EIN: 364532682
UEI: D79JETZN6NX8
Audited by: Maner Costerisan
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on April 29, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by October 29, 2026 (55 days from today).
What is a management decision? →FAC accepted this audit on August 8, 2025 — management decision was due February 8, 2026.
The Organization's data collection form and the reporting package for the year ended September 30, 2024, were not submitted to the Federal Audit Clearinghouse (FAC) within a timely manner. Cause: Due to a delay in the year-end closing process the timing of the Uniform Guidance audit was delayed. The Organization did not submit the data collection form to the Federal Audit Clearinghouse (FAC) on time. Effect: The Organization’s data collection form and reporting package were not submitted, as required under Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Question Costs: $0 Recommendation: The Organization currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Management’s View: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.
Show full finding ▾Hide full finding ▴Finding 2024-001: Considered a significant deficiency Criteria: Under the audit requirements of Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), auditees are required to submit the data collection form and the reporting package to the FAC within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the end of the audit period. Condition: The Organization's data collection form and the reporting package for the year ended September 30, 2024, were not submitted to the Federal Audit Clearinghouse (FAC) within a timely manner. Cause: Due to a delay in the year-end closing process the timing of the Uniform Guidance audit was delayed. The Organization did not submit the data collection form to the Federal Audit Clearinghouse (FAC) on time. Effect: The Organization’s data collection form and reporting package were not submitted, as required under Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Question Costs: $0 Recommendation: The Organization currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Management’s View: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.
West MI Regional Medical Consortium respectfully submits the following corrective action plan for the year ended September 30, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended September 30, 2024 Organization Contact Person: Jerry Evans, MD; Medical Director The findings from the September 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding ‐ Federal audit Finding 2024‐001 ‐ Significant Deficiency Recommendation: West MI Regional Medical Consortium currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Action to be Taken: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.
FAC accepted this audit on June 28, 2024 — management decision was due December 28, 2024.
FAC accepted this audit on September 5, 2023 — management decision was due March 5, 2024.
The Organization's data collection form and the reporting package for the year ended September 30, 2022, were not submitted to the Federal Audit Clearinghouse (FAC) within a timely manner. Cause: Due to a delay in the year-end closing process the timing of the Uniform Guidance audit was delayed. The Organization did not submit the data collection form to the Federal Audit Clearinghouse (FAC) on time. Effect: The Organization?s data collection form and reporting package were not submitted, as required under Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Question Costs: $0 Recommendation: The Organization currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Management?s View: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.
Show full finding ▾Hide full finding ▴Finding 2022-002: Considered a significant deficiency Criteria: Under the audit requirements of Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), auditees are required to submit the data collection form and the reporting package to the FAC within the earlier of 30 calendar days after receipt of the auditor?s report or nine months after the end of the audit period. Condition: The Organization's data collection form and the reporting package for the year ended September 30, 2022, were not submitted to the Federal Audit Clearinghouse (FAC) within a timely manner. Cause: Due to a delay in the year-end closing process the timing of the Uniform Guidance audit was delayed. The Organization did not submit the data collection form to the Federal Audit Clearinghouse (FAC) on time. Effect: The Organization?s data collection form and reporting package were not submitted, as required under Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Question Costs: $0 Recommendation: The Organization currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Management?s View: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.
West MI Regional Medical Consortium respectfully submits the following corrective action plan for the year ended September 30, 2022. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended September 30, 2022 Organization Contact Person: Jerry Evans, MD; Medical Director The findings from the September 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding - Financial statement audit Finding 2022-001 - Material Weakness Recommendation: The Organization should implement an additional procedure to ensure that all subrecipient activity recognized in a given year accurately represent the activity of the organization. Action to be Taken: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future. Finding - Federal audit Finding 2022-002 - Significant Deficiency Recommendation: West MI Regional Medical Consortium currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Action to be Taken: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.
FAC accepted this audit on February 7, 2023 — management decision was due August 7, 2023.
During our detailed testing of cash disbursements to grant subrecipients, it was noted that the Organization?s subrecipients were often delayed in their submission of invoices to the Organization for reimbursement for allowable activities under the grant program. As a result, grant expenses were not recorded in the proper fiscal years. Context: The Homeland Security grant allows subrecipients to submit invoices for reimbursement to the pass-through agency at any point during the three-year grant period, even if the expenditures take place outside of the fiscal year. Certain immaterial subrecipient invoices were unknowingly excluded from the prior year?s accounting records because the Organization received them after the prior fiscal year was closed. Additionally, material adjustments were required to the current fiscal year accounting records for subrecipient invoices that were incorrectly recorded to the subsequent fiscal year?s accounting records. Effect: Material adjustments were required to accounting records for the current year. Cause: The Organization did not have subrecipient monitoring procedures in place to require the timely submission of subrecipient invoices for reimbursement. The Organization outsources the accounting function, and a significant number of subrecipient invoices were recorded in the incorrect fiscal years. The Organization did not maintain proper oversight, which caused the errors to go undetected. Repeat Finding: This is not a repeat finding. Recommendation: Even though the grant agreement permits a wide reimbursement timeframe for subrecipients, the Organization should develop and enforce subrecipient monitoring procedures that require subrecipients to submit invoices for reimbursement no later than on a quarterly basis. This will enable the Organization to be accurate in the recording of grant activities and improve the completeness and accuracy of accounting records. Views of Responsible Officials: The Organization agrees with this finding.
Show full finding ▾Hide full finding ▴Finding 2021-006: MATERIAL WEAKNESS?Homeland Security Grant Program Subrecipient Monitoring Procedures U.S. Department of Homeland Security Pass-through Entity: Michigan Department of State Police, Emergency Management and Homeland Security Division Assistance Listing Number: 97.067 Award Numbers: EMW-2017-SS-00013, EMW-2018-SS-00042, EMW-2019-SS-00021 and EMW-2020-SS-00044-S01 Award Year Ends: December 31, 2020, August 31, 2021, May 31, 2022, and May 31, 2023 Specific Requirement: (M.) Subrecipient Monitoring Criteria: Section 200.331 (d) of the Cost Principles of the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires a pass-through entity to monitor the activities of subrecipients as necessary to ensure that subawards are used for authorized purpose, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that the subaward performance goals are achieved. Pass-through entity monitoring of the subrecipient must include a timely review of all financial and performance reports as required by the pass-through entity. Questioned Costs: None. Condition: During our detailed testing of cash disbursements to grant subrecipients, it was noted that the Organization?s subrecipients were often delayed in their submission of invoices to the Organization for reimbursement for allowable activities under the grant program. As a result, grant expenses were not recorded in the proper fiscal years. Context: The Homeland Security grant allows subrecipients to submit invoices for reimbursement to the pass-through agency at any point during the three-year grant period, even if the expenditures take place outside of the fiscal year. Certain immaterial subrecipient invoices were unknowingly excluded from the prior year?s accounting records because the Organization received them after the prior fiscal year was closed. Additionally, material adjustments were required to the current fiscal year accounting records for subrecipient invoices that were incorrectly recorded to the subsequent fiscal year?s accounting records. Effect: Material adjustments were required to accounting records for the current year. Cause: The Organization did not have subrecipient monitoring procedures in place to require the timely submission of subrecipient invoices for reimbursement. The Organization outsources the accounting function, and a significant number of subrecipient invoices were recorded in the incorrect fiscal years. The Organization did not maintain proper oversight, which caused the errors to go undetected. Repeat Finding: This is not a repeat finding. Recommendation: Even though the grant agreement permits a wide reimbursement timeframe for subrecipients, the Organization should develop and enforce subrecipient monitoring procedures that require subrecipients to submit invoices for reimbursement no later than on a quarterly basis. This will enable the Organization to be accurate in the recording of grant activities and improve the completeness and accuracy of accounting records. Views of Responsible Officials: The Organization agrees with this finding.
Finding 2021-006: MATERIAL WEAKNESS?Homeland Security Grant Program Subrecipient Monitoring Procedures U.S. Department of Homeland Security Pass-through Entity: Michigan Department of State Police, Emergency Management and Homeland Security Division Assistance Listing Number: 97.067 Award Numbers: EMW-2017-SS-00013, EMW-2018-SS-00042, EMW-2019-SS-00021 and EMW-2020-SS-00044-S01 Award Year Ends: December 31, 2020, August 31, 2021, May 31, 2022, and May 31, 2023 Recommendation: Even though the grant agreement permits a wide reimbursement timeframe for subrecipients, the Organization should develop and enforce subrecipient monitoring procedures that require subrecipients to submit invoices for reimbursement no later than on a quarterly basis. This will enable the Organization to be accurate in the recording of grant activities and improve the completeness and accuracy of accounting records. Action Taken: The Organization will work to create and implement a process that requires grant partners/recipients to turn financial documentation to us in a timely and consistent timeframe. The Organization will issue 90 day reminders and 180 day documentation requests. Responsible Person and Anticipated Completion Date: Medical Director, September 30, 2023.
During our detailed testing of cash disbursements for the HPP program, we noted that the check registers detailing the account distributions were not approved prior to the issuance of the cash disbursement checks. Context: Of the 40 cash disbursements selected for testing, 16 transactions tested were missing documented approval of the processed check registers, which includes approval of the accounting periods and account distributions. The sample was not a statistically valid sample. Effect: Failure to properly approve check registers and account distributions prior to payment could result in excess costs being charged to the grant program, the misappropriation of assets, and inaccuracy in the accounting records. Cause: The Organization did not properly follow its established control to review the check registers with documented approval prior to payment. Repeat Finding: This is not a repeat finding. Recommendation: The Organization should closely follow its established cash disbursements policy for an appropriate level of management to review the check registers with documented approval prior to the issuance of payments. Views of Responsible Officials: The Organization agrees with this finding.
Show full finding ▾Hide full finding ▴Finding 2021-007: National Bioterrorism Hospital Preparedness Program (HPP) Cash Disbursements Procedures U.S. Department of Health and Human Services Pass-through Entity: Michigan Department of Community Health Assistance Listing Number: 93.889 Award Numbers: E20212576-001, COVID-19 #1 E20214049-001, COVID-19 #2 E20214050-001, E20215009-001, E20213467-001, COVID-19 #1 E20214088-001, COVID-19 #2 E20214291-001 and E20215011-00 Award Year Ends: June 30, 2021 and September 30, 2021 Specific Requirement: (A.) Activities Allowed or Unallowed, (B.) Allowable Costs/Cost Principles, (H.) Period of Performance, (I.) Procurement Criteria: Section 200.303 of the Cost Principles of the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires a non-Federal entity to establish and maintain effective internal control over the Federal award that provides a reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with the specified guidance that requires proper segregation of duties by dividing key responsibilities among different people to reduce the risk of error or fraud. This should include separating the responsibilities for authorizing transactions, processing and recording them, reviewing the transactions, and handling any related assets. No one individual should control all key aspects of a transaction or event. In addition, this guidance also requires transactions and internal controls to be clearly documented, and the records should be properly maintained and readily available for examination. Questioned Costs: None. Condition: During our detailed testing of cash disbursements for the HPP program, we noted that the check registers detailing the account distributions were not approved prior to the issuance of the cash disbursement checks. Context: Of the 40 cash disbursements selected for testing, 16 transactions tested were missing documented approval of the processed check registers, which includes approval of the accounting periods and account distributions. The sample was not a statistically valid sample. Effect: Failure to properly approve check registers and account distributions prior to payment could result in excess costs being charged to the grant program, the misappropriation of assets, and inaccuracy in the accounting records. Cause: The Organization did not properly follow its established control to review the check registers with documented approval prior to payment. Repeat Finding: This is not a repeat finding. Recommendation: The Organization should closely follow its established cash disbursements policy for an appropriate level of management to review the check registers with documented approval prior to the issuance of payments. Views of Responsible Officials: The Organization agrees with this finding.
Finding 2021-007: National Bioterrorism Hospital Preparedness Program (HPP) Cash Disbursements Procedures U.S. Department of Health and Human Services Pass-through Entity: Michigan Department of Community Health Assistance Listing Number: 93.889 Award Numbers: E20212576-001, COVID-19 #1 E20214049-001, COVID-19 #2 E20214050-001, E20215009-001, E20213467-001, COVID-19 #1 E20214088-001, COVID-19 #2 E20214291-001 and E20215011-00 Award Year Ends: June 30, 2021 and September 30, 2021 Recommendation: The Organization should closely follow its established cash disbursements policy for an appropriate level of management to review the check registers with documented approval prior to the issuance of payments. Action Taken: The Organization will update internal control documentation to reflect automatic bill pay processes, as check registers are no longer utilized. The Organization will also implement a process to document constant review of all accounts payable after processed by accounting. Responsible Person and Anticipated Completion Date: Medical Director, September 30, 2023.
The equipment listings maintained by the Organization for assets acquired with federal funds were lacking certain required elements and certain assets could not be located during the physical inventory observation. A control system has not been fully implemented to safeguard the equipment to prevent loss, damage or theft and promptly investigate missing items. Context: The Organization maintains separate asset listings for property owned by Region 6 and Region 7. We noted that these listings properly contained descriptions of the property, Federal funding sources, acquisition dates, and cost of the property. However, for certain assets, the equipment listings were lacking identification numbers, allocations or percentages of Federal participation in the projects costs for the Federal awards under which the property was acquired, or the locations, uses and conditions of the property as required. In addition, while a physical inventory was performed for Region 6 and Region 7 assets within the required two-year time span, a reconciliation of the observation results with the property records revealed that some assets could not be located. It was later determined that all assets are not securely maintained with access restricted to authorized users. However, due to the COVID-19 pandemic, the inventory discrepancies have not yet been investigated, and the existence of these assets is still unknown. The sample was not a statistically valid sample, and the matter appears to be a pervasive. Effect: Failure to secure fixed assets and restrict access to authorized individuals, failure to maintain adequate detailed equipment records with all of the required elements, failure to perform a physical inventory of the property, and failure to reconcile the inventory results with the property records could lead to the loss or misappropriation of these assets. Cause: The Consortium did not have proper policies and procedures in place to ensure the following: fixed assets acquired with federal funds are secured with access restricted to authorized individuals, adequate detailed equipment records with specified elements are maintained, physical inventory of the property, including asset location and condition, is properly documented, and the results are reconciled with the property records at least once every two years. In addition, the COVID-19 pandemic restrictions prevented Consortium personnel from accessing the necessary buildings to investigate the missing equipment and determine its existence and condition, if applicable. Repeat Finding: A similar finding was reported during the single audit for the year ended September 30, 2020. Recommendation: The Organization should establish procedures to require the security of fixed assets acquired with federal funds and limit access to authorized individuals and timely investigate any suspected losses. In addition, the Organization should maintain detailed equipment records that include all of the specified elements, perform a physical inventory of the property, and reconcile the results with the property records at least once every two years. Views of Responsible Officials: The Organization agrees with this finding.
Show full finding ▾Hide full finding ▴Finding 2021-008: National Bioterrorism Hospital Preparedness Program (HPP) Equipment Procedures U.S. Department of Health and Human Services Pass-through Entity: Michigan Department of Community Health Assistance Listing Number: 93.889 Award Numbers: E20212576-001, COVID-19 #1 E20214049-001, COVID-19 #2 E20214050-001, E20215009-001, E20213467-001, COVID-19 #1 E20214088-001, COVID-19 #2 E20214291-001 and E20215011-00 Award Year Ends: June 30, 2021 and September 30, 2021 Specific Requirements: (F.) Equipment Criteria: Section 200.313(d) of the Cost Principles of the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires a non-Federal entity to (1) maintain property records that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds the title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property, (2) perform a physical inventory of the property and reconcile the results with the property records at least once every two years, (3) develop a control system to ensure adequate safeguards to prevent loss, damage, or theft of the property with any suspected loss, damage or theft investigated. Questioned Costs: None. Condition: The equipment listings maintained by the Organization for assets acquired with federal funds were lacking certain required elements and certain assets could not be located during the physical inventory observation. A control system has not been fully implemented to safeguard the equipment to prevent loss, damage or theft and promptly investigate missing items. Context: The Organization maintains separate asset listings for property owned by Region 6 and Region 7. We noted that these listings properly contained descriptions of the property, Federal funding sources, acquisition dates, and cost of the property. However, for certain assets, the equipment listings were lacking identification numbers, allocations or percentages of Federal participation in the projects costs for the Federal awards under which the property was acquired, or the locations, uses and conditions of the property as required. In addition, while a physical inventory was performed for Region 6 and Region 7 assets within the required two-year time span, a reconciliation of the observation results with the property records revealed that some assets could not be located. It was later determined that all assets are not securely maintained with access restricted to authorized users. However, due to the COVID-19 pandemic, the inventory discrepancies have not yet been investigated, and the existence of these assets is still unknown. The sample was not a statistically valid sample, and the matter appears to be a pervasive. Effect: Failure to secure fixed assets and restrict access to authorized individuals, failure to maintain adequate detailed equipment records with all of the required elements, failure to perform a physical inventory of the property, and failure to reconcile the inventory results with the property records could lead to the loss or misappropriation of these assets. Cause: The Consortium did not have proper policies and procedures in place to ensure the following: fixed assets acquired with federal funds are secured with access restricted to authorized individuals, adequate detailed equipment records with specified elements are maintained, physical inventory of the property, including asset location and condition, is properly documented, and the results are reconciled with the property records at least once every two years. In addition, the COVID-19 pandemic restrictions prevented Consortium personnel from accessing the necessary buildings to investigate the missing equipment and determine its existence and condition, if applicable. Repeat Finding: A similar finding was reported during the single audit for the year ended September 30, 2020. Recommendation: The Organization should establish procedures to require the security of fixed assets acquired with federal funds and limit access to authorized individuals and timely investigate any suspected losses. In addition, the Organization should maintain detailed equipment records that include all of the specified elements, perform a physical inventory of the property, and reconcile the results with the property records at least once every two years. Views of Responsible Officials: The Organization agrees with this finding.
Finding 2021-008: National Bioterrorism Hospital Preparedness Program (HPP) Equipment Procedures U.S. Department of Health and Human Services Pass-through Entity: Michigan Department of Community Health Assistance Listing Number: 93.889 Award Numbers: E20212576-001, COVID-19 #1 E20214049-001, COVID-19 #2 E20214050-001, E20215009-001, E20213467-001, COVID-19 #1 E20214088-001, COVID-19 #2 E20214291-001 and E20215011-00 Award Year Ends: June 30, 2021 and September 30, 2021 Recommendation: The Organization should establish procedures to require the security of fixed assets acquired with federal funds and limit access to authorized individuals and timely investigate any suspected losses. In addition, the Organization should maintain detailed equipment records that include all of the specified elements, perform a physical inventory of the property, and reconcile the results with the property records at least once every two years. Action Taken: The Organization will be revisiting and revamping all internal controls, processes and procedures related to equipment and fixed asset tracking, monitoring, and maintenance. Detailed records will be maintained, and physical inventory conducted every two years. Responsible Person and Anticipated Completion Date: Medical Director, September 30, 2023.
2020-001
During our detailed testing of suspension and debarment for the HPP program, we noted that the Organization did not verify that its contractors and vendors receiving payments in excess of $25,000 were not suspended or debarred prior to doing business with them. Context: Fifteen vendors charged to the HPP program received payments totaling in excess of the $25,000 testing threshold during the fiscal year. For the four vendors selected for testing, the Organization did not perform the necessary suspension or debarment testing prior to doing business with them. Subsequent vendor searches on the Federal System for Award Management (SAM.gov) website indicated that none of these vendors were ineligible for participation in federal assistance programs or activities. Effect: Failure to verify the status of contractors and vendors prior to entering into business contracts or transactions that equal or exceed $25,000 could result in business activities with ineligible vendors and disallowed federal program expenditures. Cause: The Organization did not have an established procedure in place for verifying that its contractors and vendors were not suspended or debarred prior to entering into business contracts or transactions that equaled or exceeded $25,000. Repeat Finding: This is not a repeat finding. Recommendation: The Organization should establish and adhere to suspension and debarment procedures for verifying the eligibility of its contractors and vendors prior to entering into business contracts or transactions that equal or exceed $25,000 in value. In addition, the Organization should retain supporting documentation of these verifications performed, such as the printing of vendor search results from the SAM.gov website. Views of Responsible Officials: The Organization agrees with this finding.
Show full finding ▾Hide full finding ▴Finding 2021-009: National Bioterrorism Hospital Preparedness Program (HPP) Suspension and Debarment Procedures U.S. Department of Health and Human Services Pass-through Entity: Michigan Department of Community Health Assistance Listing Number: 93.889 Award Numbers: E20212576-001, COVID-19 #1 E20214049-001, COVID-19 #2 E20214050-001, E20215009-001, E20213467-001, COVID-19 #1 E20214088-001, COVID-19 #2 E20214291-001 and E20215011-00 Award Year Ends: June 30, 2021 and September 30, 2021 Specific Requirement: (I.) Suspension and Debarment Criteria: Section 200.214 of the Cost Principles of the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) restricts awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. This guidance requires a non-federal entity to establish policies and procedures for verifying the status of contractors and vendors whenever the value of a contract or cumulative transactions is expected to equal or exceed $25,000 to protect the federal government from fraud, waste and abuse. Questioned Costs: None. Condition: During our detailed testing of suspension and debarment for the HPP program, we noted that the Organization did not verify that its contractors and vendors receiving payments in excess of $25,000 were not suspended or debarred prior to doing business with them. Context: Fifteen vendors charged to the HPP program received payments totaling in excess of the $25,000 testing threshold during the fiscal year. For the four vendors selected for testing, the Organization did not perform the necessary suspension or debarment testing prior to doing business with them. Subsequent vendor searches on the Federal System for Award Management (SAM.gov) website indicated that none of these vendors were ineligible for participation in federal assistance programs or activities. Effect: Failure to verify the status of contractors and vendors prior to entering into business contracts or transactions that equal or exceed $25,000 could result in business activities with ineligible vendors and disallowed federal program expenditures. Cause: The Organization did not have an established procedure in place for verifying that its contractors and vendors were not suspended or debarred prior to entering into business contracts or transactions that equaled or exceeded $25,000. Repeat Finding: This is not a repeat finding. Recommendation: The Organization should establish and adhere to suspension and debarment procedures for verifying the eligibility of its contractors and vendors prior to entering into business contracts or transactions that equal or exceed $25,000 in value. In addition, the Organization should retain supporting documentation of these verifications performed, such as the printing of vendor search results from the SAM.gov website. Views of Responsible Officials: The Organization agrees with this finding.
Finding 2021-009: National Bioterrorism Hospital Preparedness Program (HPP) Suspension and Debarment Procedures U.S. Department of Health and Human Services Pass-through Entity: Michigan Department of Community Health Assistance Listing Number: 93.889 Award Numbers: E20212576-001, COVID-19 #1 E20214049-001, COVID-19 #2 E20214050-001, E20215009-001, E20213467-001, COVID-19 #1 E20214088-001, COVID-19 #2 E20214291-001 and E20215011-00 Award Year Ends: June 30, 2021 and September 30, 2021 Recommendation: The Organization should establish and adhere to suspension and debarment procedures for verifying the eligibility of its contractors and vendors prior to entering into business contracts or transactions that equal or exceed $25,000 in value. In addition, the Organization should retain supporting documentation of these verifications performed, such as the printing of vendor search results from the SAM.gov website. Action Taken: The Organization will create and implement an internal control procedure for consistent checking and documentation of verifying the eligibility of contractors and vendors prior to conducting business over $25,000. Responsible Person and Anticipated Completion Date: Medical Director, September 30, 2023. If the Michigan Department of Community Health has questions regarding this plan, please call Dr. Jerry Evans at (231) 728-1967.
FAC accepted this audit on April 6, 2021 — management decision was due October 6, 2021.
The equipment listings maintained by the Consortium for assets acquired with federal funds were lacking certain required elements, and certain fixed assets could not be located during the physical inventory process. A control system has not been fully implemented to safeguard the equipment to prevent loss, damage or theft and promptly investigate missing items. Context: The Consortium maintains separate equipment listings for property owned by Region 6 and Region 7. We noted that these equipment listings properly contained descriptions of the property, federal funding sources, acquisition dates, and cost of the property. However, for certain assets, the equipment listings were lacking identification numbers, allocations or percentages of Federal participation in the projects costs for the Federal awards under which the property was acquired, or the locations, uses and conditions of the property as required. In addition, while a physical inventory was performed for Region 6 and Region 7 assets within the required two-year time span, a reconciliation of the observation results with the property records revealed that some assets could not be located. It was later determined that all assets are not securely maintained with access restricted to authorized users. However, due to the COVID-19 pandemic, the inventory discrepancies have not yet been investigated, and the existence of these assets is still unknown. The sample was not a statistically valid sample, and the matter appears to be a systemic condition. Effect: Failure to secure fixed assets and restrict access to authorized individuals, failure to maintain adequate detailed equipment records with all of the required elements, failure to perform a physical inventory of the property, and failure to reconcile the inventory results with the property records could lead to the loss or misappropriation of these assets. Cause: The Consortium did not have proper policies and procedures in place to ensure the following: fixed assets acquired with federal funds are secured with access restricted to authorized individuals, adequate detailed equipment records with specified elements are maintained, physical inventory of the property, including asset location and condition, is properly documented, and the results are reconciled with the property records at least once every two years. In addition, the COVID-19 pandemic restrictions prevented Consortium personnel from accessing the necessary buildings to investigate the missing equipment and determine its existence and condition, if applicable. Repeat Finding: A similar finding was reported during the single audit for the year ended September 30, 2019. Recommendation: The Consortium should establish procedures to require the security of fixed assets acquired with federal funds and limit access to authorized individuals and timely investigate any suspected losses. In addition, the Consortium should maintain detailed equipment records that include all of the specified elements, perform a physical inventory of the property, and reconcile the results with the property records at least once every two years. Views of Responsible Officials: The Consortium agrees with this finding.
Show full finding ▾Hide full finding ▴U.S. Department of Health and Human Services Pass-through Entity: Michigan Department of Community Health CFDA: 93.889 Award Numbers: E20200686-003 and E20200687-003 Award Year End: September 30, 2020 Specific Requirements: Equipment Criteria: Section 200.313(d) of the Cost Principles of the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires a non-Federal entity to (1) maintain property records that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds the title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property, (2) perform a physical inventory of the property and reconcile the results with the property records at least once every two years, (3) develop a control system to ensure adequate safeguards to prevent loss, damage, or theft of the property with any suspected loss, damage or theft investigated. Questioned Costs: None. Condition: The equipment listings maintained by the Consortium for assets acquired with federal funds were lacking certain required elements, and certain fixed assets could not be located during the physical inventory process. A control system has not been fully implemented to safeguard the equipment to prevent loss, damage or theft and promptly investigate missing items. Context: The Consortium maintains separate equipment listings for property owned by Region 6 and Region 7. We noted that these equipment listings properly contained descriptions of the property, federal funding sources, acquisition dates, and cost of the property. However, for certain assets, the equipment listings were lacking identification numbers, allocations or percentages of Federal participation in the projects costs for the Federal awards under which the property was acquired, or the locations, uses and conditions of the property as required. In addition, while a physical inventory was performed for Region 6 and Region 7 assets within the required two-year time span, a reconciliation of the observation results with the property records revealed that some assets could not be located. It was later determined that all assets are not securely maintained with access restricted to authorized users. However, due to the COVID-19 pandemic, the inventory discrepancies have not yet been investigated, and the existence of these assets is still unknown. The sample was not a statistically valid sample, and the matter appears to be a systemic condition. Effect: Failure to secure fixed assets and restrict access to authorized individuals, failure to maintain adequate detailed equipment records with all of the required elements, failure to perform a physical inventory of the property, and failure to reconcile the inventory results with the property records could lead to the loss or misappropriation of these assets. Cause: The Consortium did not have proper policies and procedures in place to ensure the following: fixed assets acquired with federal funds are secured with access restricted to authorized individuals, adequate detailed equipment records with specified elements are maintained, physical inventory of the property, including asset location and condition, is properly documented, and the results are reconciled with the property records at least once every two years. In addition, the COVID-19 pandemic restrictions prevented Consortium personnel from accessing the necessary buildings to investigate the missing equipment and determine its existence and condition, if applicable. Repeat Finding: A similar finding was reported during the single audit for the year ended September 30, 2019. Recommendation: The Consortium should establish procedures to require the security of fixed assets acquired with federal funds and limit access to authorized individuals and timely investigate any suspected losses. In addition, the Consortium should maintain detailed equipment records that include all of the specified elements, perform a physical inventory of the property, and reconcile the results with the property records at least once every two years. Views of Responsible Officials: The Consortium agrees with this finding.
U.S. Department of Health and Human Services Pass-through Entity: Michigan Department of Community Health CFDA: 93.889 Award Numbers: E20200686-003 and E20200687-003 Award Year Ends: September 30, 2020 Recommendation: The Consortium should establish procedures to require the security of fixed assets acquired with federal funds and limit access to authorized individuals and timely investigate any suspected losses. In addition, the Consortium should maintain detailed equipment records that include all of the specified elements, perform a physical inventory of the property, and reconcile the results with the property records at least once every two years. Action Taken: The Consortium, working cooperatively with the Michigan Department of Community Health, has acquired a software program for maintenance of a fixed asset inventory process. The process put in place covers all elements and requirements of federal grant guidance, and federal code of regulations. The Consortium will investigate all potential losses of equipment and the fixed asset detail will be meticulously maintained with a physical inventory performed at least once every two years. Responsible Person and Anticipated Completion Date: Medical Director, September 30, 2021.
2019-001
There is no internal control procedure in place requiring a documented review and approval of semi-annual and annual reports filed under the Homeland Security Grant Program reporting function. Context: Of the four semi-annual reports filed under the Homeland Security Grant Program during the fiscal year, the two reports tested were not reviewed with documented approval prior to submission. In addition, the annual report tested under the Homeland Security Grant Program was also lacking documented review and approval prior to submission. However, the invoices and monthly reports from which the reports were prepared were reviewed with documented approval by the Medical Director. The sample was not a statistically valid sample, and the matter appears to be a systemic condition. Effect: The lack of documented review and approval of semi-annual and annual reports could allow errors with the reports to go undetected. Cause: The Consortium was unaware of the requirement to review all reports with documented approval prior to submission. Repeat Finding: This is not a repeat finding. Recommendation: Documented review and approval should be performed prior to the filing of all semi-annual and annual reports for the Homeland Security Grant Program. Views of Responsible Officials: The Consortium agrees with this finding.
Show full finding ▾Hide full finding ▴U.S. Department of Homeland Security Pass-through Entity: Michigan State Police CFDA: 97.067 Award Numbers: EMW-2017-SS-00013 and EMW-2018-SS-00042 Award Year End: May 31, 2020 and May 31, 2021 Specific Requirements: Reporting Criteria: Section 200.303a of the Cost Principles of the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires a non-Federal entity to establish and maintain effective internal control over the federal award to provide reasonable assurance regarding the achievement of objectives in the following categories: 1) Effectiveness and efficiency of operations, 2) Reliability of financial reporting, and 3) Compliance with applicable laws and regulations. Questioned Costs: None. Condition: There is no internal control procedure in place requiring a documented review and approval of semi-annual and annual reports filed under the Homeland Security Grant Program reporting function. Context: Of the four semi-annual reports filed under the Homeland Security Grant Program during the fiscal year, the two reports tested were not reviewed with documented approval prior to submission. In addition, the annual report tested under the Homeland Security Grant Program was also lacking documented review and approval prior to submission. However, the invoices and monthly reports from which the reports were prepared were reviewed with documented approval by the Medical Director. The sample was not a statistically valid sample, and the matter appears to be a systemic condition. Effect: The lack of documented review and approval of semi-annual and annual reports could allow errors with the reports to go undetected. Cause: The Consortium was unaware of the requirement to review all reports with documented approval prior to submission. Repeat Finding: This is not a repeat finding. Recommendation: Documented review and approval should be performed prior to the filing of all semi-annual and annual reports for the Homeland Security Grant Program. Views of Responsible Officials: The Consortium agrees with this finding.
U.S. Department of Homeland Security Pass-through Entity: Michigan State Police CDFA: 97.067 Award Numbers: EMW-2017-SS-00013 and EMW-2018-SS-00042 Award Year End: May 31, 2020 and May 31, 2021 Recommendation: Documented review and approval should be performed prior to the filing of all semi-annual and annual reports for the Homeland Security Grant Program. Action Taken: The Office Manager will create a Signature Page that will be attached to all semi-annual and annual reports for the Homeland Security Grant Program. This page will be signed by the Medical Director after reviewing the semi-annual and annual reports to document his approval and prior to the Office Manager?s submission to the State. Responsible Person and Anticipated Completion Date: Office Manager, March 31, 2021.
FAC accepted this audit on October 20, 2020 — management decision was due April 20, 2021.
The equipment listings maintained by the Consortium were lacking certain required elements. In addition, a physical inventory of the property was not performed and documented, and the results were not reconciled with the property records as required. Context: The Consortium maintains separate equipment listings for property owned by Region 6 and Region 7. We noted that these equipment listings properly contained descriptions of the property, identification numbers, acquisition dates, and cost of the property. However, for certain assets, the equipment listings were lacking the sources of funding for the property, percentages of Federal participation in the projects costs for the Federal awards under which the property was acquired, the locations, uses and conditions of the property as required. In addition, the Consortium did not perform and document a physical inventory of the property and reconcile the results with the property records at least once every two years as required. The sample was not a statistically valid sample, and the matter appears to be a systemic condition. Effect: Failure to maintain adequate detailed equipment records with all of the required elements, failure to perform a physical inventory of the property, and failure to reconcile the inventory results with the property records could lead to the loss or misappropriation of these assets. Cause: The Consortium was unaware of the requirements to maintain adequate detailed equipment records with specified elements, perform a physical inventory of the property and reconcile the results with the property records at least once every two years when this finding was provided at the conclusion of the 2018 audit. As a result, the Consortium did not have proper policies and procedures in place to ensure that these required steps were completed. The Consortium did not have time to complete a physical inventory before September 30, 2019. Repeat Finding: A similar finding was reported during the single audit for the year ended September 30, 2018. Recommendation: The Consortium should establish procedures to require the maintenance of detailed equipment records that include all of the specified elements. In addition, the Consortium should perform a physical inventory of the property and reconcile the results with the property records at least once every two years. Views of Responsible Officials: The Consortium agrees with this finding.
Show full finding ▾Hide full finding ▴U.S. Department of Health and Human Services Finding 2019-001: National Bioterrorism Hospital Preparedness Program (HPP) Equipment Procedures Pass-through entity: Michigan Department of Community Health CFDA: 93.889 Award Numbers: E20192761-003 and E20192762-003 Award Year Ends: September 30, 2019 Specific Requirements: Equipment Criteria: Section 200.313(d) of the Cost Principles of the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires a non-Federal entity to (1) maintain property records that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds the title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property and (2) perform a physical inventory of the property and reconcile the results with the property records at least once every two years. Questioned Costs: None. Condition: The equipment listings maintained by the Consortium were lacking certain required elements. In addition, a physical inventory of the property was not performed and documented, and the results were not reconciled with the property records as required. Context: The Consortium maintains separate equipment listings for property owned by Region 6 and Region 7. We noted that these equipment listings properly contained descriptions of the property, identification numbers, acquisition dates, and cost of the property. However, for certain assets, the equipment listings were lacking the sources of funding for the property, percentages of Federal participation in the projects costs for the Federal awards under which the property was acquired, the locations, uses and conditions of the property as required. In addition, the Consortium did not perform and document a physical inventory of the property and reconcile the results with the property records at least once every two years as required. The sample was not a statistically valid sample, and the matter appears to be a systemic condition. Effect: Failure to maintain adequate detailed equipment records with all of the required elements, failure to perform a physical inventory of the property, and failure to reconcile the inventory results with the property records could lead to the loss or misappropriation of these assets. Cause: The Consortium was unaware of the requirements to maintain adequate detailed equipment records with specified elements, perform a physical inventory of the property and reconcile the results with the property records at least once every two years when this finding was provided at the conclusion of the 2018 audit. As a result, the Consortium did not have proper policies and procedures in place to ensure that these required steps were completed. The Consortium did not have time to complete a physical inventory before September 30, 2019. Repeat Finding: A similar finding was reported during the single audit for the year ended September 30, 2018. Recommendation: The Consortium should establish procedures to require the maintenance of detailed equipment records that include all of the specified elements. In addition, the Consortium should perform a physical inventory of the property and reconcile the results with the property records at least once every two years. Views of Responsible Officials: The Consortium agrees with this finding.
Finding 2019-001: U.S. Department of Health and Human Services Finding 2018-001: National Bioterrorism Hospital Preparedness Program (HPP) Equipment Procedures Pass-through entity: Michigan Department of Community Health CFDA: 93.889 Award Numbers: E20192761-003 and E20192762-003 Award Year Ends: September 30, 2019 Recommendation: The Consortium should establish procedures to require the maintenance of detailed equipment records that include all of the specified elements. In addition, the Consortium should perform a physical inventory of the property and reconcile the results with the property records at least once every two years. Action Taken: The Consortium has started and completed a majority of a detailed equipment inventory process subsequent to year-end. The Consortium will continue to work on completing the detailed inventory of all equipment, which will be meticulously maintained, with a physical inventory performed at least once every two years. Responsible Person and Anticipated Completion Date: Office Manager, September 30, 2020
2018-001
FAC accepted this audit on June 25, 2019 — management decision was due December 25, 2019.
GSA_MIGRATION
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GSA_MIGRATION
FAC accepted this audit on March 22, 2018 — management decision was due September 22, 2018.
FAC accepted this audit on February 22, 2017 — management decision was due August 22, 2017.
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