefore no improper payments occurred. MDHHS will identify the system issue that produced the incorrect termination date and will implement a system fix if necessary. Should such an improvement be identified, it will be submitted through the Departmental Work Intake Process for prioritization and implementation by the Bridges technical team. MDHHS maintains that documentation supporting MAGI eligibility determinations is retained within MiIntegrate and the MAGI Viewer and therefore disagrees that case file documentation was not maintained. As such, no further corrective action is planned. Anticipated Completion Date June 30, 2027 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS
View Audit 404775
Finding 1218703 (2025-011)
Material Weakness 2025
State of Michigan
MI
Subrecipient Monitoring Material Weakness Reporting
Finding 2025-011 MDHHS - FFATA Reporting Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an application programming interface (API) for the submission of the Federal Funding Accountability and Transparency Act (FFATA) data to...
Finding 2025-011 MDHHS - FFATA Reporting Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an application programming interface (API) for the submission of the Federal Funding Accountability and Transparency Act (FFATA) data to the federal system, the System for Award Management (SAM), to improve both timeliness and accuracy through automation. This API will connect the Electronic Grants Administration and Management System (EGrAMS) with SAM, enabling backend communication between the systems and allowing SAM to automatically retrieve data directly from EGrAMS. To ensure accurate reporting until the API is established, MDHHS will continue reviewing validation errors when submitting web-based information to SAM and will work with the SAM federal helpline to report federal system issues and identify interim alternatives to submit the required data. Also, MDHHS implemented an enhancement in August 2025 that validates federal funding sources in EGrAMS against their effective dates, reducing coding errors and improving data reliability. In addition, MDHHS modified the query used to obtain certain FFATA data elements during fiscal year 2026 to improve accuracy of reporting. Anticipated Completion Date December 31, 2027 Responsible Individual(s) Matt Blackburn, MDHHS Jeanette Hensler, MDHHS Rebecca Jones, MDHHS
View Audit 404775
Finding 1218701 (2025-005)
Material Weakness 2025
State of Michigan
MI
Eligibility Subrecipient Monitoring Material Weakness
Finding 2025-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., and d. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees with the conclusion that a process is not fully established to monitor the electronic ...
Finding 2025-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., and d. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees with the conclusion that a process is not fully established to monitor the electronic notifications provided to county/district office caseworkers to ensure they utilized the Income Eligibility and Verification System (IEVS) information to determine the recipients’ eligibility. MDHHS had policies and procedures in place during fiscal year 2025 to help ensure monitoring of electronic notifications occurred. Review of IEVS information is fully incorporated into the case read procedure governed by Bridges Administrative Manual 301 and further detailed in accompanying desk aids and reading guides. The MDHHS Economic Stability Administration (ESA) also provides regular direction and reminders regarding case read requirements through ESA memos. For part e., MDHHS disagrees that IEVS information is required to be requested and obtained for Medicaid Cluster Healthy Kids, Healthy Michigan Plan, Children’s Health Insurance Program (CHIP) Healthy Kids, and MiChild modified adjusted gross income (MAGI) based recipients since eligibility is verified upon determination through the MAGI eligibility determination process. MAGI verification rules are contained within federal regulation 42 CFR 435.603, which describes electronic verification through the Federal Data Services Hub, reasonable compatibility standards, and verification at application and renewal. The Centers for Medicare and Medicaid Services (CMS) MAGI Application and Eligibility Process Implementation Guides describe MAGI verification as a streamlined, electronic process using the federal hub and state data sources with no reference to IEVS. The IEVS rules are contained within federal regulations 42 CFR 435.940 through 42 CFR 435.965 and are part of the non-MAGI verification framework. Planned Corrective Action For parts a. and b., MDHHS ESA will continue to provide guidance and training to local office specialists on timely and appropriate use of IEVS when the information is critical to current eligibility determinations. MDHHS ESA will also continue to evaluate potential technical and automated solutions related to IEVS data to help ensure its proper utilization and timeliness. For parts c. and e., MDHHS disagrees with the finding and does not intend to take further action. For part d., MDHHS is collaborating with other work areas to identify potential solutions to establish and implement IEVS interfaces for adoption subsidy recipients funded by the Temporary Assistance for Needy Families (TANF) program. Anticipated Completion Date a. and b. Ongoing c. Not applicable d. MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential solutions identified. e. Not applicable Responsible Individual(s) a., b., and c. Veronica Maxson and Mariah Schaefer, MDHHS d. Kathonya Triplett, MDHHS e. Logan Dreasky, MDHHS
View Audit 404775
Finding 1218700 (2025-004)
Material Weakness 2025
State of Michigan
MI
Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.303
Finding 2025-004 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exceptio...
Finding 2025-004 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals, semi-annual review of privileged users, and annual review for all users. Security management and access control processes will continue to be a standing agenda item for ongoing quarterly training sessions with local office security coordinators (LOSC). For parts a., c., and d., the Access Management Section began implementing a process to conduct quarterly reconciliations of the DSA to the Bridges Integrated Automated Eligibility Determination System (Bridges) during March 2025. Due to the complexity of the reconciliations and time constraints, MDHHS requested the Bridges technical team to develop a consolidated Excel based report to add a level of automation to the process. The report is now available on an ad hoc basis, and the Access Management Section began utilizing it during April 2026 to conduct reviews and provide remediation with the LOSCs and end users. Full automation of the report remains in progress due to significant competing priorities and limited resources. For part b., MDHHS implemented the automated DSA periodic access review process (PAR) during January 2026 to review all users every 90 days, instead of the current 180 days for privileged users. MDHHS updated its policy to require initiation of the PAR in the DSA for all users every 90 days, without exception, to comply with State standards. For part e., MDHHS local office directors, district managers, or designees review a monthly sample of high-risk Bridges transactions to ensure documentation was properly maintained. Beginning September 2024, MDHHS Business Service Centers (BSC) implemented a monitoring process to ensure monthly reviews are completed by the local offices timely and that the documentation is properly maintained. To strengthen compliance, MDHHS will reinforce expectations through manager training and emphasize the requirement to maintain complete records and to sign and date all review reports within 30 days of the report run date. Additional training sessions will be repeated as needed to ensure consistent adherence to documentation and timeliness standards across all local offices. Anticipated Completion Date a., c., and d. Ongoing b. Completed e. September 30, 2026 Responsible Individual(s) a., b., c., and d. Tim Kwast, MDHHS e. Tim Kwast and Veronica Maxson, MDHHS
View Audit 404775
Finding 1218684 (2025-055)
Material Weakness 2025
State of Michigan
MI
Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness
Finding 2025-055 Social Services Block Grant, ALN 93.667 - Post-Expenditure Report Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is modifying the process to obtain the required post-expenditure report data to ensure all individuals receiving Social Services Block Gr...
Finding 2025-055 Social Services Block Grant, ALN 93.667 - Post-Expenditure Report Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is modifying the process to obtain the required post-expenditure report data to ensure all individuals receiving Social Services Block Grant supported services are appropriately included. Also, MDHHS will add a program validation step to review the applicable federal regulations and confirm the data extracted is accurate and complete. In addition, MDHHS will revise and resubmit the fiscal year 2025 report by September 30, 2026. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Tiffany Clarke, MDHHS Rebecca Jones, MDHHS Mary Lou Mahoney, MDHHS Aimee McDaniel, MDHHS
View Audit 404775
Finding 1218682 (2025-007)
Material Weakness 2025
State of Michigan
MI
Internal Control / Segregation of Duties Student Financial Aid Subrecipient Monitoring
Finding 2025-007 MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS currently has a process in place to review the user narrative describing the incompatible role exceptions within the DSA Michigan Statewide A...
Finding 2025-007 MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS currently has a process in place to review the user narrative describing the incompatible role exceptions within the DSA Michigan Statewide Automated Child Welfare Information System (MiSACWIS) request as part of the approval process. Also, MDHHS added an incompatible role form in the DSA MiSACWIS request with automated routing for appropriate approval on November 11, 2025. In addition, MDHHS provides ongoing education during the quarterly LOSC webinars, where guidance is shared with the LOSCs on security management and access control topics, such as the correct procedures for processing system access requests. For part b., during April 2025, MDHHS updated the renewal processing start date to 15 days earlier to ensure renewal requests are reviewed prior to the annual recertification date. Anticipated Completion Date Completed Responsible Individual(s) Tim Kwast, MDHHS Alana Lowe, MDHHS
View Audit 404775
Finding 1218662 (2025-052)
Material Weakness 2025
State of Michigan
MI
Subrecipient Monitoring § 200.332 § 200.501 § 200.521
Finding 2025-052 Low-Income Home Energy Assistance, ALN 93.568 - Subrecipient Audits Management Views The Department of Licensing and Regulatory Affairs (LARA) agrees with the finding. Planned Corrective Action The current Michigan Public Service Commission (MPSC) Michigan Energy Assistance Program ...
Finding 2025-052 Low-Income Home Energy Assistance, ALN 93.568 - Subrecipient Audits Management Views The Department of Licensing and Regulatory Affairs (LARA) agrees with the finding. Planned Corrective Action The current Michigan Public Service Commission (MPSC) Michigan Energy Assistance Program (MEAP) Request for Proposal (RFP) response template requires each recipient of federal Low-Income Home Energy Assistance Program funds to indicate whether they have filed a single audit report and to provide the Federal Audit Clearinghouse filing date for verification. While the MEAP Section, within LARA, did verify compliance, it acknowledges that the reviews were not formally documented. Beginning in October 2024, the MEAP Section started updating its internal manual to document the processes used by the grant administrator and manager to monitor MEAP subrecipients. However, the grant administrator position became vacant in mid-December 2024 before the updates to the internal manual could be completed. During the same period, new legislation amended both the MEAP and the Low-Income Energy Assistance Fund, requiring substantial updates to the existing RFP to reflect new statutory requirements and additional funding. As a result, the MEAP Section staff had to assume additional responsibilities while onboarding and training a new grant administrator as of March 31, 2025. The MEAP Section staff will complete the procedural updates to the internal manual by August 1, 2026. The MEAP Section will also establish a single audit checklist for subrecipient monitoring that complies with federal regulations 2 CFR 200.501, 2 CFR 200.332(f), and 2 CFR 200.521(d). The MEAP Section manager will review the checklists and supporting documentation annually for accuracy and completeness, and will ensure the requirements set forth in the internal manual are being followed. Anticipated Completion Date August 1, 2026 Responsible Individual(s) Anne Armstrong, LARA Wanda Clavon Jones, LARA
View Audit 404775
Finding 1218661 (2025-051)
Material Weakness 2025
State of Michigan
MI
Eligibility Subrecipient Monitoring Material Weakness § 200.516
Finding 2025-051 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action In May 2025, MDHHS issued memo 2025-20, which implemented mandatory training requirements for all eligibility staff and their managers...
Finding 2025-051 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action In May 2025, MDHHS issued memo 2025-20, which implemented mandatory training requirements for all eligibility staff and their managers to address audit-related findings. The State Emergency Relief (SER) training courses occur biannually, in March and August, and cover verification of client income, client contribution payments, and proof of energy crisis. To ensure accuracy of payment processing, in October 2025, MDHHS issued memo 2025-48 which implemented the mandatory SER Reconciliation Report requirement. As part of this updated process, each county office must run the SER Energy Reconciliation Report weekly and review all energy-related payments to ensure accuracy and confirm that required documentation is maintained. In addition, MDHHS will continue to communicate with BSCs and local offices regarding the requirements to maintain sufficient documentation to support SER processing through formal internal communication channels. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Further, MDHHS will explore a potential system enhancement that will provide automated solutions for an added layer of efficiency and compliance. Should such an improvement be identified, it will be submitted through the Departmental Work Intake Process for prioritization and implementation by the Bridges technical team. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the completion date is dependent on the priority assigned to system enhancements as determined by the Departmental Work Intake Process. Responsible Individual(s) Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS
View Audit 404775
Finding 1218656 (2025-050)
Material Weakness 2025
State of Michigan
MI
Subrecipient Monitoring
Finding 2025-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Subrecipient Audits and Subaward Information Management Views LEO agrees with the finding. Planned Corrective Action For part a., LEO implemented a standardized single audit review process,...
Finding 2025-050 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Subrecipient Audits and Subaward Information Management Views LEO agrees with the finding. Planned Corrective Action For part a., LEO implemented a standardized single audit review process, including a robust tracking mechanism, in the third quarter of fiscal year 2025. LEO subsequently reviewed all nine Refugee and Entrant Assistance State/Replacement Designee Administered Programs subrecipient single audit reports identified in the finding during the first and second quarters of fiscal year 2026. LEO will continue to implement its standardized single audit review process to ensure that all required subrecipient single audit reports are identified, obtained, reviewed, and issued a management decision letter within the federal six‑month resolution deadline when applicable, maintaining full compliance with Uniform Guidance requirements. For part b., LEO implemented new procedures as of March 31, 2026, where the LEO OGM grants administrator and LEO grants analyst perform segregated duties to ensure the required subaward information is provided within the initial grant agreement and within subsequent amendments, as required. Anticipated Completion Date a. June 30, 2026 b. Completed Responsible Individual(s) Allen Williams, LEO Christopher Blondell, LEO Benjamin Cabanaw, LEO Nicole Adams, LEO
View Audit 404775
Finding 1218655 (2025-049)
Material Weakness 2025
State of Michigan
MI
Reporting Subrecipient Monitoring Material Weakness
Finding 2025-049 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. LEO is fully committed to improving its FFATA process. It is LEO’s position that the switch from the FFATA Subaward Reporting S...
Finding 2025-049 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. LEO is fully committed to improving its FFATA process. It is LEO’s position that the switch from the FFATA Subaward Reporting System to SAM for FFATA reporting in March 2025 contributed to some of the cited deficiencies. Planned Corrective Action The LEO Finance Division is currently working with the LEO Grants Division to determine a better process of notification for new subawards and amendments so that they can be reported within the required timeframe. The process will be documented in an updated formal procedure which focuses on timely communication as the primary control and SIGMA Business Intelligence queries as a secondary control to ensure completeness of reporting. Anticipated Completion Date June 30, 2026 Responsible Individual(s) Heidi Parker, LEO Chris Johnson, LEO
View Audit 404775
Finding 1218654 (2025-048)
Material Weakness 2025
State of Michigan
MI
Allowable Costs / Cost Principles Eligibility Subrecipient Monitoring § 200.516
Finding 2025-048 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS acknowledges that documentation supporting compliance with refugee c...
Finding 2025-048 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS acknowledges that documentation supporting compliance with refugee cash assistance work registry requirements must be consistently maintained in the electronic case record. The issue identified pertains to documentation of ongoing work registration requirements within the case record to maintain eligibility, noting that the clients were eligible at the time of application approval. Beginning January 2026, MDHHS implemented a monthly manual review of active cases to ensure required documentation is present. MDHHS is also pursuing a Bridges system enhancement to automate generation and storage of the DHS-4785R (Refugee Employment Program Appointment Notice) in the electronic case file. This enhancement will be submitted through the Departmental Work Intake Process for prioritization and implementation by the Bridges technical team. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the priority assigned to the system enhancement as determined by the Departmental Work Intake Process. Responsible Individual(s) Benjamin Cabanaw, LEO Nicole Adams, LEO Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Mariah Schaefer, MDHHS
View Audit 404775
Finding 1218653 (2025-047)
Material Weakness 2025
State of Michigan
MI
Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance
Finding 2025-047 Refugee and Entrant Assistance State/Replacement Designees Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. For part a., the LEO Office of Global Michigan (OGM) maintains a limited number of internal...
Finding 2025-047 Refugee and Entrant Assistance State/Replacement Designees Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. For part a., the LEO Office of Global Michigan (OGM) maintains a limited number of internal Salesforce user licenses. As a result, internal user access is inherently constrained and proactively monitored based on employment status. LEO OGM’s existing process for validating continued need is tied to personnel changes: internal user access remains appropriate as long as the employee occupies a position with assigned Salesforce responsibilities, and access is removed when employees separate or move to roles that do not require use of the system. Because license allocation is strictly managed and user roles are position-based, LEO OGM has considered this process to constitute ongoing monitoring rather than an annual recertification process. However, LEO OGM acknowledges that this practice does not fully meet the specific requirement for a documented annual review as noted in SOM Technical Standard 1340.00.020.01 (Access Control Standard). Planned Corrective Action For part a., LEO OGM will formalize and implement an internal user account review process, including conducting and documenting an annual review of all user access accounts in accordance with the Access Control Standard. For part b., LEO OGM will work collaboratively with program and system administrators to strengthen controls around identifying and timely deactivating inactive internal and external user accounts. LEO OGM will establish clearer procedures, increase review frequency, and document the actions taken to ensure accounts exceeding inactivity thresholds are disabled consistently and timely. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Ben Cabanaw, LEO Nicole Adams, LEO
View Audit 404775
Finding 1218647 (2025-045)
Material Weakness 2025
State of Michigan
MI
Subrecipient Monitoring
Finding 2025-045 Temporary Assistance for Needy Families, ALN 93.558 - Risk Assessments Management Views MDHHS agrees with the finding. Planned Corrective Action For the one subrecipient, the annual subrecipient risk assessment was completed in fiscal year 2026 in accordance with federal requirement...
Finding 2025-045 Temporary Assistance for Needy Families, ALN 93.558 - Risk Assessments Management Views MDHHS agrees with the finding. Planned Corrective Action For the one subrecipient, the annual subrecipient risk assessment was completed in fiscal year 2026 in accordance with federal requirements and incorporated into the subrecipient monitoring plan. Moving forward, MDHHS will ensure the risk assessment is completed annually, properly documented, and incorporated into the annual subrecipient monitoring plan. Anticipated Completion Date Completed Responsible Individual(s) Lynn Hendges, MDHHS
View Audit 404775
Finding 1218552 (2025-035)
Material Weakness 2025
State of Michigan
MI
Subrecipient Monitoring
Finding 2025-035 CCDF Cluster, ALN 93.575 and 93.596 - Subaward Information Management Views MiLEAP agrees with the finding. Planned Corrective Action MiLEAP finalized grant procedures for reviewing award documents in July 2025, which includes utilizing a new grant template to ensure all requirement...
Finding 2025-035 CCDF Cluster, ALN 93.575 and 93.596 - Subaward Information Management Views MiLEAP agrees with the finding. Planned Corrective Action MiLEAP finalized grant procedures for reviewing award documents in July 2025, which includes utilizing a new grant template to ensure all requirements are included on each award. MiLEAP also hired a procurement manager in fiscal year 2025 that is responsible for including the needed information into all subrecipient grant agreements. Anticipated Completion Date: Completed Responsible Individual(s) Amanda Lopez, MiLEAP Brandon Colby, MiLEAP
View Audit 404775
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