Corrective Action Plans

Finding 567694 (2024-023)

Significant Deficiency 2024

State of Michigan

MI

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

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

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

View Audit 360209

Finding 567691 (2024-001)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Internal Control / Segregation of Duties

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

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

View Audit 360209

Finding 567688 (2024-022)

Significant Deficiency 2024

State of Michigan

MI

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

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

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

View Audit 360209

Finding 567681 (2024-060)

None 2024

State of Michigan

MI

Finding 2024-060 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency - Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2024, Corrective Action Plan, Finding 2024-003.

View Audit 360209

Finding 567680 (2024-059)

None 2024

State of Michigan

MI

Finding 2024-059 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency - Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2024, Corrective Action Plan, Finding 2024-002.

View Audit 360209

Finding 567679 (2024-058)

Material Weakness 2024

State of Michigan

MI

Questioned Costs

Finding 2024-058 Unemployment Insurance, ALN 17.225 See Department of Labor and Economic Opportunity, Unemployment Insurance Agency - Unemployment Compensation Fund, Report on Expenditure of Federal Awards, Year Ended September 30, 2024, Corrective Action Plan, Finding 2024-001.

View Audit 360209 Questioned Costs: $1

Finding 567678 (2024-021)

Significant Deficiency 2024

State of Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Period of Performance § 200.303 § 200.308

Finding 2024-021 National Guard Military Operations and Maintenance (O&M) Projects, ALN 12.401 - Extension Procedures Management Views DMVA agrees with the finding. Planned Corrective Action DMVA will set annual recurring calendar appointments to review program activities with the program managers...

Finding 2024-021 National Guard Military Operations and Maintenance (O&M) Projects, ALN 12.401 - Extension Procedures Management Views DMVA agrees with the finding. Planned Corrective Action DMVA will set annual recurring calendar appointments to review program activities with the program managers one month before the end of the period of performance to ensure a joint understanding of extension requirements, allowing sufficient time to prepare and submit period of performance extension requests timely, if needed. Anticipated Completion Date September 1, 2025 Responsible Individual(s) Rachelle Breeden, DMVA

View Audit 360209

Finding 567677 (2024-020)

Significant Deficiency 2024

State of Michigan

MI

Cash Management § 200.303

Finding 2024-020 National Guard Military Operations and Maintenance (O&M) Projects, ALN 12.401 - Timeliness of Cash Draws Management Views The Department of Military and Veterans Affairs (DMVA) agrees with the finding. Planned Corrective Action DMVA has communicated the importance of timely compl...

Finding 2024-020 National Guard Military Operations and Maintenance (O&M) Projects, ALN 12.401 - Timeliness of Cash Draws Management Views The Department of Military and Veterans Affairs (DMVA) agrees with the finding. Planned Corrective Action DMVA has communicated the importance of timely completion of cash draws. DMVA will consolidate expenditure reports sent to federal program managers to reduce overall quantity and improve timeliness. Additionally, DMVA will implement a revised document management methodology for expenditure reports returned from federal program managers that are ready for final approval and submission to the United States Property and Fiscal Office. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Rachelle Breeden, DMVA

View Audit 360209

Finding 567676 (2024-010)

Significant Deficiency 2024

State of Michigan

MI

Internal Control / Segregation of Duties § 200.303

Finding 2024-010 MDE, Change Management Process Management Views MDE agrees with the finding. Planned Corrective Action For MiND, the standard change management process requires documenting the test results. However, there are scenarios when the data in question is only in the production environme...

Finding 2024-010 MDE, Change Management Process Management Views MDE agrees with the finding. Planned Corrective Action For MiND, the standard change management process requires documenting the test results. However, there are scenarios when the data in question is only in the production environment; or it might be production specific deployment like changing application settings which does not have relevance to the test environment. In these cases, MDE will maintain documentation in DevOps that the deployment is production specific. MDE will increase the post-review process of MiND related work items from a semi-annual to quarterly basis to ensure all required evidence of testing is recorded appropriately. For NexSys, MDE will review the change management process with DTMB and implement additional steps to ensure tickets are closed in a timely manner and all testing results have been appropriately documented. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Monica Butler, MDE Peter Jones, MDE

View Audit 360209

Finding 567675 (2024-009)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring § 200.303

Finding 2024-009 MDE, Security Management and Access Controls Management Views The Michigan Department of Education (MDE) agrees with the finding. Planned Corrective Action For part a., with the release of Michigan Nutrition Data (MiND) 2.0 in November 2024, the system now has the added documentat...

Finding 2024-009 MDE, Security Management and Access Controls Management Views The Michigan Department of Education (MDE) agrees with the finding. Planned Corrective Action For part a., with the release of Michigan Nutrition Data (MiND) 2.0 in November 2024, the system now has the added documentation supporting the individual approved system roles required for this security control. For part b.1., MDE will start reviewing non-privileged internal Grant Electronic Monitoring System/Michigan Administrative Review System accounts on an annual basis and will store documentation of the review. MDE has started writing the policy adjustment for this change. To validate their continued need, MDE will annually review all MiND accounts for appropriate access that have access to SOM proprietary information. For part b.2., MDE has provided input to DTMB on this technical control, and MDE intends to comply with the revised SOM Technical Standard 1340.00.020.01 (Access Control Standard). MDE plans to complete both the policy adjustment and the annual review for 2025 by December 31, 2025. For part c., MDE implemented the process for deactivating users to meet this security requirement in November 2024 when MiND 2.0 was released. The process for deactivating users to meet this security requirement for the Next Generation Grant, Application and Cash Management System (NexSys) was implemented in May 2025. Anticipated Completion Date a. Completed b.1. September 30, 2025 b.2. December 31, 2025 c. Completed Responsible Individual(s) Monica Butler, MDE Joshua Long, MDE Peter Jones, MDE David Judd, MDE

View Audit 360209

Finding 567674 (2024-008)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Cash Management Eligibility § 200.303

Finding 2024-008 MDE, IT General Controls Management Views DTMB agrees it did not fully implement its user access removal and recertification processes when transitioning responsibilities between employees. Planned Corrective Action DTMB corrected the issues noted and the reassigned employee res...

Finding 2024-008 MDE, IT General Controls Management Views DTMB agrees it did not fully implement its user access removal and recertification processes when transitioning responsibilities between employees. Planned Corrective Action DTMB corrected the issues noted and the reassigned employee resumed DTMB’s existing user access removal and recertification processes in November 2024. Anticipated Completion Date Completed Responsible Individual(s) Rex Menold, DTMB Aaron Dupre, DTMB

View Audit 360209

Finding 567666 (2024-019)

Significant Deficiency 2024

State of Michigan

MI

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

Finding 2024-019 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS discussed the change management documented requirements with the information t...

Finding 2024-019 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS discussed the change management documented requirements with the information technology (IT) contractor during April 2025 to ensure all testing is documented appropriately. MDHHS has updated the Michigan Women, Infants, and Children Information System (MI-WIC) Change Management Controls process to include a review of each change to ensure it has successfully completed all components of the change management process prior to completion of associated release activities. Anticipated Completion Date Completed Responsible Individual(s) Kristina Brady, MDHHS Bagya Kodur, MDHHS

View Audit 360209

Finding 567665 (2024-018)

Significant Deficiency 2024

State of Michigan

MI

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

Finding 2024-018 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Access Controls Management Views MDHHS and DTMB agree with the finding. Planned Corrective Action DTMB implemented a process in November 2024 to review privileged accounts with direct ...

Finding 2024-018 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Access Controls Management Views MDHHS and DTMB agree with the finding. Planned Corrective Action DTMB implemented a process in November 2024 to review privileged accounts with direct database access semiannually. Anticipated Completion Date Completed Responsible Individual(s) Nathan Buckwalter, DTMB

View Audit 360209

Finding 567659 (2024-006)

Significant Deficiency 2024

State of Michigan

MI

Special Tests & Provisions Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Finding 2024-006 ADP Security Program Management Views Although MDHHS and DTMB agree annual testing was not conducted for one system and not all necessary updates to the system security plan were completed during the audit period for four systems, MDHHS and DTMB disagree that effective controls wer...

Finding 2024-006 ADP Security Program Management Views Although MDHHS and DTMB agree annual testing was not conducted for one system and not all necessary updates to the system security plan were completed during the audit period for four systems, MDHHS and DTMB disagree that effective controls were not implemented to ensure confidentiality, integrity, and availability of its automated data processing (ADP) information systems. MDHHS and DTMB also disagree that the security of critical systems was at risk by failing to mitigate potential vulnerabilities as described in the effect statement of the finding. MDHHS and DTMB have compensating controls in place to ensure confidentiality, integrity, and availability of its ADP information systems in addition to mitigating potential vulnerabilities. MDHHS and DTMB monitor remediation of Plans of Actions and Milestones for all information systems even after expiration of the authority to operate (ATO). For one system cited, MDHHS is required to audit the system as part of the responsibilities related to the Affordable Care Act and the Medicaid Expansion marketplace. Those audits are conducted to show compliance with federal information security and privacy requirements related to data stored in those systems. The system required to be audited as part of the Affordable Care Act, along with two other systems cited, are reviewed biennially through the Internal Control Evaluation process where control evidence is updated to demonstrate the effectiveness of controls. Each system cited did not have any significant changes and implemented controls are still working as expected. Planned Corrective Action DTMB has hired additional resources to help ensure the timely completion of the required work below. For part a., MDHHS and DTMB will conduct testing of the disaster recovery plan (DRP) by September 30, 2025, and will follow SOM Technical Standards on DRP testing going forward. For part b., MDHHS and DTMB will complete the necessary updates to the system security plans, including updating the risk assessments, and anticipate completion for all cited systems by July 1, 2025. MDHHS and DTMB anticipate that ATO renewals will be attained for all cited systems by August 30, 2025. Anticipated Completion Date a. September 30, 2025 b. August 30, 2025 Responsible Individual(s) Laura Visser, MDHHS Nathan Buckwalter, DTMB Lyndia Deromedi, MDHHS Heather Frick, DTMB Kasi Hunzinger, MDHHS Veronica Maxson, MDHHS Karen Scott, MDHHS Michelle Smith, MDHHS

View Audit 360209

Finding 567658 (2024-005)

Material Weakness 2024

State of Michigan

MI

Questioned Costs Eligibility Subrecipient Monitoring

Finding 2024-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., d., f., and g. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees that a process is not fully established to monitor the electronic notificat...

Finding 2024-005 Income Eligibility and Verification System Management Views MDHHS agrees with parts a., b., d., f., and g. of the finding. MDHHS disagrees with parts c. and e. of the finding. For part c., MDHHS disagrees 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 effect during fiscal year 2024 to help ensure monitoring of electronic notifications was taking place. Review of IEVS information is fully incorporated into the case read procedure governed by Bridges Administrative Manual 301 and detailed further in desk aids and reading guides. The MDHHS Economic Stability Administration (ESA) provides regular direction and reminders of case read requirements via ESA Memos. For part e., MDHHS disagrees that IEVS information is required to be requested and obtained for modified adjusted gross income (MAGI) based recipients since eligibility is verified upon determination through the MAGI eligibility determination process and then granted for a 12-month continuous eligibility period. Requesting and obtaining IEVS information throughout the eligibility period would be irrelevant since eligibility is continuous. Planned Corrective Action For parts a. and b., MDHHS ESA will continue to provide guidance and trainings to the local office specialists on utilizing the IEVS data timely and appropriately if the data is critical for current eligibility determinations. MDHHS ESA will also continue to review any technical automated solutions of the 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 subsidies recipients funded by Temporary Assistance for Needy Families (TANF). For part f., MDHHS worked with the Social Security Administration (SSA) to resolve a discrepancy in how the file was reported to DTMB by SSA and processed the fiscal year 2024 file during February 2025. For part g., MDHHS worked with the National Technical Information Service (NTIS) to regain access to the data during February 2024 and resume receiving the data monthly. Once access was re-established, NTIS sent a complete base file containing the data for the three months identified and the file exceeded the normal processing limit. MDHHS will work with DTMB to identify potential solutions and will process the complete file base by September 30, 2025. 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 f. Completed g. September 30, 2025 Responsible Individual(s) a., b., and c. Veronica Maxson, MDHHS d. Kathonya Rice, MDHHS e. Logan Dreasky, MDHHS f. Brant Cole, MDHHS g. Brant Cole, MDHHS Nathan Buckwalter, DTMB

View Audit 360209 Questioned Costs: $1

Finding 567657 (2024-004)

Significant Deficiency 2024

State of Michigan

MI

Internal Control / Segregation of Duties § 200.303

Finding 2024-004 Bridges Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS change control processes require a communication to be sent within three business days after each release that validates the changes to Bridges were applied as expect...

Finding 2024-004 Bridges Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS change control processes require a communication to be sent within three business days after each release that validates the changes to Bridges were applied as expected and this validation is documented and retained as part of the release close-out process. MDHHS added a checklist to immediate releases during April 2025 to help eliminate human error and ensure documentation of all post-implementation approvals is retained for each release. Anticipated Completion Date Completed Responsible Individual(s) Holly Roderick, MDHHS

View Audit 360209

Finding 567656 (2024-003)

Material Weakness 2024

State of Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.303

Finding 2024-003 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 except...

Finding 2024-003 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 (LOSCs). For parts a., c., and d., the Access Management Section began conducting quarterly reconciliations of DSA to the Bridges Integrated Automated Eligibility Determination System (Bridges) during the first quarter of fiscal year 2025. For part b., MDHHS is currently evaluating the feasibility of establishing a quarterly review process to help ensure documentation is maintained for a sample of LOSC monitoring reports. MDHHS anticipates completing the evaluation by September 30, 2025, and will determine an anticipated completion date for implementation, if necessary, at that time. 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. Anticipated Completion Date a., c., d., and e. Completed b. September 30, 2025 Responsible Individual(s) a., b., c., and d. Jim Bowen, MDHHS e. Veronica Maxson, MDHHS

View Audit 360209

Finding 567655 (2024-002)

Significant Deficiency 2024

State of Michigan

MI

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.334

Finding 2024-002 Bridges Interface Controls Management Views DTMB disagrees with the condition and the effect of the OAG’s finding. The OAG sampled 85 total files across eight interfaces. Of these, seven appeared to present issues. For five of the sampled files, detailed exception results no longer...

Finding 2024-002 Bridges Interface Controls Management Views DTMB disagrees with the condition and the effect of the OAG’s finding. The OAG sampled 85 total files across eight interfaces. Of these, seven appeared to present issues. For five of the sampled files, detailed exception results no longer existed. DTMB maintains summary tables for 10 years and purges detailed exception records at the beginning of each calendar year for anything older than 12 months. This purge process was communicated to the OAG during the fiscal year 2022 audit, and sampling was performed prior to purging for the fiscal year 2023 audit. When informed that the sample included files for which the detailed exception records had been purged, the OAG requested DTMB run a simulation processing of the original interface file in a testing environment to recreate detailed exception records. DTMB’s technical teams informed the OAG that rerunning in the current test environment would likely differ from the original results due to code changes that occurred in the test environment subsequent to when the original interface files were run in production. The OAG requested DTMB to proceed with rerunning the files in the current test environment. As a result, the OAG identified five instances where the detailed exception records from the simulation in the test environment did not exactly match the summary table from the original production interface results. For the 2 remaining files out of 85 (2.4 percent) that were cited, it should be clarified that the reconciliation being discussed is not data that was lost or misplaced between systems, but reconciliation of two exceptions correctly logged and correctly not counted in a summary report because they were alerts during processing, not errors that would be forwarded for review. These results do not present a significant deficiency in the ability of MDHHS to review the detailed exceptions. Also, these 2 records are insignificant when compared to the 11.6 million records processed in the 85 sampled files (0.000001 percent). Therefore, the current controls are reasonable to ensure that data processed from the source system to the receiving system is processed accurately, completely, and timely. Planned Corrective Action DTMB disagrees with the finding and does not intend to take further action. Anticipated Completion Date Not applicable Responsible Individual(s) Nathan Buckwalter, DTMB

View Audit 360209

Finding 567649 (2024-001)

Significant Deficiency 2024

Grameen Foundation

DC

Reporting Significant Deficiency § 200.512

View of Responsible Officials: Management carried out an after action review to identify the root cause of delays in completing the FY23 audit and timely filing of the single audit report packet. During FY24, we implemented strict timeline in completing the FY24 year end financial closing process an...

View of Responsible Officials: Management carried out an after action review to identify the root cause of delays in completing the FY23 audit and timely filing of the single audit report packet. During FY24, we implemented strict timeline in completing the FY24 year end financial closing process and accounts reconciliation. An overall Audit Coordinator was appointed and worked closely with the business process leads while Regional and Country Managers helped ensure completion of the FY24 field offices and affiliates audit reports prior to start of the global audit fieldwork. Timely filing of the single audit report packet for FY24 is a high organizational priority. While significant improvements were noted during the recent audit, management continues to identify ways to improve existing processes and ensure that any challenges encountered were assessed and action immediately taken to address them.

View Audit 360205

Finding 567648 (2024-001)

Significant Deficiency 2024

Monroe Community Mental Health Authority

MI

Procurement, Suspension & Debarment § 200.214 § 200.320

CORRECTIVE ACTION PLAN Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in Monroe Community Mental Health Authority’s (MCMHA) Single Audit report for the year ended September 30, 2024, and corrective actions to be complete...

CORRECTIVE ACTION PLAN Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in Monroe Community Mental Health Authority’s (MCMHA) Single Audit report for the year ended September 30, 2024, and corrective actions to be completed. Finding: 2024-001 – Procurement, Suspension and Debarment Auditor Description of Condition and Effect: The CMHSP did not document the noncompetitive procurement process pursuant to 2 CFR 200.320 prior to entering into a contract for services under the grant. Also, the CMHSP did not verify that the vendor was not suspended, debarred, or otherwise excluded or disqualified in accordance with 2 CFR requirements prior to entering into a contract for services under the grant. Auditor Recommendation: That the CMHSP review/update policies and procedures to ensure that formal procurement methods are documented, and verification of suspension, debarment, or exclusion is conducted prior to entering into a contract. Corrective Action: Management acknowledges the situation and is developing process and procedure to correct this going forward. Responsible People: Chief Financial Officer and Chief Operating Officer. Anticipated Completion Date: September 30, 2025

View Audit 360195

Finding 567644 (2024-001)

Material Weakness 2024

Neighborhood Housing Services of the Black Hills, Inc.

SD

Reporting Internal Control / Segregation of Duties

Finding #2024-001 – Preparation of Financial Statements and Schedule of Expenditures of Federal Awards (SEFA) and Audit Adjustments Responsible Individuals: Mike Walker (CEO) and Kathleen Burnham (Accountant) Corrective Action Plan: The Organization has accepted the risk associated with requesting t...

Finding #2024-001 – Preparation of Financial Statements and Schedule of Expenditures of Federal Awards (SEFA) and Audit Adjustments Responsible Individuals: Mike Walker (CEO) and Kathleen Burnham (Accountant) Corrective Action Plan: The Organization has accepted the risk associated with requesting the auditors to prepare the financial statements and SEFA and continues to plan for the auditors to prepare the reports. Due to the cost of hiring a full-time replacement staff accountant, the board of directors and management are willing to accept this degree of risk associated with financial statement and SEFA preparation and will assist with additional internal oversight to limit risk accordingly. Anticipated Completion Date: Ongoing

View Audit 360188

Finding 567641 (2024-002)

Significant Deficiency 2024

Tarrant County Samaritan Housing

TX

Questioned Costs Eligibility Significant Deficiency

Finding-002 Eligibility – Significant deficiency in internal control over compliance (Unit Inspection Documentation) Management Response Management acknowledges that this finding resulted in part from an over-reliance on partner organizations for performing initial and annual unit inspections, witho...

Finding-002 Eligibility – Significant deficiency in internal control over compliance (Unit Inspection Documentation) Management Response Management acknowledges that this finding resulted in part from an over-reliance on partner organizations for performing initial and annual unit inspections, without ensuring that full inspection documentation was consistently maintained in internal records. To address this, the following corrective actions have been implemented: •The Leasing Department and Support Services teams are now required to collect and retain copies of all unit inspection documentation (both initial move-in inspections and annual reinspection), even when performed by partner organizations. •A centralized tracking log for unit inspections has been created and will be maintained by the Program Director to monitor inspection status and ensure document retention for each client. •Program staff are required to upload inspection documents to a secure central drive and log inspection completion in the client case management database. •Quarterly reviews will be conducted by the Compliance team to ensure all required inspection documentation is properly retained and accessible. Training on these updated procedures will be conducted on June 10, 2025, with quarterly refresher trainings planned. Responsible Staff: Program Directors and Leasing Manager Implementation Date: June 2, 2025

View Audit 360187 Questioned Costs: $1

Finding 567640 (2024-001)

Significant Deficiency 2024

Tarrant County Samaritan Housing

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding-001 Allowable Activities – Significant deficiency in internal controls over compliance (HOPWA Payroll Allocation) Management Response The organization recognizes the importance of ensuring that payroll allocations are properly supported by approved documentation. To address this finding, the...

Finding-001 Allowable Activities – Significant deficiency in internal controls over compliance (HOPWA Payroll Allocation) Management Response The organization recognizes the importance of ensuring that payroll allocations are properly supported by approved documentation. To address this finding, the agency has implemented the following corrective actions: • Annual training on grant-specific timekeeping and payroll allocation requirements hasbeen instituted for all employees whose salaries are charged to grants. • Updated Standard Operating Procedures (SOPs) have been issued to program directorsand payroll administrators outlining the necessary approval and documentation processfor payroll allocations. • Supervisory review and certification of payroll allocation reports have been implementedto ensure compliance with approved grant allocations prior to payroll processing. Training sessions will be held on: June 10, 2025 • June 10, 2025 (initial training session for all HOPWA-funded staff) • Refresher training will be scheduled annually each June going forward. Responsible Staff: Controller and Program Directors Implementation Date: June 2, 2025

View Audit 360187 Questioned Costs: $1

Finding 567639 (2024-001)

Material Weakness 2024

Scripps Health and Affiliates

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended S...

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2024 Finding Reference Number: 2024-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of expenditures to support activities allowed or unallowed, allowable costs/cost principles, reporting and special tests and provisions related to amounts reimbursed for the project worksheet as it relates to the FEMA disposition requirements for COVID-19 related supplies. As a result, Management was reimbursed by FEMA for expenditures that were not in compliance with the FEMA disposition requirements which resulted in a questioned costs of $480,606. Corrective Action Plan: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reporting for reimbursement in the FEMA project worksheet comply with the FEMA disposition requirements. Management will work with FEMA to refund the questioned costs and discuss the extent of the additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: June 30, 2025

View Audit 360181 Questioned Costs: $1

Finding 567628 (2024-005)

Significant Deficiency 2024

Hias, Inc.

MD

Internal Control / Segregation of Duties Reporting Eligibility

Views of Responsible Officials: HIAS management accepts the recommendation and is implementing procedures to ensure that FFATA reports are submitted in a timely manner.

View Audit 360178

Corrective Action Plans

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