Corrective Action Plans

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The Alabama Emergency Management Agency (AEMA) will strengthen its subrecipient monitoring procedures to ensure compliance with the audit requirements outlined in 2 CFR 200.501. AEMA will implement formal written procedures requiring the identification of subrecipients subject to Single Audit requir...
The Alabama Emergency Management Agency (AEMA) will strengthen its subrecipient monitoring procedures to ensure compliance with the audit requirements outlined in 2 CFR 200.501. AEMA will implement formal written procedures requiring the identification of subrecipients subject to Single Audit requirements and the timely collection, review, and retention of applicable audit reports. AEMA will establish a centralized tracking system to monitor the receipt of required audit reports and identify subrecipients that have not submitted audits by the required due date. Designated personnel will be responsible for conducting and documenting reviews of all received audit reports to determine whether any findings, questioned costs, or deficiencies impact federally funded programs administered by AEMA. In instances where audit findings are identified, AEMA will follow up with subrecipients to obtain corrective action plans and monitor the implementation of corrective actions to ensure identified deficiencies are adequately addressed. Management will also implement periodic supervisory reviews to verify that audit reports are obtained, reviewed, and documented in accordance with federal requirements.
The Alabama Emergency Management Agency (AEMA) will develop and implement formal written procedures to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. These procedures will include processes for identifying all first-tier subawards subje...
The Alabama Emergency Management Agency (AEMA) will develop and implement formal written procedures to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. These procedures will include processes for identifying all first-tier subawards subject to FFATA reporting, verifying the accuracy and completeness of required subaward data elements, and ensuring timely reporting of applicable subawards and subaward amendments to SAM.gov within the required reporting deadlines. AEMA will establish a tracking mechanism to monitor all subawards of $30,000 or more and will assign responsibility to designated personnel for reviewing and submitting FFATA reports. Additionally, management will implement a supervisory review process to verify that all required reports have been submitted accurately and timely.
Finding 1218974 (2025-101)
Material Weakness 2025
PAYROLL CONTROLS Criteria: In accordance with the documentation standards of 2 CFR section 200.430(a), costs of compensation for personal services are allowable to the extent the total compensation for individual employees is reasonable for the services rendered, conforms to the established written ...
PAYROLL CONTROLS Criteria: In accordance with the documentation standards of 2 CFR section 200.430(a), costs of compensation for personal services are allowable to the extent the total compensation for individual employees is reasonable for the services rendered, conforms to the established written policy of the recipient or subrecipient and is determined and supported as provided in 2 CFR section 200.430(g), which states that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. Condition: Payroll testing was completed for a sample of 40 individuals for which time and expenses were charged to R&D grants. Within that selection, we noted instances where payroll controls did not function properly in regard to percentage of time allocated to a grant, proper pay code inclusion, fringe benefit calculation and timely and supervisor level review of time sheets. Context: Management was able to isolate the time allocation error to 20 employees for which the time and costs charges to the grants were in excess of actual time allocation. This resulted in $87,831.53 in excess charged to the grants. Additional control deficiencies did not result in significant improper grant expenditures. Cause: A new payroll system was implemented in fiscal 2025. Grant allocation percentages were not accurately established in the payroll system upon conversion. Effect: Time charged to grant efforts by certain individuals exceeded actual time worked. Recommendation: Review controls should be enhanced to ensure grant expenditures accurately reflect payroll costs. Corrective Actions Taken or Planned: Management identified the issue early following implementation of the new payroll system and performed a detailed review to isolate the impacted population. Corrections were made to payroll allocations for the affected employees, and reimbursement adjustments were processed as appropriate. To prevent recurrence, management has implemented the following control enhancements: - Standardized procedures for establishing and validating grant allocation percentages within the payroll system; - Enhanced supervisory review requirements for time reporting and payroll approvals; - Periodic monitoring and reconciliation of payroll charges to grant budgets; - Additional training for payroll and grant accounting personnel on system configuration and compliance requirements. Responsible Parties: VP of Accounting and Controller and VP of Audit & Compliance. Anticipated Completion Date: Completed in fiscal year 2025; ongoing monitoring procedures are in place.
Management Response: Management acknowledges Finding 2025-005 and agrees that the deficiency in accounting for expenses covered under the resource sharing agreement constitutes a material weakness in internal control over financial reporting and compliance. Misclassification of individual expense ca...
Management Response: Management acknowledges Finding 2025-005 and agrees that the deficiency in accounting for expenses covered under the resource sharing agreement constitutes a material weakness in internal control over financial reporting and compliance. Misclassification of individual expense categories by $70,223 affected the accuracy of category-level reporting and increased the risk of budget overages or noncompliance where federal awards and resource sharing agreements contain line-item spending limitations or require accurate reporting by cost category. Although the error did not necessarily affect total expenditures, incorrect classification can impair oversight, distort budget-to-actual monitoring, and reduce the reliability of information used for internal and external reporting. Management determined that the root causes included insufficiently detailed written guidance for coding transactions under the resource sharing agreement, inconsistent use of account mappings between the general ledger and agreement budget categories, and inadequate review of category-level coding before expenditures were finalized and reported. Existing procedures addressed expense processing generally, but they did not provide enough direction on how shared-service or agreement-covered costs should be classified into the proper expense categories for budget monitoring and reporting. To address this material weakness, management is implementing a corrective action plan focused on improving category-level classification and reporting for expenses covered under the resource sharing agreement. The plan includes four key actions: revising written accounting procedures to define category descriptions, coding rules, and decision standards; creating a standardized crosswalk between general ledger accounts and agreement budget categories; requiring supervisory review of category coding before final reporting; and implementing periodic budget-to-actual monitoring to identify unusual balances, potential overages, and coding trends that may indicate misclassification. Under the revised process, each expense charged under the resource sharing agreement will be recorded using the approved chart-of-accounts mapping and supported by documentation sufficient to identify the nature of the cost, the applicable budget category, and the reason the selected classification is appropriate. If a transaction involves a cost type that does not clearly align to an established category, accounting personnel will be required to elevate the transaction for review before posting or reporting. Any manual reclassification entries affecting agreement categories will require documented justification and supervisory approval. In addition, management will compare recorded expenditures to budgeted amounts by category on a recurring basis so that unusual fluctuations, coding anomalies, or category overages can be investigated and corrected before financial or grant reporting is finalized. Management will also provide targeted training to accounting, finance, and grants personnel responsible for recording or reviewing resource sharing agreement activity. Training will address the relationship between GAAP-based accounting records, agreement-specific budget categories, and federal compliance expectations for accurate, current, and complete financial reporting and comparison of expenditures to budget amounts. Management will supplement this training with periodic reviews of classification trends and exception items so that recurring coding issues can be identified and corrected through additional guidance, process changes, or retraining as needed. Management believes these corrective actions directly address the auditors’ recommendation to review current policies and procedures for compliance with GAAP and federal regulations. Responsibility for implementation will rest primarily with the Finance Director, in coordination with accounting and grants personnel involved in resource sharing agreement reporting. Management expects the enhanced coding guidance, account crosswalk, review controls, and category-level monitoring procedures to improve the accuracy of expense classification, strengthen budget oversight, and reduce the risk of misstatements or noncompliance related to resource sharing agreement expenditures in future periods. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Revise and adopt written accounting procedures for expenses covered under the resource sharing agreement, including category definitions, coding rules, and documentation standards for classification decisions. Finance Director; Accounting Manager June 30, 2026 Approved procedures; updated accounting manual; staff distribution records. Develop and implement a standardized crosswalk between general ledger accounts and resource sharing agreement budget categories, including guidance for common transaction types and reclassification scenarios. Accounting Manager; Finance Director July 15, 2026 Approved account crosswalk; coding reference guide; sample mapped transactions. Require documented supervisory review of category coding for resource sharing agreement transactions before final reporting, including review of manual reclasses and higher-risk expense categories. Finance Director Effective immediately Reviewer signoff on category reports; approved reclassification support; supervisory review documentation. Provide targeted training to accounting, finance, and grants personnel on category-level expense classification, use of the crosswalk, and reporting requirements under the resource sharing agreement Compliance Officer; Finance Director August 31, 2026 Training materials; attendance logs; completed acknowledgements or knowledge checks. and applicable federal regulations. Perform monthly budget-to-actual category reviews for resource sharing agreement expenditures to identify unusual balances, potential overages, and coding anomalies requiring investigation or correction. Accounting Manager; Finance Director Monthly, beginning July 31, 2026 Monthly budget-to-actual reports; exception logs; documented follow-up and corrections. Perform quarterly monitoring of a sample of resource sharing agreement transactions to verify correct category coding, consistency with the approved crosswalk, and compliance with agreement and federal reporting requirements. Compliance Officer; Finance Director Quarterly, beginning September 30, 2026 Quarterly monitoring reports; sample testing documentation; corrective action follow-up records
Management Response: Management acknowledges Finding 2025-003 and agrees that the control deficiency related to allocation of expenses within the WIOA Cluster constitutes a material weakness in internal control over compliance. This finding is distinct from Finding 2025-002 because it concerns the m...
Management Response: Management acknowledges Finding 2025-003 and agrees that the control deficiency related to allocation of expenses within the WIOA Cluster constitutes a material weakness in internal control over compliance. This finding is distinct from Finding 2025-002 because it concerns the methodology, approval, and monitoring of cost allocations affecting WIOA programs, including restrictions applicable to the Youth program, rather than the allowability of costs based on timing or period of performance. Although the identified costs were corrected, the deficiency increased the risk that shared or allocable costs could be assigned to restricted programs in a manner inconsistent with federal requirements if not detected and prevented in a timely manner. Management determined that the root causes were insufficiently detailed written procedures for allocating shared costs within the WIOA Cluster, lack of explicit documentation addressing the prohibition on transfers to or from the Youth program under 20 CFR 683.130, and inconsistent supervisory review of allocation entries before posting. Existing practices addressed cost charging generally, but they did not provide enough direction on how shared expenditures benefiting multiple WIOA funding streams should be allocated, documented, reviewed, and restricted when Youth funds were involved. To address this material weakness, management is implementing four control improvements. First, it will formalize written cost allocation policies and procedures for the WIOA Cluster that define approved methodologies, documentation standards, proportional benefit requirements, and restrictions applicable to the Youth program. Second, it will require documented supervisory review and approval of all allocation entries affecting WIOA programs before posting to the general ledger. Third, it will provide targeted training to finance, grants, and program management personnel on WIOA-specific allocation requirements, with particular emphasis on Youth program restrictions. Fourth, it will implement periodic monitoring to verify that allocations follow the approved methodology and remain consistent with federal requirements. Under the revised process, each allocation affecting WIOA programs will be supported by contemporaneous documentation identifying the nature of the cost, the programs benefiting from the expenditure, the basis used to distribute the cost, and the calculation of the amounts charged to each program. When a cost benefits multiple programs and proportional benefit can be reasonably determined, the allocation will be based on that proportional benefit. When proportional benefit cannot be determined precisely, the allocation will be supported by a reasonable documented method that is applied consistently. Allocation support must also include a compliance checkpoint confirming that no allocation results in an impermissible transfer to or from the Youth program. No allocation entry affecting WIOA programs will be recorded without documented preparer support and written supervisory review evidencing compliance with internal policy and applicable regulations. Management will also establish recurring monitoring controls to test allocations recorded during the year. On at least a quarterly basis, the Finance Director or designee will review a sample of WIOA allocation entries to confirm that the approved methodology was followed, supporting documentation was retained, supervisory approval was completed, and Youth program restrictions were observed. Exceptions identified through this monitoring process will be documented, investigated, and corrected promptly, with any necessary retraining or policy revisions implemented to prevent recurrence. Results of the monitoring process will be communicated to senior management as part of ongoing oversight of federal awards compliance. Management believes these corrective actions directly address the auditors’ recommendations and strengthen controls over allocation of expenses within the WIOA Cluster without duplicating the corrective actions described in Finding 2025-002. Responsibility for implementation will rest primarily with the Finance Director, in coordination with grants and program leadership. Management expects the enhanced policy framework, approval requirements, training, and monitoring activities to reduce the risk of noncompliant allocations, improve documentation of shared cost methodologies, and support sustained compliance with 2 CFR 200.405 and 20 CFR 683.130. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Revise and adopt written WIOA cost allocation policies and procedures that define approved allocation methodologies, documentation requirements, proportional benefit standards, and explicit restrictions applicable to the Youth program. Finance Director; Grants Manager June 30, 2026 Approved policy and procedure document; distribution to applicable staff; retained version history. Implement a standardized allocation worksheet and review checklist for all shared costs charged to WIOA programs, including a compliance checkpoint for Youth program restrictions. Accounting Manager; Finance Director July 15, 2026 Standard allocation template; completed review checklist; sample completed allocation packages. Require documented supervisory review and approval of all allocation entries affecting WIOA programs before posting to the general ledger. Finance Director Effective immediately Signed allocation entries; reviewer signoff; journal entry support retained with monthly close documentation. Provide targeted training to finance, grants, and program personnel on 2 CFR 200.405, WIOA allocation principles, and the prohibition on transfers to or Finance Director; Compliance Officer August 31, 2026 Training materials; attendance logs; completed acknowledgements or assessments. from the Youth program under 20 CFR 683.130. Perform quarterly monitoring of a sample of WIOA allocation entries to verify adherence to the approved methodology, adequacy of support, supervisory approval, and compliance with Youth program restrictions. Finance Director; Compliance Officer Quarterly, beginning September 30, 2026 Quarterly monitoring reports; exception logs; documented corrective follow-up. Evaluate the effectiveness of the revised allocation controls and update policies, training, or monitoring procedures if deficiencies or exceptions are identified. Finance Director; Executive Leadership Semi-annually during fiscal year 2027 Management review memoranda; updated procedures; remediation tracking documentation.
Finding: 2025-002 Reportable finding considered a material weakness-Expenses incurred outside of the period of performance Effect: The organization claimed and was reimbursed for unallowable costs under 2 CFR 200.458. Failure to maintain effective controls over cost allowability increases the risk o...
Finding: 2025-002 Reportable finding considered a material weakness-Expenses incurred outside of the period of performance Effect: The organization claimed and was reimbursed for unallowable costs under 2 CFR 200.458. Failure to maintain effective controls over cost allowability increases the risk of noncompliance questioned costs, and potential repayment of federal funds. Questioned costs: Known questioned costs of $403,805 were identified by reviewing each transaction prior to the date and for the month after the award began to ensure there are no likely questioned costs. Recommendation for the organization from the auditor: • Formalize and implement written policies and procedures governing identification, approval, and accounting for pre-award costs. • Require documented written approval from the federal awarding agency prior to charging any pre-award costs to federal awards. • Provide training to program and finance personnel on Uniform Guidance cost allowability requirements, including 2 CFR 200.458 and 2 CFR 200.403. • Implement supervisory review controls to ensure costs charged to federal awards are incurred within the approval period of performance or have documented prior approval. Corrective Action Plan for Pre-award costs Management acknowledges the audit finding that pre-award costs were charged to multiple federal awards for expenses incurred before the approved period of performance beginning October 1, 2024. The costs were incurred without the required written prior approval from the Maryland Department of Labor (MD DOL), the pass-through entity. As a result, unallowable costs were reimbursed and later removed from the Schedule of Expenditures of Federal Awards (SEFA). Management determined that the issue resulted from insufficient internal controls, the absence of formal written procedures for pre-award costs, and gaps in staff understanding of Uniform Guidance requirements. To address these root causes, the organization adopted a formal written policy governing the identification, approval, documentation, and accounting of pre-award costs. The policy requires written prior approval from MD DOL before any pre-award costs may be incurred or charged to a federal award and establishes documentation, retention, and accounting standards to support compliance with 2 CFR 200.458 and 2 CFR 200.403. Third, the organization also implemented a mandatory written approval workflow requiring program and grants staff to prepare and submit a formal request to MD DOL whenever pre-award costs are anticipated. No costs may be incurred until written approval is received. Approval documentation must be retained in both the official grant file and the accounting system. This workflow is now part of the grant start-up process for all federal awards. Fourth, the organization strengthened supervisory review controls to ensure that all costs charged to federal awards fall within the approved period of performance or have documented prior approval. These controls include a pre-posting cost allowability checklist, supervisory review and approval of all federal charges, and accounting system alerts that flag costs incurred outside the period of performance. Additionally, the Compliance Officer will conduct quarterly internal compliance reviews to verify adherence to federal requirements and internal policies. Finally, the organization implemented preventive measures to ensure long-term compliance. These include maintaining a centralized grant calendar with period-of-performance dates, requiring dual review of costs charged during the first 90 days of new awards, and conducting semi-annual internal audits of federal expenditures. Any discrepancies identified will be reported to senior leadership within five business days. Management is committed to ensuring full compliance with Uniform Guidance and MD DOL requirements. All corrective actions described above have been implemented or will be fully implemented by July 31, 2026. The organization believes these actions sufficiently address the audit findings and significantly strengthen internal controls over federal award management. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Develop and implement formal Pre-award Cost Policy Finance Director June 1, 2026 Final approved policy; distribution email; policy posted to shared drive Establish mandatory written prior approval workflow Finance Director June 30, 2026 Completed approval request template; sample approval documentation; updated grant file checklist Conduct Uniform Guidance training Compliance Officer July 31, 2026 Training materials; attendance logs; post-training assessments Implement supervisory review controls Finance Director June 30, 2026 Completed checklists; system screenshots; supervisor sign-offs Perform quarterly internal compliance reviews Compliance Officer Quarterly, ongoing Quarterly review reports; corrective action memos (if applicable) Maintain centralized grant calendar Director of Performance and Compliance June 30, 2026 Updated grant calendar; access logs or distribution email Conduct semi-annual internal audits Compliance Officer Semi-annual, ongoing Internal audit reports; follow-up documentation Dual review of early-period charges Finance Director; Grants Manager July 1, 2026 Dual-review sign-off forms; documented approvals
Management Response: Management acknowledges Finding 2025-004 and agrees that weaknesses in the review and approval of expenses represent a material weakness in internal control over compliance. The reimbursement of personal credit card expenses and the charging of those transactions to federal awar...
Management Response: Management acknowledges Finding 2025-004 and agrees that weaknesses in the review and approval of expenses represent a material weakness in internal control over compliance. The reimbursement of personal credit card expenses and the charging of those transactions to federal awards resulted in unallowable costs and demonstrated a breakdown in the review process for employee reimbursements and supporting documentation. Although the known questioned costs total only $46, the broader risk is that additional unallowable, unsupported, or improperly coded expenses could be charged to federal awards if review controls are not strengthened. Management determined that the root causes included insufficiently detailed procedures for reviewing employee reimbursement requests, inconsistent verification of business purpose and allowability before reimbursement, and inadequate supervisory review of expense documentation before costs were posted to federal awards. Existing controls were not precise enough to identify personal or otherwise unallowable charges embedded within reimbursement activity, particularly when descriptions were incomplete or reviewers did not independently confirm that the expense was necessary, reasonable, properly documented, and allowable under Uniform Guidance. To address this material weakness, management is implementing a corrective action plan focused on strengthening pre-payment and pre-posting review of employee reimbursements and other expense transactions charged to federal awards. The plan includes four key actions: revising reimbursement and accounts payable procedures to require detailed support for every request; requiring documented secondary review by supervisory or finance personnel independent of the submitter; implementing exception-based review procedures for higher-risk transactions; and performing periodic post-payment monitoring to confirm that review procedures are operating effectively and that unallowable costs are promptly identified and corrected. Under the revised process, no employee reimbursement or expense charged to a federal award will be approved unless the request includes sufficient supporting documentation to allow the reviewer to determine that the cost is necessary, reasonable, allocable as applicable, consistently treated, and adequately documented in accordance with Uniform Guidance cost principles. Reviewers will be required to confirm the business purpose of the transaction, assess whether the type of cost is allowable under the terms of the award and applicable federal regulations, and verify that no personal items, duplicate charges, sales tax errors, or unsupported amounts are included. If documentation is incomplete or a charge appears questionable, the transaction will be held pending clarification, recoded to a non-federal source, or denied reimbursement as appropriate. Any unallowable expense identified after reimbursement will be promptly removed from the applicable federal award and reported through management’s corrective follow-up procedures. Management will also reinforce accountability through targeted training and oversight. Employees who prepare, review, approve, or process reimbursements and expense reports affecting federal awards will receive training on allowable cost principles, documentation expectations, and the importance of careful review under 2 CFR Part 200, including the requirement that costs be adequately documented and necessary and reasonable for the performance of the federal award. In addition, Finance will generate periodic exception reports highlighting reimbursement activity charged to federal awards, personal credit card reimbursements, and other transactions meeting defined risk criteria. These reports will be reviewed by management to identify trends, address control failures, and implement additional corrective measures when needed. Management believes these corrective actions directly address the auditors’ recommendations and strengthen controls over the review and approval of expenses charged to federal awards without repeating the corrective actions already established for pre-award costs, allocation methodology, or broader financial close procedures. Responsibility for implementation will rest primarily with the Finance Director, in coordination with accounts payable, grants, and program leadership. Management expects enhanced documentation standards, independent review requirements, exception-based oversight, and monitoring activities to reduce the risk of personal or otherwise unallowable expenses being reimbursed and charged to federal awards in future periods. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Revise and adopt written expense reimbursement and accounts payable review procedures requiring itemized receipts, documented business purpose, funding source identification, and explicit confirmation that requested costs are not personal in nature. Finance Director; Accounts Payable Supervisor June 30, 2026 Approved procedures; updated reimbursement forms; staff distribution records. Implement a standardized reimbursement review checklist requiring reviewer validation of allowability, Accounts Payable Supervisor; July 15, 2026 Completed checklist template; sample reviewed reimbursement business purpose, receipt support, coding accuracy, and identification of any personal or unsupported charges before reimbursement or posting to a federal award. Finance Director packages; approval signoff documentation. Require independent supervisory review and approval for all employee reimbursements and any expense transaction charged in whole or in part to a federal award, including personal credit card reimbursement requests. Finance Director Effective immediately Supervisor approval records; signed reimbursement packages; workflow evidence showing independent review. Provide targeted training for employees, supervisors, accounts payable, and grants personnel on allowable cost principles, documentation standards, and reviewer responsibilities for expenses affecting federal awards. Compliance Officer; Finance Director August 31, 2026 Training materials; attendance logs; completed acknowledgements or knowledge checks. Create periodic exception reports for reimbursement activity charged to federal awards, missing receipt transactions, unusual merchants, and other higher-risk expense patterns, and require documented management review of the results. Accounting Manager; Finance Director September 30, 2026 Exception report format; monthly or quarterly review logs; documented follow-up on exceptions. Perform quarterly post-payment monitoring of a sample of reimbursed expenses charged to federal awards to verify compliance with documentation, Compliance Officer; Finance Director Quarterly, beginning September 30, 2026 Quarterly monitoring reports; exception logs; evidence of recoding, recovery, or corrective follow-up. approval, and allowability requirements and to ensure prompt correction of any identified exceptions.
The Division is in the process of designing and implementing a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and that such evidence is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major,...
The Division is in the process of designing and implementing a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and that such evidence is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.
The Division is in the process of designing and implementing a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Com...
The Division is in the process of designing and implementing a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Various ...
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Various agencies Award Names: Southeast Region Cybersecurity Collaboration Center (SERC3), Establish, manage, and maintain a public-private partnership (PPP) additive manufacturing (AM) consortium for the Rapid Manufacturing Propulsion Technology (RAMPT), Developing effective adaptation strategies to enhance the resilience of farmers under changing climate, Towards a sustainable bioeconomy: Biotransformation of paper mill sludge for value-added chirally pure (R)-1,3-butanediol production, A systems approach to perennial forage management using plant growth-promoting rhizobacteria Award Numbers: 212514, 208409, 200987, 205258, and 205264 Assistance Listing Title: Cybersecurity, Energy Security & Emergency Response (CESER), Science, Integrative Activities, and Agriculture and Food Research Initiative (AFRI) Assistance Listing Number: 81.008, 43.RD, 47.083, and 10.310, Award Year: 2024 - 2025 Pass-through entity: UT-Batelle LLC, RPM Innovations, Inc., New Mexico State University, Regents of University of the University of California, and University of Tennessee Management notes 2025-002 is a repeat finding of 2024-002, but given the timing of the finding last year, our 2024 CAP was anticipated to be completed as of October 1, 2025. To ensure Auburn University is in compliance with 2CFR 200.332(f), Auburn University has implemented the following corrective action plan: Since the audit period, the University has completed a comprehensive review of its subrecipient monitoring framework and has been working to distribute workload more effectively with the goal of building consistency in subrecipient monitoring procedures. This includes efforts to clarify ownership of monitoring tasks, implementing a more centralized and standardized approach to documentation, and balancing the day-to-day operational duties across the subaward team to allow for appropriate focus on Uniform Guidance compliance. Brief internal training sessions or check-ins will be conducted to reinforce expectations and ensure that all staff are aligned with the updated documentation practices. Current procedures were revised to address risk assessments and annual monitoring. These improvements are designed to ensure consistency, accountability, and compliance with Uniform Guidance expectations moving forward. We will document when all reviews of sub-recipients’ financial statements/Uniform Guidance reports occur and who completes the reviews. These reviews will be entity-specific and conducted annually. The corrective actions noted herein have been implemented as of October 1, 2025. Contact: Tony Ventimiglia Asst. VP Research Administration Office of the Senior VP for Research & Economic Development Amy Douglas Associate VP Financial Services/Controller Completed Date: October 1, 2025
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.
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.
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
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
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.
Finding 1218757 (2025-002)
Material Weakness 2025
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.
Finding 1218756 (2025-001)
Material Weakness 2025
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.
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.
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
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
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
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
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
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
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
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