HomeMy WebLinkAboutResolutions - 2024.09.05 - 41456
AGENDA ITEM: Application to the Michigan Department of Health and Human Services for FY 2025
Pontiac Integrated Urgent Care
DEPARTMENT: Health & Human Services - Health Division
MEETING: Board of Commissioners
DATE: Thursday, September 5, 2024 9:42 PM - Click to View Agenda
ITEM SUMMARY SHEET
COMMITTEE REPORT TO BOARD
Resolution #2024-4301
Motion to approve the application submission to the Michigan Department of Health and Human
Services for the FY 2025 Pontiac Integrated Urgent Care Agreement within the amount of
$1,000,000 for the period October 1, 2024 through September 30, 2025.
ITEM CATEGORY SPONSORED BY
Grant Penny Luebs
INTRODUCTION AND BACKGROUND
The integrated urgent care will provide the ability for individuals to receive improved access to
primary care and behavioral health services. Target population includes those experiencing medical
and/or mental health concerns regardless of insurance/ability to pay. The center would provide
integrated services on an urgent basis with same-day appointments with a Primary Care Provider
(PCP). Mental health triage by a behavioral health consultant is also available if needed, as well as
referrals to a psychiatric nurse practitioner.
POLICY ANALYSIS
BUDGET AMENDMENT REQUIRED: No
Committee members can contact Barbara Winter, Policy and Fiscal Analysis Supervisor at
248.821.3065 or winterb@oakgov.com or the department contact persons listed for additional
information.
CONTACT
Leigh-Anne Stafford, Director Health & Human Services
ITEM REVIEW TRACKING
Aaron Snover, Board of Commissioners Created/Initiated - 9/5/2024
AGENDA DEADLINE: 09/15/2024 9:42 PM
ATTACHMENTS
1. Att_F FFATA25_UEI
2. Boilerplate contract
3. EGrAMS Application form sample
4. FY_25_Fiscal Questionnaire
5. Indirect Costs and Cost Allocation Plan Instructions
6. Application addendum A
7. Application Att B.3
8. Application Att C
9. Application Att E
10. Grant Review Sign-Off
11. Grant Application
COMMITTEE TRACKING
2024-08-20 Public Health & Safety - Recommend to Board
2024-09-05 Full Board - Adopt
Motioned by: Commissioner Michael Gingell
Seconded by: Commissioner Penny Luebs
Yes: David Woodward, Michael Spisz, Michael Gingell, Penny Luebs, Karen Joliat, Kristen
Nelson, Christine Long, Philip Weipert, Gwen Markham, Angela Powell, Marcia Gershenson,
Yolanda Smith Charles, Charles Cavell, Brendan Johnson, Ajay Raman, Ann Erickson Gault,
Linnie Taylor (17)
No: None (0)
Abstain: None (0)
Absent: William Miller III, Robert Hoffman (2)
Passed
Federal Funding Accountability and Transparency Act (FFATA) Reporting
Award Recipient’s Name ____________________________________________________ UEI # ______________
Location Address ________________________________________________________________________________
9 Digit Zip Code _______________ Congressional District _______________
Address of Performance (if different from above) ______________________________________________________
9 Digit Zip Code _______________ Congressional District _______________
Parent Organization DUNS # (if applicable) _______________
In order to determine whether you are required to provide executive compensation data, please answer the following
questions:
1. In your organization’s preceding completed fiscal year, did your organization receive:
a) 80 percent or more of your annual gross revenues in U.S. federal contracts, subcontracts, loans, grants,
subgrants, and/or cooperative agreements?
☐Yes ☐No
b) $25,000,000 or more in annual gross revenues from U.S. federal contracts, subcontracts, loans, grants,
subgrants, and/or cooperative agreements?
☐Yes ☐No
If you selected “Yes” for both a and b, please answer number 2 below. If you selected “No” for either or both
options, you are finished completing this form.
2. Does the public have access to information about the compensation of executives in your organization or
parent organization through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act pf
1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986?
☐Yes ☐No
If you selected “Yes” for number 2, you are finished completing this form. If you selected “No,” please provide the
Names and Total Compensation for your five highest compensated executives (i.e. officers, managing partners, or any
other employees in management positions).
Name: ________________________________________________ Total Compensation: $ ____________________
Name: ________________________________________________ Total Compensation: $ ____________________
Name: ________________________________________________ Total Compensation: $ ____________________
Name: ________________________________________________ Total Compensation: $ ____________________
Name: ________________________________________________ Total Compensation: $ ____________________
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Grant Language Template FY 2025 (Rev. 1/2024)
Agreement #:
Grant Agreement Between
Michigan Department of Health and Human Services
hereinafter referred to as the “Department”
and
,
Federal I.D.#: , UEI#
hereinafter referred to as the “Grantee”
for
Part 1
1. Period of Agreement: This Agreement will commence on the date of the Grantee’s signature or
, whichever is later, and continue through . No activity will be performed and no costs to the
state will be incurred prior to or the effective date of the Agreement, whichever is later.
Throughout the Agreement, the date of the Grantee’s signature or , whichever is later, will be
referred to as the start date. This Agreement is in full force and effect for the period specified.
2. Program Budget and Agreement Amount
A. Agreement Amount
The total amount of this Agreement is $ . Under the terms of this Agreement, the
Department will provide funding not to exceed $ . The source of funding provided by
the Department can be obtained in the Schedule of Financial Assistance, available on-
demand in the EGrAMS electronic grants management system (http://egrams-
mi.com/mdhhs).
The Agreement is designated as a:
Subrecipient relationship (federal funding); or
Recipient (non-federal funding).
The Agreement is designated as:
Research and development project; or
Not a research and development project.
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Grant Language Template FY 2025 (Rev. 1/2024)
B. Equipment Purchases and Title
Any Grantee equipment purchases supported in whole or in part through this Agreement
must be listed in the supporting Equipment Inventory Schedule which should be attached
to the Final Financial Status Report. Equipment means tangible, non-expendable,
personal property having a useful life of more than one year and an acquisition cost of
$5,000 or more per unit. Title to items having a unit acquisition cost of less than $5,000
will vest with the Grantee upon acquisition. The Department reserves the right to retain or
transfer the title to all items of equipment having a unit acquisition cost of $5,000 or more,
to the extent that the Department’s proportionate interest in such equipment supports such
retention or transfer of title.
C. Deviation Allowance
A deviation allowance modifying an established budget category by $10,000 or 15%,
whichever is greater, is permissible without prior written approval of the Department. Any
modification or deviations in excess of this provision, including any adjustment to the total
amount of this Agreement, must be made in writing, and executed by all parties through
an amendment to this Agreement before the modifications can be implemented. This
deviation allowance does not authorize new categories, subcontracts, equipment items or
positions not shown in the attached Program Budget Summary and supporting detail
schedules.
3. Purpose: The focus of the program is to:
4. Statement of Work: The Grantee agrees to undertake, perform, and complete the activities
described in Attachment A, which is part of this Agreement.
5. Financial Requirements: The financial requirements must be followed as described in Part 2
and Attachment B, which are part of this Agreement.
6. Performance/Progress Report Requirements: The progress reporting methods must be
followed as described in Part 2 and Attachment C, which are part of this Agreement.
7. General Provisions: The Grantee agrees to comply with the General Provisions as described
in Part 2 and Attachment E, which are part of this Agreement.
8. Administration of the Agreement:
The person acting for the Department in administering this Agreement (hereinafter referred to
as the Contract Manager) is:
Name, Title Telephone No. Email Address
9. Grantee’s Financial Contact for the Agreement:
The financial contact acting on behalf of the Grantee for this Agreement is:
Name Title
E-Mail Address Telephone No.
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Grant Language Template FY 2025 (Rev. 1/2024)
10. Special Conditions:
A. This Agreement is valid upon approval and execution by the Department which may be
contingent upon approval by the State Administrative Board and signature by the Grantee.
B. This Agreement is conditionally approved subject to and contingent upon the availability
of funds.
C. Based on the availability of funding, the Department may specify the amount of funding
the Grantee may expend during a specific time period within the Agreement Period.
D. The Department will not assume any responsibility or liability for costs incurred by the
Grantee prior to the start date of this Agreement.
E. The Grantee is required by 2004 PA 533 to receive payments by electronic funds
transfer.
11. Special Certification:
The individual or officer signing this Agreement certifies by their signature that they are
authorized to sign this Agreement on behalf of the responsible governing board, official or
Grantee.
12. Signature Section:
For the GRANTEE
Name (Please print) Title
Signature Date
For the MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Christine H. Sanches, Director, Bureau of Grants and Purchasing Date
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Grant Language Template FY 2025 (Rev. 1/2024)
Part 2
General Provisions
I. Responsibilities - Grantee
The Grantee, in accordance with the general purposes and objectives of this Agreement, must:
A. Publication Rights
1. Copyright materials only when the Grantee exclusively develops books, films or
other such copyrightable materials through activities supported by this Agreement.
The copyrighted materials cannot include recipient information or personal
identification data. Grantee provides the Department a royalty-free, non-exclusive
and irrevocable license to reproduce, publish and use such materials copyrighted
by the Grantee and authorizes others to reproduce and use such materials.
2. Obtain prior written authorization from the Department’s Office of Communications
for any materials copyrighted by the Grantee or modifications bearing
acknowledgment of the Department's name prior to reproduction and use of such
materials. The state of Michigan may modify the material copyrighted by the
Grantee and may combine it with other copyrightable intellectual property to form
a derivative work. The state of Michigan will own and hold all copyright and other
intellectual property rights in any such derivative work, excluding any rights or
interest granted in this Agreement to the Grantee. If the Grantee ceases to conduct
business for any reason or ceases to support the copyrightable materials
developed under this Agreement, the state of Michigan has the right to convert its
licenses into transferable licenses to the extent consistent with any applicable
obligations the Grantee has.
3. Obtain written authorization, at least 14 days in advance, from the Department’s
Office of Communications and give recognition to the Department in any and all
publications, papers and presentations arising from the Agreement activities.
4. Notify the Department’s Bureau of Grants and Purchasing 30 days before applying
to register a copyright with the U.S. Copyright Office. The Grantee must submit an
annual report for all copyrighted materials developed by the Grantee through
activities supported by this Agreement and must submit a final invention statement
and certification within 60 days of the end of the Agreement period.
5. Not make any media releases related to this Agreement, without prior written
authorization from the Department’s Office of Communications.
B. Fees
1. Guarantee that any claims made to the Department under this Agreement will not
be financed by any sources other than the Department under the terms of this
Agreement. If funding is received through any other source, the Grantee agrees to
budget the additional source of funds and reflect the source of funding on the
Financial Status Report.
2. Make reasonable efforts to collect 1st and 3rd party fees, where applicable, and
report those collections on the Financial Status Report. Any under recoveries of
otherwise available fees resulting from failure to bill for eligible activities will be
excluded from reimbursable expenditures.
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Grant Language Template FY 2025 (Rev. 1/2024)
C. Grant Program Operation
Provide the necessary administrative, professional, and technical staff for operation of the
grant program. The Grantee must obtain and maintain all necessary licenses, permits or
other authorizations necessary for the performance of this Agreement.
Use an accounting system that can identify and account for the funds received from each
separate grant, regardless of funding source, and assure that grant funds are not
commingled.
D. Reporting
Utilize all report forms and reporting formats required by the Department at the start date
of this Agreement and provide the Department with timely review and commentary on any
new report forms and reporting formats proposed for issuance thereafter.
E. Record Maintenance/Retention
Maintain adequate program and fiscal records and files, including source documentation,
to support program activities and all expenditures made under the terms of this
Agreement, as required. The Grantee must assure that all terms of the Agreement will be
appropriately adhered to and that records and detailed documentation for the grant project
or grant program identified in this Agreement will be maintained for a period of not less
than seven years from the date of termination, the date of submission of the final
expenditure report or until litigation and audit findings have been resolved. This section
applies to the Grantee, any parent, affiliate, or subsidiary organization of the Grantee and
any subcontractor that performs activities in connection with this Agreement.
F. Authorized Access
1. Permit within 10 calendar days of providing notification and at reasonable times,
access by authorized representatives of the Department, Federal Grantor Agency,
Inspector Generals, Comptroller General of the United States and State Auditor
General, or any of their duly authorized representatives, to records, papers, files,
documentation, and personnel related to this Agreement, to the extent authorized
by applicable state or federal law, rule or regulation.
2. Acknowledge the rights of access in this section are not limited to the required
retention period. The rights of access will last as long as the records are retained.
3. Cooperate and provide reasonable assistance to authorized representatives of the
Department and others when those individuals have access to the Grantee’s grant
records.
G. Audits
This section only applies to Grantees designated as subrecipients by the Department (see
Part 1, Section 2.A.).
1. Required Audit or Audit Exemption Notice
Submit to the Department either a Single Audit, Financial Related Audit or Audit
Exemption Notice as described below. A Financial Related Audit is applicable to
for-profit Grantees that are designated as subrecipients. If submitting a Single Audit
or Financial Related Audit, Grantees must also submit a corrective action plan
prepared in accordance with 2 CFR 200.511(c) for any audit findings that impact
the Department funded programs, and management letter (if issued) with a
corrective action plan.
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Grant Language Template FY 2025 (Rev. 1/2024)
a. Single Audit
Grantees that are a state, local government or non-profit organization that
expend $1,000,000 or more in federal awards during the Grantee’s fiscal
year must submit a Single Audit to the Department, regardless of the amount
of funding received from the Department. The Single Audit must comply with
the requirements of 2 CFR 200 Subpart F. The Single Audit reporting
package must include all components described in 2 CFR 200.512 (c).
b. Financial Related Audit
Grantees that are for-profit organizations that expend $1,000,000 or more
in federal awards during the Grantee’s fiscal year must submit either a
financial related audit prepared in accordance with Government Auditing
Standards relating to all federal awards, or an audit that meets the
requirements contained in 2 CFR 200 Subpart F, if required by the federal
awarding agency.
c. Audit Exemption Notice
Grantees exempt from the Single Audit and Financial Related Audit
requirements (a. and b. above) must submit an Audit Exemption Notice that
certifies these exemptions. The template Audit Exemption Notice and further
instructions are available at State of Michigan - MDHHS by selecting Inside
MDHHS – MDHHS Audit – Audit Reporting.
2. Financial Statement Audit
Grantees exempt from the Single Audit and Financial Related Audit requirements
(that are required to submit an Audit Exemption Notice as described above) must
submit to the Department a Financial Statement Audit prepared in accordance with
generally accepted auditing standards if the audit includes disclosures that may
negatively impact the Department funded programs including but not limited to
fraud, going concern uncertainties, financial statement misstatements and
violations of the Agreement requirements. If submitting a Financial Statement Audit,
Grantees must also submit a corrective action plan for any audit findings that impact
the Department funded programs.
3. Due Date and Where to Send
The required audit and any other required submissions (i.e., corrective action plan,
and management letter with a corrective action plan), and/or Audit Exemption
Notice must be submitted to the Department within the earlier of 30 calendar days
after receipt of the auditor’s report(s) or nine months after the end of the Grantee’s
fiscal year by e-mail to MDHHS-AuditReports@michigan.gov. Single Audit reports
must be submitted simultaneously to the Department and Federal Audit
Clearinghouse, in accordance with 2 CFR 200.512(a). The required submissions
must be assembled in PDF files and compatible with Adobe Acrobat (read only).
The subject line must state the agency name and fiscal year end. The Department
reserves the right to request a hard copy of the audit materials if for any reason the
electronic submission process is not successful.
4. Penalty
a. Delinquent Single Audit or Financial Related Audit
If the Grantee does not submit the required Single Audit or Financial Related
Audit, including any management letter and applicable corrective action
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Grant Language Template FY 2025 (Rev. 1/2024)
plan(s) within nine months after the end of the Grantee’s fiscal year, the
Department may withhold from any payment from the Department to the
Grantee an amount equal to five percent of the audit year’s grant funding
(not to exceed $200,000) until the required filing is received by the
Department. The Department may retain the amount withheld if the Grantee
is more than 120 days delinquent in meeting the filing requirements. The
Department may terminate any current grant agreements if the Grantee is
more than 180 days delinquent in meeting the filing requirements.
b. Delinquent Audit Exemption Notice
Failure to submit the Audit Exemption Notice, when required, may result in
withholding from any payment from Department to the Grantee an amount
equal to one percent of the audit year’s grant funding until the Audit
Exemption Notice is received.
5. Other Audits
The Department or federal agencies may also conduct or arrange for agreed
upon procedures or additional audits to meet their needs.
H. Subrecipient Monitoring
1. When passing federal funds through to a subrecipient (if the Agreement does not
prohibit the passing of federal funds through to a subrecipient), the Grantee must:
a. Ensure that every subaward is clearly identified to the subrecipient as a
subaward and includes the information required by 2 CFR 200.332.
b. Ensure the subrecipient complies with all the requirements of this
Agreement.
c. Evaluate each subrecipient’s risk for noncompliance as required by 2 CFR
200.332(b).
d. Monitor the activities of the subrecipient as necessary to ensure that the
subaward is used for authorized purposes, in compliance with federal
statutes, regulations and the terms and conditions of the subawards; that
subaward performance goals are achieved; and that all monitoring
requirements of 2 CFR 200.332(d) are met including reviewing financial and
programmatic reports, following up on corrective actions and issuing
management decisions for audit findings.
e. Verify that every subrecipient is audited as required by 2 CFR 200 Subpart
F.
2. Develop a subrecipient monitoring plan that addresses the above requirements and
provides reasonable assurance that the subrecipient administers federal awards in
compliance with laws, regulations and the provisions of this Agreement, and that
performance goals are achieved. The subrecipient monitoring plan should include
a risk-based assessment to determine the level of oversight and monitoring
activities, such as reviewing financial and performance reports, performing site
visits and maintaining regular contact with subrecipients.
3. Establish requirements to ensure compliance for for-profit subrecipients as required
by 2 CFR 200.501(h), as applicable.
4. Ensure that transactions with subrecipients/contractors comply with laws,
regulations and provisions of contracts or grant agreements.
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Grant Language Template FY 2025 (Rev. 1/2024)
I. Notification of Modifications
Provide notification to the Department within 14 days or sooner if circumstances warrant,
in writing, of any action by its governing board or any other funding source that would
require or result in significant modification in the provision of activities, funding or
compliance with operational procedures.
J. Software Compliance
Ensure software compliance and compatibility with the Department’s data systems for
activities provided under this Agreement, including but not limited to stored data,
databases and interfaces for the production of work products and reports. All required data
under this Agreement must be provided in an accurate and timely manner without
interruption, failure or errors due to the inaccuracy of the Grantee’s business operations
for processing data. All information systems, electronic or hard copy, that contain state or
federal data must be protected from unauthorized access. State or federal data includes
data and information provided to Grantee or Grantee’s Subcontractor by or on behalf of
the State or federal government, and all data and information derived therefrom, is the
exclusive property of the State or federal government.
K. Human Subjects
Comply with Federal Policy for the Protection of Human Subjects, 45 CFR 46. The Grantee
agrees that prior to the initiation of the research, the Grantee will submit Institutional
Review Board (IRB) application material for all research involving human subjects, which
is conducted in programs sponsored by the Department or in programs which receive
funding from or through the state of Michigan, to the Department’s IRB for review and
approval, or the IRB application and approval materials for acceptance of the review of
another IRB. All such research must be approved by a federally assured IRB, but the
Department’s IRB can only accept the review and approval of another institution’s IRB
under a formally approved interdepartmental agreement. The manner of the review will be
agreed upon between the Department’s IRB Chairperson and the Grantee’s authorized
official.
L. Mandatory Disclosures
1. Disclose to the Department in writing within 14 days, or sooner if circumstances
warrant, of receiving notice of any litigation, investigation, arbitration, or other
proceeding (collectively, “Proceeding”) involving Grantee, a subcontractor or an
officer or director of Grantee or subcontractor that arises during the term of this
Agreement including:
a. All violations of federal and state criminal law involving fraud, bribery, or
gratuity violations potentially affecting the Agreement.
b. A criminal Proceeding;
c. A parole or probation Proceeding;
d. A Proceeding under the Sarbanes-Oxley Act;
e. A civil Proceeding involving;
i. A claim that might reasonably be expected to adversely affect
Grantee’s viability or financial stability; or
ii. A governmental or public entity’s claim or written allegation of fraud;
or
iii. Any complaint filed in a legal or administrative proceeding alleging the
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Grant Language Template FY 2025 (Rev. 1/2024)
Grantee or its subcontractors discriminated against its employees,
subcontractors, vendors, or suppliers during the term of this Agreement; or
f. A Proceeding involving any license that Grantee is required to possess in
order to perform under this Agreement.
g. Any criminal activity that occurs by an employee, agent, or subcontractor of Grantee
while conducting activities pursuant to this Agreement.
2. Notify the Department, at least 90 calendar days before the effective date, of a
change in Grantee’s ownership or executive management.
M. Statement of Work Progress Reports
Submit quarterly Statement of Work progress reports to the Department via the
http://egrams-mi.com/mdhhs website by the 15th day of the month following the end of the
quarter and a final report no later than 15 days following the end of this Agreement.
N. Conflict of Interest and Code of Conduct Standards
1. Be subject to the provisions of 1968 PA 317, as amended, 1973 PA 196, as
amended, and 2 CFR 200.318 (c)(1) and (2).
2. Uphold high ethical standards and be prohibited from the following:
a. Holding or acquiring an interest that would conflict with this Agreement;
b. Doing anything that creates an appearance of impropriety with respect to the
award or performance of this Agreement;
c. Attempting to influence or appearing to influence any state employee by the
direct or indirect offer of anything of value; or
d. Paying or agreeing to pay any person, other than employees and
consultants working for Grantee, any consideration contingent upon the
award of this Agreement.
3. Immediately notify the Department of any violation or potential violation of these
standards. This section applies to Grantee, any parent, affiliate or subsidiary
organization of Grantee, and any subcontractor that performs activities in
connection with this Agreement.
O. Travel Costs
1. Be reimbursed for travel costs (including mileage, meals and lodging) budgeted
and incurred related to activities provided under this Agreement.
a. If the Grantee has a documented policy related to travel reimbursement for
employees and if the Grantee follows that documented policy, the
Department will reimburse the Grantee for travel costs at the Grantee’s
documented reimbursement rate for employees. Otherwise, the state of
Michigan travel reimbursement rate applies.
b. Federally funded Grantees must comply with Title 2 CRF 200.475.
c. State of Michigan travel rates may be found at the following website:
https://www.michigan.gov/dtmb/0,5552,7-358-82548_13132---,00.html
d. International travel must be preapproved by the Department and itemized in
the budget.
P. Federal Funding Accountability and Transparency Act (FFATA)
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Grant Language Template FY 2025 (Rev. 1/2024)
1. Complete and upload the FFATA Executive Compensation report to the EGrAMS
agency profile if:
a. The Grantee’s federal revenue was 80% or more of the Grantee’s annual
gross revenue; AND
b. Grantee’s gross revenue from federal awards was $25,000,000 or more;
AND
c. The public does not have access to the information about executive officers’
compensation through periodic reports filed under Section 13(a) or 15 (d)
of the Securities Exchange Act of 1934 or Section 6104 of the Internal
Revenue Code of 1986.
2. The FFATA Executive Compensation report template can be found in EGrAMS
documents.
Q. Insurance Requirements
1. Maintain at least a minimum of the insurances or governmental self-insurances
listed below and be responsible for all deductibles. All required insurance or self-
insurance must:
a. Protect the state of Michigan from claims that may arise out of, are alleged
to arise out of, or result from Grantee’s or a subcontractor’s performance;
b. Be primary and non-contributing to any comparable liability insurance
(including self-insurance) carried by the state; and
c. Be provided by a company with an A.M. Best rating of “A-” or better and a
financial size of VII or better or governmental self-insurance
2. Insurance Types
a. Commercial General Liability Insurance or Governmental Self-Insurance:
Except for Governmental Self-Insurance, policies must be endorsed to add
“the state of Michigan, its departments, divisions, agencies, offices,
commissions, officers, employees, and agents” as additional insureds using
endorsement CG 20 10 11 85, or both CG 20 10 12 19 and CG 20 37 12 19.
If the Grantee will interact with children, schools, or the cognitively impaired,
the Grantee must maintain appropriate insurance coverage related to sexual
abuse and molestation liability.
b. Workers’ Compensation Insurance or Governmental Self-Insurance:
Coverage according to applicable laws governing work activities. Policies
must include waiver of subrogation, except where waiver is prohibited by
law.
c. Employers Liability Insurance or Governmental Self-Insurance.
d. Privacy and Security Liability (Cyber Liability) Insurance: cover information
security and privacy liability, privacy notification costs, regulatory defense
and penalties, and website media content liability.
3. Require that subcontractors maintain the required insurances contained in this
Section.
4. This Section is not intended to and is not to be construed in any manner as waiving,
restricting or limiting the liability of the Grantee from any obligations under this
Agreement.
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5. Each Party must promptly notify the other Party of any knowledge regarding an
occurrence which the notifying Party reasonably believes may result in a claim
against either Party. The Parties must cooperate with each other regarding such
claim.
R. Fiscal Questionnaire
1. Complete and upload the yearly fiscal questionnaire to the EGrAMS agency profile
within three months of the start of the agreement.
2. The fiscal questionnaire template can be found in EGrAMS documents.
S. Criminal Background Check
1. Conduct or cause to be conducted a search that reveals information similar or
substantially similar to information found on an Internet Criminal History Access
Tool (ICHAT) check and a national and state sex offender registry check for each
new employee, employee, subcontractor, subcontractor employee, or volunteer
who under this Agreement works directly with clients or has access to client
information.
a. ICHAT: Home Page - ICHAT Menu (michigan.gov)
b. Michigan Public Sex Offender Registry: http://www.mipsor.state.mi.us
c. National Sex Offender Registry: http://www.nsopw.gov
2. Conduct or cause to be conducted a Central Registry (CR) check for each new
employee, employee, subcontractor, subcontractor employee, or volunteer who
under this Agreement works directly with children.
a. Central Registry: https://www.michigan.gov/mdhhs/0,5885,7-
339-73971_7119_50648_48330-180331--,00.html
3. Require each new employee, employee, subcontractor, subcontractor employee or
volunteer who, under this Agreement, works directly with clients or who has access
to client information to notify the Grantee in writing of criminal convictions (felony
or misdemeanor), pending felony charges, or placement on the Central Registry as
a perpetrator, at hire or within 10 days of the event after hiring.
4. Determine whether to prohibit any employee, subcontractor, subcontractor
employee, or volunteer from performing work directly with clients or accessing client
information related to clients under this Agreement, based on the results of a
positive ICHAT response or reported criminal felony conviction or perpetrator
identification.
5. Determine whether to prohibit any employee, subcontractor, subcontractor
employee or volunteer from performing work directly with children under this
Agreement, based on the results of a positive CR response or reported perpetrator
identification.
6. Require any employee, subcontractor, subcontractor employee or volunteer who
may have access to any databases of information maintained by the federal
government that contain confidential or personal information, including but not
limited to federal tax information, to have a fingerprint background check performed
by the Michigan State Police.
II. Responsibilities - Department
The Department in accordance with the general purposes and objectives of this Agreement will:
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Grant Language Template FY 2025 (Rev. 1/2024)
A. Reimbursement
Provide reimbursement in accordance with the terms and conditions of this Agreement
based upon appropriate reports, records and documentation maintained by the Grantee.
B. Report Forms
Provide any report forms and reporting formats required by the Department at the start
date of this Agreement and provide to the Grantee any new report forms and reporting
formats proposed for issuance thereafter at least 30 days prior to their required usage in
order to afford the Grantee an opportunity to review.
III. Assurances
The following assurances are hereby given to the Department:
A. Compliance with Applicable Laws
The Grantee will comply with applicable federal and state laws, guidelines, rules and
regulations in carrying out the terms of this Agreement. The Grantee will also comply with
all applicable general administrative requirements, such as 2 CFR 200, covering cost
principles, grant/agreement principles and audits, in carrying out the terms of this
Agreement. The Grantee will comply with all applicable requirements in the original grant
awarded to the Department if the Grantee is a subgrantee. The Department may
determine that the Grantee has not complied with applicable federal or state laws,
guidelines, rules and regulations in carrying out the terms of this Agreement and may then
terminate this Agreement under Part 2, Section V.
B. Anti-Lobbying Act
The Grantee will comply with the Anti-Lobbying Act (31 U.S.C. 1352) as revised by the
Lobbying Disclosure Act of 1995 (2 U.S.C. 1601 et seq.), Federal Acquisition Regulations
52.203.11 and 52.203.12, and Section 503 of the Departments of Labor, Health & Human
Services, and Education, and Related Agencies section of the current fiscal year Omnibus
Consolidated Appropriations Act. Further, the Grantee must require that the language of
this assurance be included in the award documents of all subawards at all tiers (including
subcontracts, subgrants, and contracts under grants, loans and cooperative agreements)
and that all subrecipients must certify and disclose accordingly.
C. Non-Discrimination
1. The Grantee must comply with the Department’s non-discrimination statement:
”The Michigan Department of Health and Human Services does not discriminate
against any individual or group on the basis of race, national origin, color, sex,
disability, religion, age, height, weight, familial status, partisan considerations, or
genetic information. Sex-based discrimination includes, but is not limited to,
discrimination based on sexual orientation, gender identity, gender expression, sex
characteristics, and pregnancy.”
2. The Grantee further agrees that every subcontract entered into for the performance
of any contract or purchase order resulting therefrom, will contain a provision
requiring non-discrimination in employment, activity delivery and access, as herein
specified, binding upon each subcontractor. This covenant is required pursuant to
the Elliot-Larsen Civil Rights Act (1976 PA 453, as amended; MCL 37.2101 et seq.)
and the Persons with Disabilities Civil Rights Act (1976 PA 220, as amended; MCL
37.1101 et seq.), and any breach thereof may be regarded as a material breach of
this Agreement.
3. The Grantee will comply with all federal and state statutes relating to
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Grant Language Template FY 2025 (Rev. 1/2024)
nondiscrimination. These include but are not limited to:
a. Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits
discrimination based on race, color or national origin;
b. Title IX of the Education Amendments of 1972, as amended (20 U.S.C.
1681-1683, 1685-1686), which prohibits discrimination based on sex;
c. Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794),
which prohibits discrimination based on disabilities;
d. The Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107),
which prohibits discrimination based on age;
e. The Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as
amended, relating to nondiscrimination based on drug abuse;
f. The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment,
and Rehabilitation Act of 1970 (P.L. 91-616) as amended, relating to
nondiscrimination based on alcohol abuse or alcoholism;
g. Sections 523 and 527 of the Public Health Service Act of 1944 (42 U.S.C.
290dd-2), as amended, relating to confidentiality of alcohol and drug abuse
patient records;
h. Any other nondiscrimination provisions in the specific statute(s) under which
application for federal assistance is being made; and,
i. The requirements of any other nondiscrimination statute(s) which may apply
to the application.
4. Additionally, assurance is given to the Department that proactive efforts will be
made to identify and encourage the participation of minority-owned and women-
owned businesses, and businesses owned by persons with disabilities in contract
solicitations. The Grantee must include language in all contracts awarded
under this Agreement which (1) prohibits discrimination against minority-owned and
women-owned businesses and businesses owned by persons with disabilities in
subcontracting; and (2) makes discrimination a material breach of contract.
D. Debarment and Suspension
The Grantee will comply with federal regulation 2 CFR 180 and certifies to the best of its
knowledge and belief that it, its employees and its subcontractors:
1. Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by any federal
department or contractor;
2. Have not within a five-year period preceding this Agreement been convicted of or
had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(federal, state, or local) or private transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, tax
evasion, receiving stolen property, making false claims, or obstruction of justice;
3. Are not presently indicted or otherwise criminally or civilly charged by a government
entity (federal, state or local) with commission of any of the offenses enumerated
in section 2;
4. Have not within a five-year period preceding this Agreement had one or more public
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transactions (federal, state or local) terminated for cause or default; and
5. Have not committed an act of so serious or compelling a nature that it affects the
Grantee’s present responsibilities.
E. Pro-Children Act
1. The Grantee will comply with the Pro-Children Act of 1994 (P.L. 103-227; 20 U.S.C.
6081, et seq.), which requires that smoking not be permitted in any portion of any
indoor facility owned or leased or contracted by and used routinely or regularly for
the provision of health, day care, early childhood development activities, education
or library activities to children under the age of 18, if the activities are funded by
federal programs either directly or through state or local governments, by federal
grant, contract, loan or loan guarantee. The law also applies to children’s activities
that are provided in indoor facilities that are constructed, operated, or maintained
with such federal funds. The law does not apply to children’s activities provided in
private residences; portions of facilities used for inpatient drug or alcohol treatment;
activity providers whose sole source of applicable federal funds is Medicare or
Medicaid; or facilities where Women, Infants, and Children (WIC) coupons are
redeemed. Failure to comply with the provisions of the law may result in the
imposition of a civil monetary penalty of up to $1,000 for each violation and/or the
imposition of an administrative compliance order on the responsible entity. The
Grantee also assures that this language will be included in any subawards which
contain provisions for children’s activities.
2. The Grantee also assures, in addition to compliance with P.L. 103-227, any activity
funded in whole or in part through this Agreement will be delivered in a smoke-free
facility or environment. Smoking must not be permitted anywhere in the facility, or
those parts of the facility under the control of the Grantee. If activities are delivered
in facilities or areas that are not under the control of the Grantee (e.g., a mall,
restaurant or private work site), the activities must be smoke-free.
F. Hatch Act and Intergovernmental Personnel Act
The Grantee will comply with the Hatch Act (5 U.S.C. 1501-1508, 5 U.S.C. 7321-7326),
and the Intergovernmental Personnel Act of 1970 (P.L. 91-648) as amended by Title VI of
the Civil Service Reform Act of 1978 (P.L. 95-454). Federal funds cannot be used for
partisan political purposes of any kind by any person or organization involved in the
administration of federally assisted programs.
G. Employee Whistleblower Protections
The Grantee will comply with 41 U.S.C. 4712 and must insert this clause in all
subcontracts.
H. Clean Air Act and Federal Water Pollution Control Act
The Grantee will comply with the Clean Air Act (42 U.S.C. 7401-7671(q)) and the Federal
Water Pollution Control Act (33 U.S.C. 1251-1388), as amended.
This Agreement and anyone working on this Agreement will be subject to the Clean Air
Act and Federal Water Pollution Control Act and must comply with all applicable
standards, orders or regulations issued pursuant to these Acts. Violations must be
reported to the Department.
I. Victims of Trafficking and Violence Protection Act
The Grantee will comply with the Victims of Trafficking and Violence Protection Act of 2000
(P.L. 106-386), as amended.
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This Agreement and anyone working on this Agreement will be subject to P.L. 106-386
and must comply with all applicable standards, orders or regulations issued pursuant to
this Act. Violations must be reported to the Department.
J. Procurement of Recovered Materials
The Grantee will comply with section 6002 of the Solid Waste Disposal Act of 1965 (P.L.
89-272), as amended.
This Agreement and anyone working on this Agreement will be subject to section 6002 of
P.L. 89-272, as amended, and must comply with all applicable standards, orders or
regulations issued pursuant to this act. Violations must be reported to the Department.
K. Subcontracts
For any subcontracted activity or product, the Grantee will ensure:
1. That a written subcontract is executed by all affected parties prior to the initiation
of any new subcontract activity or delivery of any subcontracted product.
Exceptions to this policy may be granted by the Department if the Grantee asks the
Department in writing within 30 days of execution of the Agreement.
2. That any executed subcontract to this Agreement must require the subcontractor
to comply with all applicable terms and conditions of this Agreement. In the event
of a conflict between this Agreement and the provisions of the subcontract, the
provisions of this Agreement will prevail.
A conflict between this Agreement and a subcontract, however, will not be deemed
to exist where the subcontract:
a. Contains additional non-conflicting provisions not set forth in this
Agreement;
b. Restates provisions of this Agreement to afford the Grantee the same or
substantially the same rights and privileges as the Department; or
c. Requires the subcontractor to perform duties and/or activities in less time
than that afforded the Grantee in this Agreement.
3. That the subcontract does not affect the Grantee’s accountability to the Department
for the subcontracted activity.
4. That any billing or request for reimbursement for subcontract costs is supported by
a valid subcontract and adequate source documentation on costs and activities.
5. That the Grantee will submit a copy of the executed subcontract if requested by the
Department.
L. Procurement
1. Grantee will ensure that all purchase transactions, whether negotiated or
advertised, are conducted openly and competitively in accordance with the
principles and requirements of 2 CFR 200.
2. Funding from this Agreement must not be used for the purchase of foreign goods
or services.
3. Preference must be given to goods and services manufactured or provided by
Michigan businesses, if they are competitively priced and of comparable quality.
4. Preference must be given to goods and services that are manufactured or
provided by Michigan businesses owned and operated by veterans, if they are
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competitively priced and of comparable quality.
5. Records must be sufficient to document the significant history of all purchases and
must be maintained for a minimum of seven years after the end of the Agreement
period.
M. Health Insurance Portability and Accountability Act
To the extent that the Health Insurance Portability and Accountability Act (HIPAA) is
applicable to the Grantee under this Agreement, the Grantee assures that it is in
compliance with requirements of HIPAA including the following:
1. The Grantee must not share any protected health information provided by the
Department that is covered by HIPAA except as permitted or required by applicable
law, or to a subcontractor as appropriate under this Agreement.
2. The Grantee will ensure that any subcontractor will have the same obligations as
the Grantee not to share any protected health data and information from the
Department that falls under HIPAA requirements in the terms and conditions of the
subcontract.
3. The Grantee must only use the protected health data and information for the
purposes of this Agreement.
4. The Grantee must have written policies and procedures addressing the use of
protected health data and information that falls under the HIPAA requirements. The
policies and procedures must meet all applicable federal and state requirements
including the HIPAA regulations. These policies and procedures must include
restricting access to the protected health data and information by the Grantee’s
employees.
5. The Grantee must have a policy and procedure to immediately report to the
Department any suspected or confirmed unauthorized use or disclosure of
protected health information that falls under the HIPAA requirements of which the
Grantee becomes aware. The Grantee will work with the Department to mitigate
the breach and will provide assurances to the Department of corrective actions to
prevent further unauthorized uses or disclosures. The Department may demand
specific corrective actions and assurances and the Grantee must provide the same
to the Department.
6. Failure to comply with any of these contractual requirements may result in the
termination of this Agreement in accordance with Part 2, Section V.
7. In accordance with HIPAA requirements, the Grantee is liable for any claim, loss or
damage relating to unauthorized use or disclosure of protected health data and
information, including without limitation the Department’s costs in responding to a
breach, received by the Grantee from the Department or any other source.
8. The Grantee will enter into a business associate agreement should the Department
determine such an agreement is required under HIPAA.
N. Website Incorporation
The Department is not bound by any content on Grantee’s website or other internet
communication platforms or technologies, unless expressly incorporated directly into this
Agreement. The Department is not bound by any end user license agreement or terms of
use unless specifically incorporated in this Agreement or any other agreement signed by
the Department. The Grantee must not refer to the Department on the Grantee’s website
or other internet communication platforms or technologies without the prior written
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approval of the Department.
O. Survival
The provisions of this Agreement that impose continuing obligations will survive the
expiration or termination of this Agreement.
P. Non-Disclosure of Confidential Information
1. The Grantee agrees that it will use confidential information solely for the purpose
of this Agreement. The Grantee agrees to hold all confidential information in strict
confidence and not to copy, reproduce, sell, transfer or otherwise dispose of, give
or disclose such confidential information to third parties other than employees,
agents, or subcontractors of a party who have a need to know in connection with
this Agreement or to use such confidential information for any purpose whatsoever
other than the performance of this Agreement. The Grantee must take all
reasonable precautions to safeguard the confidential information. These
precautions must be at least as great as the precautions the Grantee takes to
protect its own confidential or proprietary information.
2. Meaning of Confidential Information
For the purpose of this Agreement the term “confidential information” means all
information and documentation that:
a. Has been marked “confidential” or with words of similar meaning, at the time
of disclosure by such party;
b. If disclosed orally or not marked “confidential” or with words of similar
meaning, was subsequently summarized in writing by the disclosing party
and marked “confidential” or with words of similar meaning;
c. Should reasonably be recognized as confidential information of the
disclosing party;
d. Is unpublished or not available to the general public; or
e. Is designated by law as confidential.
3. The term “confidential information” does not include any information or
documentation that was:
a. Subject to disclosure under the Michigan Freedom of Information Act (FOIA);
b. Already in the possession of the receiving party without an obligation of
confidentiality;
c. Developed independently by the receiving party, as demonstrated by the
receiving party, without violating the disclosing party’s proprietary rights;
d. Obtained from a source other than the disclosing party without an obligation
of confidentiality; or
e. Publicly available when received or thereafter became publicly available
(other than through an unauthorized disclosure by, through or on behalf of,
the receiving party).
4. The Grantee must notify the Department within one business day after discovering
any unauthorized use or disclosure of confidential information. The Grantee will
cooperate with the Department in every way possible to regain possession of the
confidential information and prevent further unauthorized use or disclosure.
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Grant Language Template FY 2025 (Rev. 1/2024)
Q. Cap on Salaries
None of the funds awarded to the Grantee through this Agreement will be used to pay,
either through a grant or other external mechanism, the salary of an individual at a rate in
excess of Executive Level II. The current rates of pay for the Executive Schedule are
located on the United States Office of Personnel Management web site,
http://www.opm.gov, by navigating to Policy — Pay & Leave — Salaries & Wages. The
salary rate limitation does not restrict the salary that a Grantee may pay an individual
under its employment; rather, it merely limits the portion of that salary that may be paid
with funds from this Agreement.
IV. Financial Requirements
A. Operating Advance
An operating advance may be requested by the Grantee to assist with program operations.
The request should be addressed to the Contract Manager identified in Part 1, Section 8.
The operating advance will be administered as follows:
1. The operating advance amount requested must be reasonable in relation to factors
including but not limited to program requirements, the period of the Agreement, and
the financial obligation. The advance must not exceed 16.67 percent of operating
expenses. Operating advances will be monitored and adjusted by the Department
relative to the Agreement amount.
2. The operating advance must be recorded as an account payable liability to the
Department in the Grantee’s financial records. The operating advance payable
liability must remain in the Grantee’s financial records until fully recovered by the
Department.
3. The reimbursement for actual expenditures by the Department should be used by
the Grantee to replenish the operating advance used for program operations.
4. The operating advance must be returned to the Department within 30 days of the
end date of this Agreement unless the Grantee has a recurring agreement with the
Department. Subsequent Department agreements may not be executed if an
outstanding operational advance has not been repaid.
The Department may obtain the Michigan Department of Treasury’s assistance in
collecting outstanding operating advances. The Department will comply with the
Michigan Department of Treasury’s due process procedures prior to forwarding
claims to Treasury. Specific due process procedures include the following:
a. An offer from the Department of a hearing to dispute the debt, identifying the
time, place and date of such hearing.
b. A hearing by an impartial official.
c. An opportunity for the Grantee to examine the Department’s associated
records.
d. An opportunity for the Grantee to present evidence in person or in writing.
e. A hearing official with full authority to correct errors and decide not to forward
debt to Treasury.
f. Grantee representation by an attorney and presentation of witnesses if
necessary.
5. If the Grantee has a recurring agreement with the Department, the Department
requires an annual confirmation of the outstanding operating advance. At the end
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Grant Language Template FY 2025 (Rev. 1/2024)
of either the Agreement period or Department’s fiscal year, whichever is first, the
Grantee must respond to the Department’s request for confirmation of the operating
advance. Failure to respond to the confirmation request may result in the
Department recovering all or part of an outstanding operating advance.
B. Reimbursement Method
The Grantee will be paid for allowable expenditures incurred by the Grantee, submitted
for reimbursement on the Financial Status Reports (FSRs) and approved by the
Department. Reimbursement from the Department is based on the understanding that
Department funds will be paid up to the total Department allocation as agreed to in the
approved budget. Department funds are the first source after the application of fees and
earmarked sources unless a specific local match condition exists.
C. Financial Status Report Submission
The Grantee must electronically prepare and submit FSRs to the Department via the
EGrAMS website (http://egrams-mi.com/mdhhs).
FSRs must be submitted on a monthly basis, no later than 30 days after the close of each
calendar month. The monthly FSRs must reflect total actual program expenditures, up to
the total agreement amount. Failure to meet financial reporting responsibilities as
identified in this Agreement may result in withholding future payments.
The Grantee representative who submits the FSR is certifying to the best of their
knowledge and belief that the report is true, complete and accurate and the expenditures,
disbursements and cash receipts are for the purposes and objectives set forth in the terms
and conditions of this Agreement. The individual submitting the FSR should be aware that
any false, fictitious or fraudulent information, or the omission of any material facts, may
subject them to criminal, civil or administrative penalties for fraud, false statements, false
claims or otherwise.
The instructions for completing the FSR form are available on the EGrAMS website.
Send FSR questions to FSRMDHHS@michigan.gov.
D. Reimbursement Mechanism
All Grantees must register using the on-line vendor self-service site to receive all state of
Michigan payments as Electronic Funds Transfers (EFT)/Direct Deposits, as mandated by
MCL 18.1283a. Vendor registration information is available through the Department of
Technology, Management and Budget’s web site: https://www.michigan.gov/sigmavss.
E. Final Obligations and Financial Status Report Requirements
1. Obligation Report
The Obligation Report, based on annual guidelines, must be submitted by the due
date established by and using the format provided by the Department’s
Expenditures Operations Division. The Grantee must provide an estimate of
unbilled expenditures for the entire Agreement period. The information on the report
will be used to record the Department’s year-end accounts payable and receivable
for this Agreement.
2. Department-wide Payment Suspension
A temporary payment suspension is in effect on agreements during the
Department’s year-end closing period. The Department will notify the Grantee of
the date by which FSRs should be submitted to ensure payment prior to the
payment suspension period.
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Grant Language Template FY 2025 (Rev. 1/2024)
3. Final FSRs
Final FSRs are due 30 days following the end of the Agreement period. The final
FSR must be clearly marked “Final”. Final FSRs not received by the due date may
result in the loss of funding requested on the Obligation Report and may result in a
potential reduction in a subsequent year’s Agreement amount.
F. Unobligated Funds
Any unobligated balance of funds held by the Grantee at the end of the Agreement period
will be returned to the Department within 30 days of the end of the Agreement or treated
in accordance with instructions provided by the Department.
G. Indirect Costs
The Grantee may use an approved federal or state indirect rate in their budget calculations
and financial status reporting. If the Grantee does not have an existing approved federal
or state indirect rate, they may use a 15% de minimis rate in accordance with 2 CFR 200
to recover their indirect costs. Subrecipients may elect to use the cost allocation method
to account for indirect costs in accordance with § 200.405(d).
V. Agreement Termination
This Agreement may be terminated without further liability or penalty to the Department for any
of the following reasons:
A. By either party by giving 30 days written notice to the other party stating the reasons for
termination and the effective date.
B. By either party with 30 days written notice upon the failure of either party to carry out the
terms and conditions of this Agreement, provided the alleged defaulting party is given
notice of the alleged breach and fails to cure the default within the 30-day period.
C. Immediately if the Grantee or an official of the Grantee or an owner is convicted of any
activity referenced in Part 2 Section III. D. of this Agreement during the term of this
Agreement or any extension thereof.
D. Immediately if the Department determines that Grantee fails or has failed to meet its obligations
under Part 2 Section III. R.
E. Immediately if the Grantee, as determined by the State, (i) endangers the value,
integrity, or security of any facility, data, or personnel; or (ii) engages in any conduct
that may expose the State to liability.
F. Immediately by mutual agreement of both parties
VI. Stop Work Order
The Department may suspend any or all activities under this Agreement at any time. The
Department will provide the Grantee with a written stop work order detailing the suspension.
Grantee must comply with the stop work order upon receipt. The Department will not pay for
activities, Grantee’s incurred expenses or financial losses, or any additional compensation during
a stop work period.
VII. Final Reporting Upon Termination
Should this Agreement be terminated by either party, within 30 days after the termination, the
Grantee must return all State and federal data and provide the Department with all financial,
performance and other reports required as a condition of this Agreement. The Department will
make payments to the Grantee for allowable reimbursable costs not covered by previous
payments or other state or federal programs. The Grantee must immediately refund to the
Department any funds not authorized for use and any payments or funds advanced to the
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Grant Language Template FY 2025 (Rev. 1/2024)
Grantee in excess of allowable reimbursable expenditures.
VIII. Severability
If any part of this Agreement is held invalid or unenforceable by any court of competent
jurisdiction, that part will be deemed deleted from this Agreement and the severed part will be
replaced by agreed upon language that achieves the same or similar objectives. The remaining
parts of the Agreement will continue in full force and effect.
IX. Waiver
Failure by the Department to enforce any provision of this Agreement will not constitute a waiver
of the Department’s right to enforce any other provision of this Agreement.
X. Amendments
Any changes to this Agreement will be valid only if made in writing and executed by all parties
through an amendment to this Agreement. Any change proposed by the Grantee which would
affect the Department funding of any project must be submitted in writing to the Department
immediately upon determining the need for such change. The Department has sole discretion to
approve or deny the amendment request. The Grantee must, upon request of the Department
and receipt of a proposed amendment, amend this Agreement.
XI. Liability
The Grantee assumes all liability to third parties, loss, or damage because of claims, demands,
costs, or judgments arising out of activities, such as but not limited to direct activity delivery, to
be carried out by the Grantee in the performance of this Agreement, under the following
conditions:
A. The liability, loss, or damage is caused by, or arises out of, the actions of or failure to act
on the part of the Grantee, any of its subcontractors, anyone directly or indirectly employed
by the Grantee, or anyone performing activities at the direction of the Grantee under this
agreement.
B. Nothing herein will be construed as a waiver of any governmental immunity that has been
provided to the Grantee or its employees by statute or court decisions.
The Department is not liable for consequential, incidental, indirect or special damages,
regardless of the nature of the action.
In the event of an incident the Grantee must:
1. Cooperate with the Department in investigating the occurrence, making available all
relevant records, logs, files, data reporting, and other materials required to comply with
applicable law or as otherwise required by the Department;
2. In the case of unauthorized disclosure or breach of confidential information, at the
Department’s sole election, with approval and assistance from the Department, notify
the affected individuals with comprised Personally Identifiable Information (PII) or
Protected Health Information (PHI) as soon as practicable but no later than is required
to comply with applicable law and provide third-party credit and identity monitoring
services to each of the affected individuals for the period required to comply with
applicable law, or, in the absence of any legally required monitoring services, for no
less than 24 months following the date of notification to such individuals;
3. Perform or take any other actions required to comply with applicable law as a result of
the occurrence including pay for: any costs associated with the occurrence, any costs
incurred by the Department in investigating and resolving the occurrence, reasonable
attorney’s fees associated with such investigation and resolution.
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XII. State of Michigan Agreement
This Agreement is governed, construed, and enforced in accordance with Michigan law,
excluding choice-of-law principles, and all claims relating to or arising out of this Agreement are
governed by Michigan law, excluding choice-of-law principles. Any dispute arising from this
Agreement must be resolved in the Michigan Court of Claims. Complaints against the State must
be initiated in Ingham County, Michigan. Grantee waives any objections, such as lack of personal
jurisdiction or forum non conveniens. Grantee must appoint an agent in Michigan to receive
service of process.
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Grant Language Template FY 2025 (Rev. 1/2024)
ATTACHMENT A
STATEMENT OF WORK
Methodology: Activities, Responsible Individual(s), Timeline and Deliverable(s)
Responsible
Individual(s)
Timeline Deliverable(s)
Objective 1
Activity 1
Activity 2
Activity 3
Objective 2
Activity 1
Activity 2
Activity 3
Objective 3
Activity 1
Activity 2
Activity 3
Objective 4
Activity 1
Activity 2
Activity 3
Objective 5
Activity 1
Activity 2
Activity 3
Page 24 of 30
Grant Language Template FY 2024 (Rev. 1/2023)
ATTACHMENT B.1
PROGRAM BUDGET SUMMARY
View at 100% or Larger MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Use WHOLE DOLLARS Only
PROGRAM DATE PREPARED Page Of
GRANTEE NAME BUDGET PERIOD
From: Error! Reference source not found. To:
MAILING ADDRESS (Number and Street) BUDGET AGREEMENT
ORIGINAL AMENDMENT
AMENDMENT #
CITY STATE ZIP CODE FEDERAL ID NUMBER
DIRECT EXPENSES TOTAL BUDGET
(Use Whole Dollars)
1. SALARIES & WAGES
2. FRINGE BENEFITS
3. EMPLOYEE TRAVEL AND TRAINING
4. SUPPLIES & MATERIALS
5. SUBAWARDS- SUBRECIPIENT SERVICES
6. CONTRACTUAL- PROFESSIONAL SERVICES
7. COMMUNICATIONS
8. GRANTEE RENT COSTS
9. SPACE COSTS
10. CAPITAL EXPENDITURES -EQUIPMENT
&OTHER
11. CLIENT ASSISTANCE – RENT
12. CLIENT ASSISTNACE – ALL OTHER
13. OTHER EXPENSE
14. TOTAL DIRECT EXPENSES
(Sum of Lines 1-13)
$0 $0 $0 $0
15. INDIRECT COSTS
16. COST ALLOCATION PLAN
17. TOTAL INDIRECT
EXPENDITURES
(Sum of Lines 15-16)
$0 $0 $0 $0
18. TOTAL EXPENDITURES $0 $0 $0 $0
Page 25 of 30
Grant Language Template FY 2024 (Rev. 1/2023)
SOURCE OF FUNDS
19. MDHHS STATE AGREEMENT
20. FEES & COLLECTIONS -1st and 2nd Party
21. FEES & COLLECTIONS -3rd Party
22. LOCAL
23. NON-MDHHS STATE AGREEMENTS
22. FEDERAL
23. OTHER
24. IN-KIND
24. FEDERAL COST BASED REIMBURSEMENT
25. TOTAL SOURCE OF FUNDS $0 $0 $0 $0
AUTHORITY: P.A. 368 of 1978
COMPLETION: Is Voluntary, but is required as a condition of
funding
The Michigan Department of Health and Human Services
is an equal opportunity employer, activities and programs provider.
Page 26 of 30
Grant Language Template FY 2024 (Rev. 1/2023)
ATTACHMENT B.2
PROGRAM BUDGET – COST DETAIL SCHEDULE
View at 100% or Larger MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES Page Of
Use WHOLE DOLLARS Only
PROGRAM BUDGET PERIOD DATE PREPARED
From:
Error! Reference
source not found.
To:
GRANTEE NAME BUDGET AGREEMENT
ORIGINAL AMENDMENT
AMENDMENT #
1. SALARY & WAGES
POSITION DESCRIPTION COMMENTS POSITIONS REQUIRED TOTAL SALARY
$0
$0
$0
$0
$0
$0
$0
1. TOTAL SALARIES & WAGES: 0 $ 0
2. FRINGE BENEFITS (Specify)
FICA LIFE INS. DENTAL INS. COMPOSITE RATE
UNEMPLOY INS. VISION INS. WORK COMP. AMOUNT 0.00%
RETIREMENT HEARING INS.
HOSPITAL INS. OTHER (specify) 2. TOTAL FRINGE
BENEFITS
$0
3. EMPLOYEE TRAVEL AND TRAINING (Specify if category exceeds 10% of Total Expenditures)
3 TOTAL TRAVEL AND TRAINING
$0
4. SUPPLIES & MATERIALS (Specify if category exceeds 10% of Total Expenditures)
4. TOTAL SUPPLIES & MATERIALS
$0
5. SUBAWARDS-SUBRECIPIENT SERVICES (Specify Subrecipients)
Name Address Amount
5. TOTAL SUBAWARDS
$0
6. CONTRACTUAL-PROFESSIONAL SERVICES (Specify contracts)
Name Address Amount
6. TOTAL CONTRACTUAL
$0
7. COMMUNITCATIONS
7. TOTAL COMMUNICATIONS
$0
8. GRANTEE RENT COSTS
8. GRANTEE RENT COSTS
$0
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9. SPACE COSTS
9. SPACE COSTS
$0
10. CAPITAL EXPENDITURES - EQUIPMENT & OTHER(Specify items)
10. TOTAL CAPITAL EXPENDITURES- EQUIPMENT & OTHER:
$0
11. CLIENT ASSISTANCE - RENT
11. CLIENT ASSISTANCE - RENT
$0
12. CLIENT ASSISTANCE - OTHER
12. CLIENT ASSISTANCE- OTHER
$0
13. OTHER EXPENSES (Specify if category exceeds 10% of Total Expenditures)
13. TOTAL OTHER:
$0
14. TOTAL DIRECT EXPENDITURES (Sum of Totals 1-13) 14. TOTAL DIRECT
EXPENDITURE
$ 0
15. INDIRECT COST CALCULATIONS Rate #1: Description Base $0 X Rate 0.0000 % Total
Rate #2: Description Base $0 X Rate 0.0000 % Total
15. TOTAL INDIRECT COST
$ 0
$ 0
$ 0
16. COST ALLOCATION
16. COST ALLOCATION
$0
17. TOTAL INDIRECT EXPENDITURES (Sum of lines 15-16) $ 0
18. TOTAL EXPENDITURES (Sum of lines 14 & 17) $ 0
AUTHORITY: P.A. 368 of 1978
COMPLETION: Is Voluntary, but is required as a condition of funding
The Michigan Department of Health and Human Services is an equal opportunity
employer, activities and programs provider.
DCH-0386 (E) (Rev 6/15) (W) Previous Edition Obsolete. Use Additional Sheets as Needed
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ATTACHMENT B.3
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
EQUIPMENT INVENTORY SCHEDULE
Please list equipment items that were purchased during the Agreement period as specified in the Agreement
budget’s cost detail schedule - Attachment B.2. Provide as much information about each piece as possible,
including quantity, item name, item specifications: make, model, etc. Equipment is defined to be an article of non-
expendable tangible personal property having a useful life of more than one year and an acquisition cost of $5,000
or more per unit. Please complete and attach this form to the final FSR progress report.
Grantee Name: Agreement #: Date:
Quantity Item Name Item Specification Tag
Number
Purchased
Amount
$
$
$
$
$
$
$
$
$
$
Total $ 0
Grantee’s Signature: Date:
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ATTACHMENT C
PERFORMANCE / PROGRESS REPORT REQUIREMENTS
A. The Grantee must submit the following reports on the following dates:
B. Any such other information as specified in the Statement of Work, Attachment A
must be developed and submitted by the Grantee as required by the Contract
Manager.
C. Reports and information must be submitted to the Contract Manager at:
D. The Contract Manager will evaluate the reports submitted as described in Attachment C,
Items A. and B. for their completeness and adequacy.
E. The Grantee must permit the Department or its designee to visit and to make an evaluation
of the project as determined by Contract Manager.
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ATTACHMENT E
OTHER SPECIFIC PROGRAM REQUIREMENTS
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Application Preview
Facesheet
Facesheet for Pontiac Integrated Urgent Care - 2025 7/5/2024__________________________________________________________________________
1.Demographic Information
Please review the pre-populated information and edit as needed. Enter the first month and date of the grantee agency's
fiscal year.
a.Demographic Information Name
b.Organizational Unit
c.Address
d.Address 2
e.City State Zip
f.Federal ID Number Reference No.Unique Entity Id.
g.Agency's fiscal year (beginning month and day)
h.Agency Type
Private, Non-Profit Public
1.Select the appropriate radio button to indicate the agency method of accounting.
Accrual
Cash
Modified Accrual
2.Program / Service Information
Please indicate if the grantee agency is implementing the program. If no is selected, enter the implementing agency's
name. Click on the mailbox to enter the implementing agency's contact information.
a.Program / Service Information Name
b.Is implementing agency same as Demographic Information Yes No
c.Implementing Agency Name
Address
City State Zip
Phone Fax
d.Project Start Date End Date
e.Amount of Funds Allocated Project Cost
APPLICATIONS MUST BE SUBMITTED VIA EGrAMS. HANDWRITTEN APPLICATIONS WILL NOT BE CONSIDERED FOR FUNDING.
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Contact & Certification Information for Pontiac Integrated Urgent Care - 2025 7/5/2024__________________________________________________________________________
3. Contact Information
At a minimum, the grantee Agency must identify an Authorized Official, Financial Officer and a Project Director in the
application. If the individuals identified are system users, select the applicable user name from the lookup menu. Review
and edit their contact information as needed.
a.Contact Type
Name
Title
Mailing Address
City State Zip Code
Telephone Fax
E-mail Address
APPLICATIONS MUST BE SUBMITTED VIA EGrAMS. HANDWRITTEN APPLICATIONS WILL NOT BE CONSIDERED FOR FUNDING.
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Certifications
Certifications for Pontiac Integrated Urgent Care - 2025 7/5/2024__________________________________________________________________________
4.Assurances and Certifications
A. SPECIAL CERTIFICATIONS
a By checking this box, the individual or officer certifies that the individual or officer is authorized to approve
this grant application for submission to the Department of Health and Human Services on behalf of the
responsible governing board, official or Grantee.
b By checking this box, the individual or officer certifies that the individual or officer is authorized to sign the
agreement on behalf of the responsible governing board, official or Grantee.
B. State of Michigan Information Technology Information Security Policy
1.By checking the following boxes, the Grantee acknowledges compliance with State of Michigan Information
Technology Information Security Policy* and provides the following assurances:
a.The Grantee Project Director will be notified within 24 hours when its users are terminated or transferred
or immediately if after an unfriendly separation.
b.The Grantee Project Director will annually review and certify user accounts to verify the user’s access is
still required and the user is assigned the appropriate permissions.
c.The Grantee Project Director will remove user’s access within 48 hours of notification when users are
terminated or transferred, or immediately if after an unfriendly separation.
d.After 120 days of inactivity, when the user attempts to log into their account they will receive a message
stating their account has been deactivated, and the user will have to request the account be reinstated.
*Policy available at https://www.michigan.gov/documents/dmb/1340_193162_7.pdf
APPLICATIONS MUST BE SUBMITTED VIA EGrAMS. HANDWRITTEN APPLICATIONS WILL NOT BE CONSIDERED FOR FUNDING.
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Narrative
Narrative for Pontiac Integrated Urgent Care - 2025 7/5/2024__________________________________________________________________________
5.Program Synopsis
Please provide a brief synopsis of the project, including background, purpose and/or overall goal of the project.
6.Program Target Area
Please identify the counties that will directly receive services or be impacted by the project.
Counties project will serve (check all that apply):
Alcona Alger Allegan
Alpena Antrim Arenac
Baraga Barry Bay
Benzie Berrien Branch
Calhoun Cass Charlevoix
Cheboygan Chippewa Clare
Clinton Crawford Delta
Dickinson Eaton Emmet
Genesee Gladwin Gogebic
Grand Traverse Gratiot Hillsdale
Houghton Huron Ingham
Ionia Iosco Iron
Isabella Jackson Kalamazoo
Kalkaska Kent Keweenaw
Lake Lapeer Leelanau
Lenawee Livingston Luce
Mackinac Macomb Manistee
Marquette Mason Mecosta
Menominee Midland Missaukee
Monroe Montcalm Montmorency
Muskegon Newaygo Oakland
Oceana Ogemaw Ontonagon
Osceola Oscoda Otsego
Ottawa Presque Isle Roscommon
Saginaw St. Clair St. Joseph
Sanilac Schoolcraft Shiawassee
Tuscola Van Buren Washtenaw
Wayne Wexford Out Wayne
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Work Plan
Work Plan for Pontiac Integrated Urgent Care - 2025 7/5/2024__________________________________________________________________________
FOR OFFICE USE ONLY: Version # ______ APP # ______
7.Workplan
Objectives—List the objectives necessary to successfully achieve the program goal(s). If there is more than one program
goal, group the related objectives and activities under the appropriate goal. Objectives should respond to the identified
need and be SMART (specific, measurable, appropriate, realistic and time-based).
Activities—for each objective, include the major activities necessary to accomplish the objective. The activities should
clearly describe what actions or steps will be taken to accomplish each objective (i.e. the “to-do” list). Activities should be
grouped under the objective to which they pertain.
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Budget
Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
Line Item Qty Rate Units UOM Total
Amou
nt 1.Salary & Wages
Instructions : Select all the position titles or job descriptions required to staff the program. Enter the quantity and rate as average cost per FTE. Positions may also be entered
with hourly rate information. Select the UOM (Unit of Measure) using the look-up icon as 'FTE'.
Using Notes enter information to clarify the position description or the calculation of the positions salary and wages or fringe benefits as needed (i.e., if the employee is limited
term and/or does not receive fringe benefits).
This category includes compensation paid to permanent and part-time employees on the payroll of the Grantee who work in the program. Is reasonable for the services rendered
and conforms to the established written policy of the Grantee consistently applied to both Federal and non-Federal activities.
This category may include the cost of leave/paid time off (e.g., vacation, sick, holiday, bereavement, military) or it may be included as a fringe benefit, based on the Grantee’s
written policy. See Section 2. It cannot be included in both categories and must be consistently budgeted and expensed for all Federally and non-Federally funded programs and
activities of the Grantee.
This category does not include personnel hired on a private contract basis or through a personnel service, contractual services, or professional fees. Consulting services,
professional fees or personnel hired on a private contracting basis should be included in Contractual – Professional Services.
1. Accountant
2. Administrator
3. Analyst
4. Assistant
5. Attorney
6. Chief Executive Officer
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
7. Clerk
8. Data Entry/Coder
9. Consultant
10. Coordinator
11. Counselor
12. Case Manager
13. Case Worker
14. Customer Support
15. Director
16. Educator
17. Epidemiologist
18. Evaluator
19. Executive Director
20. Financial Analyst/Specialist
21. Field Coordinator
22. Financial Officer
23. Health Educator
24. Health Officer
25. Intern
26. Information Officer
27. Laboratory Technician
28. Lead Worker
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
29. Medical Personnel
30. Manager
31. Nurse
32. Nutritionist/Dietician
33. Outreach Worker
34. Program/Project Manager
35. Programmer
36. Physician
37. Principle Investigator
38. Planner
39. Researcher
40. Sanitarian
41. Secretary
42. Senior Analyst
43. Specialist
44. Student
45. Surveyor
46. Social Worker
47. Technician
48. Trainer
49. Volunteer
50. Web Developer
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
51. Other [ ]
2.Fringe Benefits
Instructions : Enter composite rate for fringe benefit or select the applicable fringe benefits using the look-up icon for employees assigned to this program.
Enter Composite Rate for fringe benefit or select the applicable fringe benefits using the look-up icon for employees assigned to this program. If selecting 'All Composite Rate' is
includes the following fringe benefits; FICA, Unemployment Ins., Retirement, Health Ins., Life Ins., Visions Ins., Dental Ins., and Work Comp. If selecting 'Composite Rate', enter
the specific fringe benefits, when using composite rate.
Fringe benefits include, but are not limited to, the costs of leave/paid time off (e.g., vacation, sick, holiday, bereavement, military), employee insurance (e.g., employer paid
portion of health, dental, vision, life), pensions, employer contribution to a retirement account, bonuses, health stipends in lieu of health insurance, unemployment, workers
compensation, social security.
The cost of leave/paid time off, and other taxable income (e.g., bonuses, health stipends in lieu of health insurance) may be included in salaries/wages, , . See Item 1 above. It
cannot be included in both categories and must be consistently budgeted and expensed for all Federally and non-Federally funded programs and activities of the Grantee.
The cost of fringe benefits is allowable provided they are reasonable and are required by law, or a Grantee-employee agreement or established in the Grantee’s written policy.
Fringe benefit costs must be equitably allocated to all activities (Federal award activity and non-Federal award activity).
See Title 2 CFR 200.431 for fringe benefit regulations.
1. All Composite Rate
2. Composite Rate
3. Dental Insurance
4. FICA
5. Hearing
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
6. Hospitalization
7. Life Insurance
8. Longevity
9. Retirement
10. Tuition Remissions
11. Unemployment
12. Vision Insurance
13. Worker's Compensation
14. Other [ ]
3.Employee Travel and Training
Instructions : Enter cost of employee travel. Use only for travel costs of permanent and part-time employees assigned to the program.
This category includes the cost of travel and training for full and part-time employees working in the program.
This category does not include travel and training costs for personnel hired on a private contract basis or through a personnel service, for contractual services, or for volunteers.
This category includes the cost of mileage, lodging, per diem, meals, tips, modes of transportation, approved registration fees for conferences, seminars, and other types of
training related to the program.
The costs must be consistent with the Grantee’s written policy and procedures to be allowable.
See Title 2 CFR 200.474 for travel expense requirements.
Specific detail should be stated in the space provided if the category exceeds 10% of the Total Expenditures.
1. Conference Registration
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
2. Air Fare
3. Lodging
4. Mileage [ ]
5. Per Diem [ ]
6. Lease Vehicle
7. Other [ ]
4.Supplies & Materials
Instructions : Enter cost of supplies & materials.
This category includes consumable and short-term items costing less than five thousand dollars ($5,000).
Examples include office supplies, office furniture, computers, computer software, printers, printing, postage, janitorial supplies, educational supplies, medical supplies, etc.
according to the requirements of the program.
This category does not include the cost of supplies and materials related to operating a shelter or other emergency housing.
Purchases of materials and supplies must be charged at the actual price, net of applicable credits.
For budgeting purposes, when the Supplies and Materials line item budget will not exceed 10 percent of the total budgeted grant expenses, specific detail will not be required.
Detail is required only when the Supplies and Materials line item budget will exceed 10 percent.
Specific detail should be stated in the space provided if the category exceeds 10% of the Total Expenditures.
1. Clinical Supplies
2. Computer
3. Drugs/Pharmaceuticals
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
4. Educational Films
5. Educational Supplies
6. Formula
7. Office Furniture
8. Janitorial Supplies/Services
9. Medical Supplies
10. Office Supplies
11. Postage
12. Printing
13. Printer
14. Screening Supplies
15. Software
16. Vaccines
17. Other [ ]
5.Subawards – Subrecipient Services
Instructions : Enter costs of subawards (including subrecipient agreements). Statements of work are required for agreements above $50,000 and must be attached.
This category includes the cost of an agreement (subaward) between the Grantee and another organization for the purpose of carrying out a portion of the Grant program. A
subaward is a subrecipient relationship
Title 2 CFR 200.331states that a pass-through entity (in this case the Grantee) must make case by case determinations whether an agreement it makes for the disbursement of
Federal funds casts the party receiving the funds in the role of a subrecipient or contractor.
In determining whether an agreement casts the role of party receiving the Federal funds from the Grantee as a subrecipient or contractor, the substance of the relationship is
more important than the form of the agreement. All characteristics listed below may not be present in all cases and the Grantee must use judgement when determining if the
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
agreement is a subaward or a procurement contract.
Subrecipient Characteristics
A subaward is for the purpose of carrying out a portion of a Federal award and creates a Federal assistance relationship with the subrecipient. Characteristics of a subrecipient
include:
(1) In accordance with its agreement, uses the Federal awards to carry out a public purpose specified in authorizing statute, as opposed to providing goods and services for the
benefit of the pass-through entity.
(2) Is responsible for adherence to applicable Federal program requirements specified in the Federal award.
(3) Has responsibility for programmatic decision making.
(4) Determines who is eligible to receive what Federal assistance.
(5) Has its performance measured in relation to whether objectives of the Federal program are met.
1. Subrecipient Agency [ ]
2. Other [ ]
6.Contractual - Professional Services
Instructions : Enter contracts for professional and/or personnel services. Statements of work are required for contracts above $50,000 and must be attached.
This category includes the costs of professional and personnel services rendered by members of a particular profession or possess a certain skill set and are not employees of
the Grantee.
This category includes the costs of services such as accounting, auditing, payroll, consulting, services, contract employees, etc.
Grantees generally hire contract employees in place of part-time or full-time staff because of the need for specialized skills or budgetary reasons.
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
The Grantee is not responsible for taxes, social security, workers compensation, unemployment, health benefits, sick or vacation time for contract employees.
Travel expenses may be included when it is part of the contract terms between the Grantee and the contractor.
Training expenses may be included when it is part of the contract terms between the Grantee and the contractor.
1. Accounting Services [ ]
2. Audit Services [ ]
3. Evaluation Services [ ]
4. Payroll Services [ ]
5. Subcontracting Agency [ ]
6. Other [ ]
7.Communications
Instructions : Enter communication costs. This category includes the cost of telephone services (cell and/or land lines), hotline, data lines, internet services, cloud services, copy
machine, and website necessary for the operation of the program,
The cost of certain telecommunication and video surveillance services or equipment are prohibited in accordance with Title 2 CFR 200.216.
For budgeting purposes, when the Communications line item budget will not exceed 10 percent of the total budgeted grant expenses, specific detail will not be required. Detail is
required only when the Communications line item budget will exceed 10 percent.
Specific detail should be stated in the space provided if the category exceeds 10% of the Total Expenditures.
1. Cellular Telephone Service
2. Cloud Services
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
3. Data Line
4. Fax Line
5. Hotline
6. Internet Services
7. Office Telephone Service
8. Video Conferencing Service
9. Website
10. Other [ ]
8.Grantee Rent Costs
Instructions : Enter agency rent costs. This category includes the cost of rent/leases by the Grantee for space related to the operation of the program.
This category does not include the cost of client rent assistance or equipment rentals/leases.
Specific detail should be stated in the space provided if the category exceeds 10% of the Total Expenditures.
1. Rent/Lease
2. Other [ ]
9.Space Costs
Instructions : Enter agency space costs. This category includes costs to maintain a facility related to the operation of the program. Costs include electricity, heating and air
conditioning, maintenance and repairs, lawncare and snowplowing, janitorial services, insurance, security system, depreciation (when the space is owned by the Grantee), etc.
These costs must be allocated equitably to all Federal and non-Federal activities related to the space.
Shelter Expenses – The costs associated with operating a shelter. Includes such things as rent or depreciation, insurance, utilities, maintenance and repairs, snow removal, lawn
care, trash removal, security system etc.
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
Specific detail should be stated in the space provided if the category exceeds 10% of the Total Expenditures.
1. Building Insurance
2. Depreciation
3. Electricity
4. Heating and Air Conditioning
5. Lawncare
6. Maintenance and Repairs
7. Security System
8. Snow Removal
9. Other [ ]
10.Capital Expenditures - Equipment & Other
Instructions : Enter a description of the equipment being purchased, enter number of units and the unit value.
Title 2 CFR 200.1 defines capital assets as tangible or intangible assets used in operations having a useful life of more than one year which are capitalized in accordance with
Generally Accepted Accounting Principles and includes:
• Land, buildings (facilities), equipment, and intellectual property (including software) whether acquired by purchase, construction, manufacture, exchange, or through a lease
accounted for as financial purchase under GASB or a finance lease under FASB.
• Additions, improvements, modifications, replacements, rearrangements, reinstallations, renovations, or alterations to capital assets that materially increase their value or useful
life.
Please refer to Title 2 CFR 200.439(b) for rules of allowability for equipment and other capital expenditures.
Title 2 CFR 200.436(d)(2) states that when computing depreciation the depreciation method used must reflect the pattern of consumption of asset during its useful life.
• In the absence of clear evidence indicating that the expected consumption will be significantly greater in the early portions of its useful life, the straight-line method must be
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
presumed to be the appropriate method.
• Depreciation methods once used may not be changed unless approved by the cognizant agency.
• The depreciation methods used to calculate depreciation for indirect rate purposes must be the same methods used by the non-Federal entity for its financial statements.
Upon completing equipment purchase, equipment must be tagged and listed on the Equipment Inventory Schedule (see Attachment B.3) and submitted to the agreement’s
contract manager with the final Financial Status Report.
1. Capital Expenditure: Improvements [ ]
2. Capital Expenditures: Other [ ]
3. Equipment: Communication System [ ]
4. Equipment: Computer Systems/Servers [ ]
5. Equipment: Lab Equipment [ ]
6. Equipment: Medical Equipment [ ]
7. Equipment: Vehicle [ ]
8. Other [ ]
11.Client Assistance - Rent
Instructions : Enter client rental assistance. This category includes the cost of rental assistance provided for eligible clients in accordance with the program requirements.
The Grantee must account for rental assistance separate from all other client assistance.
Specific detail should be stated in the space provided if the category exceeds 10% of the Total Expenditures.
1. Client Rent
2. Other [ ]
12.Client Assistance - All Other
Instructions : Enter costs for client assistance, excluding rental assistance.
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This category includes the costs of providing assistance for eligible clients in accordance with program requirements. The guidance below is not meant to be comprehensive and
some costs may not be allowable for a particular program. It is the Grantee’s responsibility to budget and report expenses in accordance with the program requirements.
Examples include:
(1) Gift Cards/Prepaid Cards/E-Cards/Store Cards/Vouchers – The cost various types of purchase cards (e.g., gas, phone, food), vouchers (e.g., laundry vouchers for a local
laundromat), and public transportation cards/tokens, etc. in accordance with program requirements.
(2) Transportation – The cost of taxis, Uber, Lyft, etc. for eligible clients when necessary for the health and safety for eligible clients in accordance with program requirements.
(3) Utilities – The costs associated with heat, electricity, water, etc. for eligible clients in accordance with program requirements.
(4) Personal Care – The costs associated with food, formula, clothing, diapers, toiletries, medication, medical equipment, etc. for eligible clients in accordance with program
requirements.
(5) Safety – The cost of changing windows and doors or locks, cost of short-term alternative housing (e.g., hotel due to shelter capacity), security cameras, assistance for
obtaining long-term housing for a victim (regardless of distance, based on safety needs) etc. for eligible clients in accordance with program requirements.
(6) Other – The cost of assistance not specifically identified above for eligible clients in accordance with program requirements.
Specific detail should be stated in the space provided if the category exceeds 10% of the Total Expenditures.
1. Emergency Financial Assistance
2. Gift/Prepaid/Store Cards/Vouchers
3. Personal Care
4. Relocation
5. Safety Costs
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6. Shelter Expenses
7. Transportation (taxi, rideshare)
8. Utility Assistance
9. Other [ ]
13.Other Expense
Instructions : Enter cost of other expenses. This cost category includes expenses not previously identified on other line items purchased for the operation of the program.
If the Grantee will claim the DeMinimis Indirect rate, the Grantee’s accounting records must clearly identify the following excluded expenses which are included as Other
Expenses for budget and FSR purposes and excluded when determining Total Modified Direct Costs.
(1) Charges for Patient Care – Medical, social, and educational services to patients relating to prevention, diagnosis, and treatment. Includes medical fees, laboratory, pharmacy,
and other health inpatient care, home care services, treatments, professional and consultation fees and related travel costs, transportation of patients including accompanying
parents or guardians (or other escort), and for sundry related support such as meals and housing.
(2) Participant Support Costs – Direct costs for such items for stipends or subsistence allowances, travel allowances, and registration fees paid to or on behalf of participants or
trainees (not employees) in connection with conferences or training projects.
2 CFR 200.201
(3) Tuition Remission – Refers to ways that a college or university pays tuition costs for students. Includes tuition waivers and tuition payments.
(4) Scholarships and Fellowships – A scholarship is generally an amount paid or allowed to a student at an educational institution for the purpose of study. A fellowship grant is
generally an amount paid or allowed to an individual for the purpose of study or research.
Specific detail should be stated in the space provided if the category exceeds 10% of the Total Expenditures.
1. Audit Services
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
2. Auto Insurance
3. External Consultant
4. Equipment Leasing
5. Fixed Unit Rate/Fee for Service
6. Honorarium
7. Incentives
8. Legal Fees
9. Membership
10. Meetings
11. Patient Care
12. Participant Support Costs
13. Scholarships/Fellowships
14. Subscriptions
15. Training/Conference
16. Other [ ]
14.Indirect Costs
Instructions : Please reference the "Indirect Costs and Cost Allocation Plan Instructions" by clicking the "Show Documents".
Please note that If “Federal Approval” is selected the agency’s Federal Indirect Approval Letter must be attached to the Agency’s profile in EGrAMS.
Please note that if you selecting "De Minimis Rate" you must attach the B.4 - Budget De Minimis form.
1. Federal Approval [ ]
2. State Approval [ ]
________________________________________________________________________________________________________________
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Budget Detail for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
3. Other Approval
4. De Minimis Rate [ ]
5. University Indirect Rate
15.Cost Allocation Plan
Instructions : Please reference the "Indirect Costs and Cost Allocation Plan Instructions" by clicking the "Show Documents".
1. Cost Allocation Plan
2. Nonprofit CAP (pre-approved only)
3. Other Indirect Cost Distributions
Totals
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Budget Summary for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
Category Total Amount Narrative
1.Salary & Wages
2.Fringe Benefits
3.Employee Travel and Training
4.Supplies & Materials
5.Subawards – Subrecipient Services
6.Contractual - Professional Services
7.Communications
8.Grantee Rent Costs
9.Space Costs
10.Capital Expenditures - Equipment & Other
11.Client Assistance - Rent
12.Client Assistance - All Other
13.Other Expense
14.Indirect Costs
15.Cost Allocation Plan
Totals
SOURCE OF FUNDS
Category Total Amount Cash Inkind Narrative
1.MDHHS State Agreement
2.Fees and Collections - 1st and 2nd
Party
3.Fees and Collections - 3rd Party
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Budget Summary for Pontiac Integrated Urgent Care - 2025 7/5/2024________________________________________________________________________________________________________________
4.Local
5.Non-MDHHS State Agreements
6.Federal
7.Other
8.In-Kind
9.Federal Cost Based
Reimbursement
Totals
APPLICATIONS MUST BE SUBMITTED VIA EGrAMS. HANDWRITTEN APPLICATIONS WILL NOT BE CONSIDERED FOR FUNDING.
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Miscellaneous
Miscellaneous for Pontiac Integrated Urgent Care - 2025 7/5/2024__________________________________________________________________________
11.Supporting documentation, if required
Please attach additional documents that are required by the Contract Manager.
Attachment Title Attachment
APPLICATIONS MUST BE SUBMITTED VIA EGrAMS. HANDWRITTEN APPLICATIONS WILL NOT BE CONSIDERED FOR FUNDING.
__________________________________________________________________________
Page: 24 of 24
Last Revised date: 2/27/2024
1
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
A. Activities Allowed, Allowable Costs, Cost Principles, Accounting System and Controls
A.1.Are grant funds only used on allowable activities and
not on items prohibited by the laws, regulations, and
provisions of each MDHHS contract and program?
☐ Yes
☐ No
A.2.Are staff aware of the applicable cost principles in Title
2 CFR 200, Subpart E?
☐ Yes
☐ No
A.3.Are staff aware of unallowable charges (e.g., alcoholic
beverages, bad debts, contingency reserves,
contributions and donations, fund raising, use
allowances, etc.)?
☐ Yes
☐ No
A.4.If costs are allocated to multiple funding sources, are
they allocated in accordance with benefits received and
comply with the cost principles and documented
process?
☐ Yes
☐ No
A.5.Does the Agency have written accounting policies and
procedures for receipt and disbursement of funds,
purchasing, and payment of expenses?
☐ Yes
☐ No
A.6.Does the Agency have a financial management system
that provides for identification of all Federal awards
received and expended, and the Federal programs
under which they were received? [Title 2 CFR
200.302(b)(1)]
☐ Yes
☐ No
A.7 Does the financial management system provide a clear
and accurate record of receipt and disbursement of
grant funds with separate revenue and expense
accounts for each separate program and agreement?
☐ Yes
☐ No
A.8 Is the financial management system capable of tracking
revenues and expenses by the MDHHS grant period
when it differs from the Agency’s fiscal year?
☐ Yes
☐ No
A.9 Does the Agency have written procedures for
determining reasonableness, allocability, and
allowability of costs in accordance with Title 2 CFR
subpart E and the conditions of the Federal award?
[Title 2 CFR 200.302(b)(7)]
☐ Yes
☐ No
A.10 Does the Agency have an effective internal control
system over Federal awards that provides reasonable
assurance that the Agency manages Federal awards in
compliance with Federal statutes, regulations, and the
terms and conditions of the Federal awards; and these
internal controls comply with guidance issued by the
Comptroller General of the United States and the
Committee of Sponsoring Organization of the Treadway
Commission (COSO)? [Title 2 CFR 200.303(a)]
☐ Yes
☐ No
A.11 Does the Agency evaluate and monitor its compliance
with statutes, regulations, and the terms and conditions
of Federal awards? [Title 2 CFR 200.303(c)]
☐ Yes
☐ No
Last Revised date: 2/27/2024
2
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
A.12 Does the Agency use an automated accounting system
with controls in place to limit access to authorized
personnel only (e.g., access is limited by secure user ID
and password, are roles based on least privilege?
☐ Yes
☐ No
A.13 Does the Agency maintain a complete set of books that
include a cash receipts journal, a cash disbursements
journal or transaction/voucher listing, and general
ledger?
☐ Yes
☐ No
A.14 Does the general ledger include account titles, posting
dates, descriptions of transactions, posting references,
debit and credit amounts and balances?
☐ Yes
☐ No
A.15 Does the Agency have a chart of accounts that is used
by all programs/activities of the Agency?
☐ Yes
☐ No
A.16 Does the accounting line detail enable reporting of
MDHHS grant expenditures to compare easily with the
MDHHS grant budget line items?
☐ Yes
☐ No
A.17 Do the general ledger revenue and expense accounts
for MDHHS grants agree with the reports (e.g.,
Financial Status Report or Statement of Expenditures,
etc.)?
☐ Yes
☐ No
A.18 Does the Agency follow Generally Accepted Accounting
Principles (GAAP) to record financial information?
☐ Yes
☐ No
A.19 Is the modified accrual (government) or accrual
(nonprofit) basis of accounting used to record revenues
and expenses?
☐ Yes
☐ No
A.20 Are there clearly defined responsibilities for the
following duties, including consideration for access and
use within the automated accounting system? Indicate
all that apply and identify the position title(s)
responsible.
☐ Yes
☐ No
a.Reconciliation of bank accounts a. Click or tap here to enter text.
b.Approving invoices for payment b. Click or tap here to enter text.
c.Approving time records c. Click or tap here to enter text.
d.Payroll preparation d. Click or tap here to enter text.
e.Approving payroll for payment e. Click or tap here to enter text.
f.Mailing or delivering payroll checks f. Click or tap here to enter text.
g.Opening mail g. Click or tap here to enter text.
h.Preparing bank deposit slips h. Click or tap here to enter text.
i.Making bank deposit i. Click or tap here to enter text.
j.Posting receipts to the accounting system j. Click or tap here to enter text.
k.Posting expenses to the accounting system k.Click or tap here to enter text.
A.21 Is the person that approves invoices for payment (a)
other than someone that requesting payment, and (b)
knowledgeable about allowable and unallowable costs?
☐ Yes
☐ No
Last Revised date: 2/27/2024
3
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
A.22 Does that person authorizing invoices for payment
review original invoices and other supporting
documentation?
☐ Yes
☐ No
A.23 Are all expenditure payments supported by
documentation and include (a) type of purpose of
expense, (b) amount, (c) date service was provided, (e)
date of invoice, and (f) programs to be charged?
☐ Yes
☐ No
A.24 Are original invoices marked paid to prevent a duplicate
payment?
☐ Yes
☐ No
A.25 Do only persons authorized to prepare or supervise the
preparation of checks has access to blank checks?
☐ Yes
☐ No
A.26 Are all checks pre-numbered?☐ Yes
☐ No
A.27 Are all voided checks retained?☐ Yes
☐ No
A.28 Are all voided checks clearly marked as void?☐ Yes
☐ No
A.29 Do all checks require two signatures?☐ Yes
☐ No
A.30 Are there dollar threshold limitations when checks
require only one signature?
☐ Yes
☐ No
A.31 Do the Agency’s policies and procedures prohibit
signing blank checks?
☐ Yes
☐ No
A.32 Do the Agency’s policies and procedures prohibit
checks to be made out to Cash?
☐ Yes
☐ No
A.33 Are individuals (a) who sign checks, (b) have
disbursement responsibilities, or (c) receipting
responsibilities, properly bonded?
☐ Yes
☐ No
A.34 Do the Agency’s policies and procedures describe when
petty cash may be used, the dollar threshold, and
documentation required, and a process to account for
the petty cash fund?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
A.35 Are the accounting records current and balanced
regularly?
☐ Yes
☐ No
A.36 Are the Agency’s bank accounts reconciled monthly by
someone who does not authorize transactions and/or
are the reconciliations reviewed by management?
☐ Yes
☐ No
A.37 Is the Agency current with filing payroll, unemployment,
and filings with the Internal Revenue Service?
☐ Yes
☐ No
A.38 Are the accounting records and confidential client
records adequately protected in accordance with laws
regarding privacy and confidentiality, and protected from
fire and damage? [Title 2 CFR 200.303(e)]
☐ Yes
☐ No
Last Revised date: 2/27/2024
4
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
A.39 Is source documentation (e.g., vouchers and original
invoices, etc.) readily available to support amounts
entered in IT systems and charged to MDHHS grants?
☐ Yes
☐ No
A.40 When the accrual basis of accounting is used, are all
costs reported to MDHHS actually incurred during the
funding period and paid within the time period specified
(i.e., reported in the proper grant year)?
☐ Yes
☐ No
A.41 Do the Agency’s record retention policies comply with
the contract provisions and Title 2 CFR 200.334?
☐ Yes
☐ No
A.42 Does the Agency have back up policies and procedures
to ensure that data can be retrieved in the event of
system failure?
☐ Yes
☐ No
A.43 Does the Agency’s accounting system have budgetary
controls, by line item and total, to prevent excess
expenses from being charged to funding sources?
☐ Yes
☐ No
A.44 Does the Agency have written policies and procedures
for management and the governing board to document
its review of a functional budget compared to actual
expenses by funding source and program?
[Title 2 CFR 200.302(b)]
☐ Yes
☐ No
A.45 Does the Agency have policies and procedures for
management and the governing board to follow-up on
budget variances when they occur?
☐ Yes
☐ No
A.46 Does the governing board have an Audit and/or Finance
Committee that convenes and communicates regularly
with the governing board to assist in understanding and
responding to adverse financial developments?
☐ Yes
☐ No
A.47 Does the Agency have adequate controls over the
financial management system to provide complete and
accurate data processing (e.g., sequence checks,
referential integrity checks, control/hash totals, range
checks, run totals, reconciliations, etc.)?
☐ Yes
☐ No
A.48 Does the Agency have procedures to identify and
correct processing errors?
☐ Yes
☐ No
A.49 Does the Agency’s financial management system
produce logs or audit trails for all user activity, including
system administrators and transaction processing?
☐ Yes
☐ No
A.50 Can users modify the financial management system
logs or audit trails?
☐ Yes
☐ No
A.51 Are third party contractors used to provide accounting
systems, processing, or functions?
☐ Yes
☐ No
A.52 Are third party contracts or service level agreements in
place?
☐ Yes
☐ No
☐ N/A
Last Revised date: 2/27/2024
5
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
A.53 Are external audits performed of third-party contractors
that provide accounting systems, processing, or
functions?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
A.54 Are SSAE 18 reports of third-party contractors required
and reviewed?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
A.55 Does the Agency have policies and procedures
regarding updating or changing the automated financial
management system?
☐ Yes
☐ No
A.56 Does the Agency have a formal change management
process in place to ensure data integrity?
☐ Yes
☐ No
B. Personnel Costs
B.1 Does the Agency have a documented process for
allocating staff time among all programs and activities to
accurately reflect personnel costs reported for each
benefitting grant?
☐ Yes
☐ No
B.2 Are personnel records supported by a system of internal
control which provides reasonable assurance that
personnel expenses are accurate, allowable, and
properly allocated? [Title 2 CFR, 200.430(i)(1)(i)]
☐ Yes
☐ No
B.3 Do personnel expense records reasonably reflect the
TOTAL activity (i.e., time worked and paid time off) for
which the employee is compensated by the Agency, not
to exceed 100% of compensated activities?
[Title 2 CFR 200.430(i)(1)(iii)]
☐ Yes
☐ No
B.4 Do personnel expense records support distribution of an
employee’s salary and wages among specific activities
or cost objectives if the employee works on more than
one Federal award; a Federal award and a non-Federal
award; an indirect cost activity and a direct cost activity;
two or more indirect cost categories which are allocated
using different allocation bases; or an unallowable
activity and a direct or indirect cost activity? [Title 2
CFR 200.430(i)(1)(vii)]
☐ Yes
☐ No
B.5 If budget estimates (determined before services are
performed) are used for interim accounting purposes for
allocating and reporting personnel costs, are the
following in place:
a. The system for establishing the estimates produces
reasonable approximations of the activity actually
performed?
b. Significant changes in the corresponding work
activity are identified and entered into the records in
a timely manner?
c. The system of internal controls includes processes
to review after-the-fact activity in comparison to the
budget estimates, with adjustments to ensure the
☐ Yes
☐ No
☐ N/A
Click or tap here to enter text.
Last Revised date: 2/27/2024
6
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
final amount charged to the Federal award is
accurate, allowable, and properly allocated?
[Title 2 CFR 200.430(i)(1)(viii)]
B.6 For local governments and Indian Tribes using
substitute processes or systems (other than those
described in Title 2 CFR 200.430(i)(1) for allocating
salaries and wages to Federal awards, such as but not
limited to, random moment sampling, rolling time
studies, case counts, or other quantifiable measures of
work performed, is the substitute system approved by
the cognizant agency for indirect costs? [Title 2 CFR
200.430(i)(5)]
☐ Yes
☐ No
☐ N/A
Click or tap here to enter text.
B.7 Do personnel positions charged to the grant generally
conform to positions in the MDHHS budget?☐ Yes
☐ No
B.8 Are attendance records maintained to monitor leave
usage?
☐ Yes
☐ No
B.9 Do supervisors approve leave time taken?☐ Yes
☐ No
B.10 Does the Agency have a written Personnel Policy?☐ Yes
☐ No
B.11 Are fringe benefits, in the form of employer expenses for
employee health, life, unemployment, and workers
compensation insurance, charged based on actual
costs incurred, and supported by invoices?
☐ Yes
☐ No
B.12 Are fringe benefits, in the form of regular compensation
paid to employees during periods of authorized
absences from the job, and employer contributions for
social security, insurance, and pension costs, allocated
equitably to all related activities?
☐ Yes
☐ No
B.13 Are fringe benefit costs allocated on a per person basis
based on hours worked in the program?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
B.14 Are total fringe benefit costs allocated based on the
percentage of total salaries and wages attributable to
the program?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
B.15 Does the Agency have a documented fringe benefit
policy which includes all fringe benefits? [Title 2 CFR
200.431(a)]
☐ Yes
☐ No
C. Travel Costs
C.1 Does the Agency have written travel policies and
procedures defining reasonable limits for hotel and meal
reimbursements, mileage rates, unallowable costs, and
documentation requirements? [Title 2 CFR 200.475(a)]
☐ Yes
☐ No
Last Revised date: 2/27/2024
7
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
C.2 Is travel charged to MDHHS grants supported by
employee travel vouchers that include the purpose of
travel, period covered, destination, departure and arrival
times, with appropriate documentation? [Title 2 CFR
200.475(b)(1) requires documentation that justifies
participation of the individual is necessary to the Federal
award]
☐ Yes
☐ No
D. Space Costs
D.1 Agency Owned Buildings – Is space based on
depreciation plus actual operating and maintenance
costs with NO use allowance?
☐ Yes
☐ No
☐ N/A Agency does not own buildings.
D.2 Agency Rented Buildings – Is the space cost supported
by a current signed lease agreement?
☐ Yes
☐ No
☐ N/A Agency does not rent space.
D.3 Is space cost allocated to all benefitting programs by
square footage used by each program or another
consistently applied allocation base?
☐ Yes
☐ No
☐ N/A Space costs are not funded with MDHHS
funded grants.
D.4 Does the Agency have a documented written space
cost policy and procedure?☐ Yes
☐ No
☐ N/A Space costs are not funded with MDHHS
funded grants.
E. Contractual Costs
E.1 Does the Agency have a current executed contract for
each contractor?
If N/A, proceed to Section F.
☐ Yes
☐ No
☐ N/A No contractual costs are funded with
MDHHS funded grants.
E.2 Do the contracts contain the applicable provisions
described in Title 2 CFR Appendix II?
☐ Yes
☐ No
E.3 Are contractor charges supported by detailed billings
that include type and amount of services/goods
provided rather than only stating For Services
Rendered?
☐ Yes
☐ No
E.4 Are contract billings reviewed prior to payment to
ensure consistency with the contract terms and
objectives?
☐ Yes
☐ No
F. Indirect Costs
F.1 Are indirect costs charged to MDHHS programs (e.g.,
agency-wide administration, division level
administration, county/city central services, nursing
supervision, general nursing, etc.)?
☐ Yes
☐ No
F.2 If charging indirect costs to the MDHHS, is the
methodology being consistently used for all grant
awards (MDHHS and other funding sources) in
accordance with Title 2 CFR Part 200?
☐ Yes
☐ No
Last Revised date: 2/27/2024
8
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
F.3 Select the indirect methodology used:
a. A DeMinimis rate of 10% of modified total direct
costs.
☐
b. A Federally approved indirect cost rate
negotiated between the Agency and the Federal
government.
☐
c. A rate negotiated between MDHHS and the
Agency.
☐
d. A rate approved by another Department of the
State of Michigan and accepted via contract by
MDHHS.
☐
e. Actual indirect costs allocated in accordance
with the Agency’s documented cost allocation
plan which complies with the provisions of 2
CFR Part 200 (e.g., based on a pro rate share
of personnel costs, total direct costs of the
benefitting programs, etc.).
☐
f. Indirect costs not consistently applied to all
awards and benefitting activities using one
methodology. Explain in comments column.
☐ Click or tap here to enter text.
F.4 Does the Agency comply with the indirect cost rate/cost
allocation plan documentation that provides a fair and
equitable distribution of indirect costs to all Agency
programs and activities that benefit from the indirect
expenses in accordance with 2 CFR Part 200 (e.g.,
based on a pro rate share of personnel costs, total
direct costs of the benefitting programs, etc.)?
☐ Yes
☐ No
F.5 Does the Agency comply with the indirect cost rate/cost
allocation plan documentation and certification
requirements in accordance with the appropriate
appendix of 2 CFR Part 200?
▪Appendix III – Institutions of Higher Education
▪Appendix IV – Nonprofit Organizations
▪Appendix V – Local Governments and Indian Tribe-
Wide Central Services Cost Allocation Plan
▪Appendix VI – Local Government and Indian Tribe
Indirect Cost Proposals
☐ Yes
☐ No
F.6 Which of the costs are included in the Agency-wide
administration cost pool and allocated as indirect costs.
a. Salaries/Wages/Fringe Benefit of Adm Staff ☐
b. Data Management ☐
c. Space Costs ☐
d. Communication Costs ☐
e. Equipment Depreciation ☐
f. Central Service Cost Allocation Plan (County/City)☐
g. Other (describe)☐ Click or tap here to enter text.
Last Revised date: 2/27/2024
9
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
F.7 Describe the indirect rate computation and methodology
for allocating Agency-wide costs.
Click or tap here to enter text.
F.8 Are any other indirect costs (e.g., nursing supervision,
general nursing, other) charged to MDHHS grants. If
yes, please describe the cost and how they are
allocated to the benefitting MDHHS grants and other
benefitting Agency programs and activities.
☐ Yes
☐ No
Click or tap here to enter text.
G. Cash Management
G.1 For programs funded by MDHHS on a reimbursement
basis, are costs paid for by the Agency before
reimbursements are requested from MDHHS?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
G.2 For programs funded by MDHHS on a reimbursement
basis, does the Agency have provisions in place for
timely submission of requests for reimbursement?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
G.3 If MDHHS advances funds to the Agency for any
programs, does the Agency have procedures to ensure
that time elapsed between the pre-payment (advance)
and disbursements are minimized?
[2 CFR 200.305(b)]
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
H. Equipment and Supplies
H.1 If MDHHS grant funds were used to purchase
equipment, were the items purchased specifically
approved in the MDHHS original or amended budget?
☐ Yes
☐ No
H.2 Are the equipment purchases supported by approved
invoices?
☐ Yes
☐ No
H.3 Do the Agency’s procedures designate the person(s)
authorized to approve equipment purchases?
Identify the position title(s) in the comments column.
☐ Yes
☐ No
Click or tap here to enter text.
H.4 Does the Agency maintain inventory records (for
equipment costing over $5,000), as well as adequate
safeguards over government-financed property and
equipment including an inventory every two years?
[2 CFR 200.313(d)(1),(2),(3)]
☐ Yes
☐ No
H.5 Does the Agency maintain equipment inventory records
that provide the following detail in accordance with 2
CFR 200.313(d)(1) requirements? Check all that apply
to your Agency.
☐ Yes
☐ No
a. Item Description ☐
b. Serial Number ☐
c. Cost ☐
d. Acquisition and Disposal Dates ☐
e. Location/Responsible Program ☐
f. Funding Source (including the FAIN)☐
g. Tag Number ☐
Last Revised date: 2/27/2024
10
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
H.6 Are MDHHS grant-funded supplies maintained in a
secure location with access limited to applicable
program staff?
☐ Yes
☐ No
H.7 Are there controls in place to prevent unauthorized
consumption of MDHHS grant-funded supplies?
☐ Yes
☐ No
H.8 Does the Agency maintain a perpetual inventory of
MDHHS grant-funded supplies, and perform periodic
physical inventories of grant supplies?
☐ Yes
☐ No
H.9 If yes, how often are the physical inventories
performed?
Click or tap here to enter text.
I. Matching, Level of Effort, Earmarking
I.1 Does the Agency’s financial report to MDHHS include
the required match?
☐ Yes
☐ No
☐ N/A
Click or tap here to enter text.
Click or tap here to enter text.
I.2 Is the reported match from allowable sources and
comply with the requirements specified in 2 CFR
200.306(b)?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
I.3 Does the Agency have procedures in place to ensure
required levels of effort are maintained?
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
I.4 Were required levels of effort maintained?
If no, explain in comments column.
☐ Yes
☐ No
☐ N/A
Click or tap here to enter text.
Click or tap here to enter text.
I.5 Has the Agency adhered to all earmarks established by
MDHHS grants? (e.g. Women’s Specialty Services
target; maximum amount or percentage for program
development and coordination activities; a minimum
amount or percentage for services related to access, in-
home services, and legal assistance; etc.)
If no, explain in comments column.
☐ Yes
☐ No
☐ N/A Click or tap here to enter text.
J. Procurement
J.1 Does the Agency comply with the General Procurement
Standards contained in 2 CFR 200.318, which include,
but are not limited to the following?
•The non-Federal entity must have and use
documented procurement procedures,
consistent with State, local, and tribal laws and
regulations and the standards of this section, for
the acquisition of property or services required
under a Federal award or subaward. The non-
Federal entity’s documented procedures must
conform to the procurement standards identified
in 2 CFR 200.317 through 200.327.
☐ Yes
☐ No
•Maintaining oversight to ensure that contractors
perform in accordance with the terms,
conditions, and specifications of their contracts
or purchase orders?
☐ Yes
☐ No
Last Revised date: 2/27/2024
11
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
•Maintaining written standards of conduct
covering conflicts of interest and governing the
performance of its employees engaged in the
selection, award, and administration of
contracts?
☐ Yes
☐ No
•Awarding contracts only to responsible
contractors possessing the ability to perform
successfully under the terms and conditions of
a proposed procurement?
☐ Yes
☐ No
•Maintaining records sufficient to detail the
history of procurement including the rationale
for the method of procurement, selection of
contract type, contractor selection or rejection,
and the basis for the contract price?
☐ Yes
☐ No
J.2 Does the Agency conduct all procurement transactions
in a manner providing full and open competition
consistent with the standards of 2 CFR 200.319?
☐ Yes
☐ No
J.3 Does the Agency have written procedures for
procurement transactions ensuring that all solicitations
incorporate a clear and accurate description of the
technical requirements for the material, product, or
service to be procured; all requirements which the
offerors must fulfill; and all other factors to be used in
evaluating bids or proposals? [2 CFR 200.319(d)]
☐ Yes
☐ No
J.4 Does the Agency comply with the following allowed
methods of procurement and requirements for each
(including establishing appropriate thresholds) as
specified in 2 CFR 200.320?
a. Micro-purchases (generally less than or equal to
$10,000 without quotes if price is reasonable)
b. Small purchase procedures (generally less than
$250,000 with quotes from adequate sources)
c. Sealed bids
d. Competitive proposals
e. Non-competitive procurement
☐ Yes
☐ No
K. Suspension and Debarment
K.1 Did the Agency verify that subcontractors and
subrecipients under covered transactions (procurement
contracts for goods and services under a grant or
cooperative agreement that are expected to equal or
exceed $25,000, and all subawards to subrecipients
irrespective of award amount) are not suspended or
debarred or otherwise excluded?
Note: Verification may be accomplished by checking
the System for Award Management for excluded parties
maintained by the General Services Administration at
www.sam.gov, collecting a certification from the entity,
☐ Yes
☐ No
☐ N/A
Click or tap here to enter text.
Click or tap here to enter text.
Last Revised date: 2/27/2024
12
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
or adding a clause or condition to the covered
transaction with that entity per 2 CFR 180.300.
L. Program Income
L.1 Does the Agency have program income (fees and
collections)?
☐ Yes
☐ No If no, proceed to Section M, Reporting.
L.2 Is program income (fees and collections) billed on a
sliding fee scale?
☐ Yes
☐ No
L.3 Does the fee scale conform to applicable poverty
guidelines?
☐ Yes
☐ No
L.4 Are duplicate receipt slips prepared for every receipt,
and a copy given to the client?
☐ Yes
☐ No
L.5 Are all receipts recorded promptly and deposited daily
or at appropriate intervals?
☐ Yes
☐ No
L.6 If receipts must be kept overnight, are they adequately
safeguarded?
☐ Yes
☐ No
L.7 Is all MDHHS grant program income revenue posted to
separate program revenue accounts?
☐ Yes
☐ No
L.8 Are duplicate deposit slips prepared?☐ Yes
☐ No
L.9 Are deposit slips stamped by the bank or treasurer’s
office and checked against records of receipt?
☐ Yes
☐ No
L.10 Does the Agency use program income for current costs,
and deduct program income from total allowable costs
to determine the net allowable costs [2 CFR
200.307(e)]?
☐ Yes
☐ No
M. Reporting
M.1 Are financial reports (e.g. Financial Status Reports,
Statement of Expenditures) submitted timely to
MDHHS?
☐ Yes
☐ No
M.2 Do financial reports to MDHHS include actual costs, and
not budgeted amounts?
☐ Yes
☐ No
M.3 Do financial reports to MDHHS include costs in the
appropriate line item categories?
☐ Yes
☐ No
N. Subrecipient Monitoring and Management
N.1 Does the Agency act as a pass-through entity and enter
into subaward agreements related to the subawards
passed through from MDHHS to the Agency?
☐ Yes
☐ No If no, proceed to Section O, Policies and
Procedures.
N.2 Does the Agency identify every subaward to
subrecipients as a subaward and include the following
required information [2 CFR 200.332(a)(1)]?
Check those that the Agency includes in its subaward
agreement(s).
a. Subrecipient’s unique identifier ☐
b. Federal award identification number ☐
Last Revised date: 2/27/2024
13
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
c. Federal award date ☐
d. Subaward period of performance start and end
dates
☐
e. Subaward budget period start and end dates ☐
f. Total amount of Federal award ☐
g. Federal award project description ☐
h. Name of Federal awarding agency, pass-
through entity, and contract information for
awarding official
☐
i. Assistance Listing number and name ☐
j. Whether the award is research and
development
☐
k. Indirect cost rate ☐
N.3 Does the Agency communicate all requirements
imposed on the subrecipient, including requirements
imposed by MDHHS, so that the Federal award is used
in accordance with Federal statutes, regulations and the
terms and conditions of the Federal award? [2 CFR
200.332(a)(2)]
☐ Yes
☐ No
N.4 Do the Agency subawards with subrecipients include a
requirement that the subrecipient permit the pass-
through entity and auditors to have access to the
subrecipient’s records and financial statements as
necessary? [2 CFR 200.332(a)(5)]
☐ Yes
☐ No
N.5 Does the Agency evaluate each subrecipient’s risk of
noncompliance with Federal statutes, regulations, and
the terms and conditions of the subaward for purposes
of determining the appropriate subrecipient monitoring?
[2 CFR 200.332(b)]
☐ Yes
☐ No
N.6 Does the Agency monitor the activities of subrecipients
to ensure that the subawards are used for authorized
purposes, in compliance with Federal statutes,
regulations, and the terms and conditions of the
subawards; and that subaward performance goals are
achieved? [2 CFR 200.332(d)]
☐ Yes
☐ No
N.7 Does the Agency monitor the subrecipients with on-site
reviews?
☐ Yes
☐ No
N.8 Does the Agency monitor the subrecipients with a
financial review checklist?
☐ Yes
☐ No
N.9 Does the Agency monitor the subrecipients with any
other checklists or procedures?
☐ Yes
☐ No
N.10 Does the Agency review financial and performance
reports of the subrecipients? [2 CFR 200.332(d)(1)]
☐ Yes
☐ No
N.11 Are subrecipient’s financial reports or billing reports
reviewed by the Agency for budgetary compliance and
allowable costs before reimbursing the subrecipients?
☐ Yes
☐ No
Last Revised date: 2/27/2024
14
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
N.12 Does the Agency verify that each subrecipient’s
financial reports or billings report actual expenses and
revenues, and not budgeted amounts?
☐ Yes
☐ No
N.13 Does the Agency verify that each subrecipient’s time
documentation for volunteer services used to match
requirements?
☐ Yes
☐ No
☐ N/A No volunteer time used for match.
N.14 Does the Agency test program income reported by
subrecipients for accuracy and completeness?
☐ Yes
☐ No
N.15 Does the Agency verify that its subrecipients are
audited as required by Title 2 CFR 200, Subpart F,
when it is expected that the subrecipient’s Federal
awards from all funding sources during the
subrecipient’s fiscal year exceed the $750,000 threshold
that requires a Single Audit?
[Title 2 CFR, 200.332(f)]
☐ Yes
☐ No
N.16 Does the Agency receive and review its subrecipients’
Single Audit reports, if applicable?☐ Yes
☐ No
☐ N/A
Subrecipients do not meet the threshold
for a single audit. Proceed to Section O,
Policies and Procedures.
N.17 Does the Agency follow-up to ensure its subrecipients
take timely and appropriate action on all deficiencies
pertaining to the Federal awards provided by the
Agency that are detected through audits, on-site
reviews, and receive written confirmation from the
subrecipient, highlighting the status of corrective actions
to address the deficiencies?
[2 CFR 200.332(d)(2)]
☐ Yes
☐ No
N.18 Does the Agency issue management decisions which
pertain to deficiencies provided by the Agency to the
subrecipient?
[2 CFR 200.332(d)(3)]
☐ Yes
☐ No
N.19 Does the Agency issue its management decisions within
six months of receiving the subrecipient’s audit report?
☐ Yes
☐ No
O. Policies and Procedures
O.1 Does the Agency have a documented Confidentiality
Policy? [Title 2 CFR 200.303(e)]
☐ Yes
☐ No
O.2 Does the Agency maintain written standards of conduct
covering conflicts of interest for the action of its
employees engaged in the selection, award, and
administration of contracts if there is a real or apparent
conflict of interest? [Title 2 CFR, 200.318(c)(1) and (2)]
☐ Yes
☐ No
O.3 Does the Agency have a written procedure to disclose,
in writing, any potential conflict of interest to MDHHS?
[Title 2 CFR 200.112]
☐ Yes
☐ No
Last Revised date: 2/27/2024
15
Name and Title of Authorized Representative
Click or tap here to enter text.
Email Address
Click or tap here to enter text.
Date
Click or tap here to enter text.
Signature
FOR MDHHS USE ONLY
Evaluator Name Click or tap here to enter text.
Evaluator Title Click or tap here to enter text.
Date Click or tap here to enter text.
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FISCAL QUESTIONNAIRE
Agency Name: Click or tap here to enter text.
Fiscal Year: Click or tap here to enter text.
NOTE: Any question answered N/A must have an explanation in the comment’s column.
Answer Comments
O.4.Does the Agency have written procedures for
determining the allowability of costs in accordance with
Title 2 CFR Subpart E and the terms and conditions of
the Federal award? [Title 2 CFR 200.302(b)(7)]
☐ Yes
☐ No
O.5 Does the Agency have written procedures for managing
equipment (including replacement), whether acquired in
whole or in part under a Federal award, until disposition
takes place? [Title 2 CFR 200.313(d)]
☐ Yes
☐ No
O.6 Does the Agency have written policies which include
fringe benefits offered to employees to ensure expenses
are allowed? [Title 2 CFR 200.431(a)]
☐ Yes
☐ No
O.7 Does the Agency have a written travel policy that
includes all types of expenses (e.g., lodging, meals,
mileage, modes of transportation, etc.) that are
reimbursable by the Agency when an employee is
traveling for the benefit of the Federal program?
[Title 2 CFR 200.475(a)]
☐ Yes
☐ No
O.8 Does the Agency have a written Whistleblower policy
and procedure? [41 U.S.C. 4712]
☐ Yes
☐ No
O.9 Does the Agency have a written procedure to notify
MDHHS within one business day after discovering any
unauthorized use or disclosure of confidential
information?
☐ Yes
☐ No
O.10 Does the Agency have a written HIPAA policy and
procedure?
☐ Yes
☐ No
☐ N/A
O.11 Does the Agency have a written policy and procedure to
immediately report breaches of protected health data to
MDHHS?
☐ Yes
☐ No
☐ N/A
Last Revised date: 2/27/2024
16
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indirect Costs and Cost Allocation Plan Instructions
Effective for Agreements beginning on or after 10/01/2024
1
05/08/2024
General and Administrative Indirect Expenses
1. DeMinimis Rate
a. Any non-Federal entity that does not have a negotiated rate, may elect to charge a de minimis
rate of 15% of modified total direct costs. No documentation is required to justify the 15% de
minimis indirect cost rate.
If chosen, this methodology once elected must be used consistently for all Federal awards
until such time the non-Federal entity chooses to negotiate for a rate, which the non-Federal
entity may apply to do so at any time.
See Title 2 CFR 200.414(f).
b. Modified Total Direct Costs (MTDC) means all direct salaries and wages, applicable fringe
benefits, materials and supplies, services, travel, up to the first $50,000 of each subaward
(regardless of the performance period of the subawards under the award).
MTDC excludes equipment, capital expenditures, charges for patient care, rental costs,
tuition remission, scholarships and fellowships, participant support costs, and the portion of
each subaward in excess of $50,000. Other items may only be excluded when necessary to
avoid a serious inequity in the distribution of indirect costs, and with the approval of the
cognizant agency for indirect costs.
c. When a grantee selects to utilize the DeMinimis Indirect rate, it must be applied to all Federal
awards, whether funded by MDHHS or by other sources.
2. Approved Federal Indirect Rate
a. Governmental Grantees receiving more than $35 million in direct Federal awards are
required to have an approved indirect cost rate from a Federal cognizant agency.
Governmental Grantees are defined as State and Local governments, and Indian Tribes.
b. Governmental and nonprofit Grantees which have received an approved indirect rate from
its Federal cognizant agency must provide the Federal approval letter.
c. A nonprofit may have a Federal approved indirect rate although it is not common.
d. See Title 2 CFR Part 200
Appendix VII – State and Local Governments
Appendix IV – Nonprofit Organizations
3. University Indirect Rate
a. Federal Regulations:
Title 2 CFR 200, Appendix III, C.2., states indirect costs must be distributed to applicable
Federal awards and other benefitting activities within each major function on the basis of
MTDC.
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indirect Costs and Cost Allocation Plan Instructions
Effective for Agreements beginning on or after 10/01/2024
2
05/08/2024
Title 2 CFR 200, Appendix III, C.8., states administrative costs charged to Federal awards
must be limited to 26% of MTDC for the total of General Administration and General
Expenses.
Title 2 CFR 200.1 defines MTDC as all direct salaries and wages, applicable fringe benefits,
materials and supplies, services, travel, and up to the first $50,000 of each subaward
(regardless of the period of performance of the subawards under the award). MTDC excludes
equipment, capital expenditures, charges for patient care, rental costs, tuition remission,
scholarships and fellowships, participant support costs and the portion of each subaward in
excess of $50,000. Other items may only be excluded when necessary to avoid a serious
inequity in the distribution of indirect costs, and with the approval of the cognizant agency for
indirect costs.
b. Guidance:
The following establishes a single indirect standardized rate for the Department’s grants with
State public-funded universities:
Indirect costs will be allowed up to and not to exceed 26% of MTDC for the total of General
Administration and General Expenses per the federal guidelines for all on grants regardless
the source of funds (i.e. Federal, State, Private).
4. Other Department Approved Indirect Rate
a. In some cases, a department of the State of Michigan (e.g. Department of Education) may
approve an indirect rate.
b. The Grantee must provide the approval letter which identifies the rate and what the rate is
applied to (e.g., total direct expenses, salaries and wages, modified total direct costs, etc.)
5. County-City Central Services Cost Allocation Plan
a. This category includes the allocation of central services costs allocated to the program.
b. Central service departments are within the county or city government that exist to provide
support services to other operating departments within that unit of government.
c. Examples of central service departments include finance, accounting, facilities maintenance,
information technology, human resources, purchasing, motor pools, etc.
d. All costs and data used the distribute the costs included in the plan must be supported by
formal accounting and other records that support the propriety of the costs assigned to
Federal awards.
e. Each central service cost allocation plan is required to be certified by the local government.
f. See Title 2 CFR Part 200 Appendix V, State/Local Governmentwide Central Service Cost
Allocation Plans for specific requirements.
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indirect Costs and Cost Allocation Plan Instructions
Effective for Agreements beginning on or after 10/01/2024
3
05/08/2024
6. Other Indirect Cost Distributions
a. This category includes various contributing activity costs to appropriate program areas based
on a documented allocation methodology in accordance with Title 2 CFR 200.
b. This category is generally associated with governmental entities that utilize a City-County
Central Services Plan.
Version: Standard
1
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
FY 24/25 AGREEMENT ADDENDUM A
1. This addendum adds the following section to Part I and Renumbers existing 11
Special Certification to 12 and existing 12 Signature Section to 13:
Part I
11. Agreement Exceptions and Limitations
Notwithstanding any other term or condition in this Agreement including, but
not limited to, any provisions related to any services as described in the
Annual Action Plan, any Contractor (Oakland County) services provided
pursuant to this Agreement, or any limitations upon any Department funding
obligations herein, the Parties specifically intend and agree that the
Contractor may discontinue, without any penalty or liability whatsoever, any
Contractor services or performance obligations under this Agreement when
and if it becomes apparent that State or Department funds for any such
services will be no longer available. Notwithstanding any other term or
condition in this Agreement, the Parties specifically understand and agree
that no provision in this Agreement shall operate as a waiver, bar or limitation
of any kind, on any legal claim or right the Contractor may have at any time
under any Michigan constitutional provision or other legal basis (e.g., any
Headlee Amendment limitations) to challenge any State or Department
program funding obligations; and, the parties further agree that no term or
condition in this Agreement is intended and no such provision shall be
argued to state or imply that the Contractor voluntarily assumed or undertook
to provide any services as described in the Annual Action Plan, and thereby,
waived any rights the Contractor may have had under any legal theory, in law
or equity, without regard to whether or not the Contractor continued to
perform any services herein after any State or Department funding ends.
2. This addendum modifies the following sections of Part II, General Provisions:
Part II
I. Responsibilities-Grantee
J. Software Compliance. This section will be deleted in its entirety and
replaced with the following language:
Version: Standard
2
The Michigan Department of Health and Human Services and the
County of Oakland will work together to identify and overcome
potential data incompatibility problems.
III. Assurances
A. Compliance with Applicable Laws. This first sentence of this
paragraph will be stricken in its entirety and replace with the following
language:
The Contractor will comply with applicable Federal and State laws,
and lawfully enacted administrative rules or regulations, in carrying out
the terms of this agreement.
M. Health Insurance Portability and Accountability Act. The
provisions in this section shall be deleted in their entirety and replaced
with the following language:
The Grantee agrees that it will comply with the Health Insurance
Portability and Accountability Act of 1996, and the lawfully enacted
and applicable Regulations promulgated there under.
P. Grant Data
1. Grant Data. The Department’s and Grantee’s data (“Grant
Data,” which will be treated by the Parties as Confidential
Information) includes: (a) the Department’s data, user data,
and any other data collected, used, processed, stored, or
generated as the result of this Agreement; (b) personally
identifiable information (“PII“) collected, used, processed,
stored, or generated as the result of this Agreement,
including, without limitation, any information that identifies an
individual, such as an individual’s social security number or
other government-issued identification number, date of birth,
address, telephone number, biometric data, mother’s maiden
name, email address, credit card information, or an
individual’s name in combination with any other of the
elements here listed; and, (c) protected health information
(“PHI”) collected, used, processed, stored, or generated as
the result of this Agreement, which is defined under the
Health Insurance Portability and Accountability Act (HIPAA)
and its related rules and regulations.
2. Grantee Use of Grant Data. Grantee must: (a) keep and
maintain Grant Data, using such degree of care as is
Version: Standard
3
appropriate and consistent with its obligations as further
described in this Agreement and applicable law to avoid
unauthorized access, use, disclosure, or loss; (b) use and
disclose Grant Data solely and exclusively for the purpose of
providing the activities described in the Statement of Work,
such use and disclosure being in accordance with this
Agreement, any applicable Statement of Work, and
applicable law; (c) keep and maintain Grant Data in the
continental United States and (d) not sell, rent, or
commercially exploit Grant Data. Grantee's misuse of Grant
Data may violate state or federal laws, including but not
limited to MCL 752.795.
3. Extraction of Grant Data. Grantee must, within a reasonable
timeframe of the Department’s request, provide the
Department, an extract of the Grant Data in the format
agreed upon by the Department and Grantee.
4. Backup and Recovery of Grant Data. Grantee is responsible
for maintaining a backup of Grant Data and for an orderly
and timely recovery of such data.
5. Loss or Compromise of Data. In the event of any act, error or
omission, negligence, misconduct, or breach on the part of
Grantee that compromises or is suspected to compromise
the security, confidentiality, or integrity of Grant Data or the
physical, technical, administrative, or organizational
safeguards put in place by Grantee that relate to the
protection of the security, confidentiality, or integrity of Grant
Data, Grantee must work with the Department to comply with
all applicable laws regarding such an incident.
6. Surrender of Confidential Information upon Termination.
Upon termination or expiration of this Contract or a
Statement of Work, in whole or in part, each party must upon
request, within a reasonable timeframe from the date of
termination, return to the other party any and all Confidential
Information received from the other party, or created or
received by a party on behalf of the other party, which are in
such party’s possession, custody, or control. Upon
confirmation from the State, of receipt of all data, Grantee
must permanently sanitize or destroy the State’s Confidential
Information, including Grant Data, from all media including
backups using National Security Agency (“NSA”) and/or
National Institute of Standards and Technology (“NIST”)
(NIST Guide for Media Sanitization 800-88) data sanitization
methods or as otherwise instructed by the State. If the State
determines that the return of any Confidential Information is
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4
not feasible or necessary, Grantee must destroy the
Confidential Information as specified above. The Grantee
must certify the destruction of Confidential Information
(including Grant Data) in writing within 5 Business Days from
the date of confirmation from the State. Any requirement on
the Grantee’s part to retain data beyond the end of this
contract must be authorized by the State. Notwithstanding
the language herein, the Grantee shall retain any
Confidential Information that it is required to retain by law.
T. Data Privacy and Information Security
1. Undertaking by Grantee. Without limiting Grantee’s
obligation of confidentiality as further described, Grantee is
responsible for establishing and maintaining a data privacy
and information security program, including physical,
technical, administrative, and organizational safeguards, that
is designed to: (a) ensure the security and confidentiality of
the Grant Data; (b) protect against any anticipated threats or
hazards to the security or integrity of the Grant Data; (c)
protect against unauthorized disclosure, access to, or use of
the Grant Data; (d) ensure the proper disposal of Grant
Data; and (e) ensure that all employees, agents, and
subcontractors of Grantee, if any, comply with all of the
foregoing.
2. Right of Audit by the State. Without limiting any other audit
rights of the Department, the Department has the right to
review Grantee’s data privacy and information security
program prior to the commencement of the Agreement’s
Statement of Work and from time to time during the term of
this Agreement. During the providing of the Agreement’s
Statement of Work, on an ongoing basis from time to time
and without notice, the Department, at its own expense, is
entitled to perform, or to have performed, an on-site audit of
Grantee’s data privacy and information security program. In
lieu of an on-site audit, upon request by the Department,
Grantee agrees to complete, within 45 calendar days of
receipt, an audit questionnaire provided by the Department
regarding Grantee’s data privacy and information security
program.
3. Audit Findings. Grantee must implement any reasonable
safeguards as identified by the Department or by any audit
of Grantee’s data privacy and information security program.
Version: Standard
5
XI. Liability. Paragraph A. will be deleted in its entirety and replaced with the
following language.
A. Except as otherwise provided by law neither Party shall be
obligated to the other, or indemnify the other for any third party
claims, demands, costs, or judgments arising out of activities to be
carried out pursuant to the obligations of either party under this
Contract, nothing herein shall be construed as a waiver of any
governmental immunity for either party or its agencies, or officers
and employees as provided by statute or modified by court
decisions.
FY 2025 ATTACHMENT B.3
MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES
BUREAU OF GRANTS AND PURCHASING
EQUIPMENT INVENTORY SCHEDULE
Please list equipment items that were purchased during the grant agreement period as specified in the grant
agreement budget’s cost detail schedule - Attachment B.2. Provide as much information about each piece as
possible, including quantity, item name, item specifications: make, model, etc. Equipment is defined to be an
article of non-expendable tangible personal property having a useful life of more than one (1) year and an
acquisition cost of $5,000 or more per unit. Please complete and forward this form to the MDHHS contract
manager with the final progress report.
Grantee Name: Contract #: Date:
Quantity Item Name Item Specification Tag
Number
Purchased
Amount
Total
Grantee’s Signature: Date:
ATTACHMENT C
PERFORMANCE / PROGRESS REPORT REQUIREMENTS
A. The Grantee shall submit the following reports on the following dates:
The grantee must submit bi-monthly updates on status of funds being provided
by MDHHS to support the Pontiac Integrated Urgent Care project. Reports must
include:
• Status of project implementation
• Status of funding (funds spent, plan for continued utilization of funds, etc.)
• Challenges/barriers to project implementation
• Identified support being requested from MDHHS to support
implementation
Bi-monthly reports must be submitted to the contract administrator on or before the
following dates:
• November 30
• January 31
• March 31
• May 31
• July 31
• September 30
Concerns with the ability to submit reports timely to the MDHHS contract
administrator, or identification of barriers that impede project implementation
should be communicated to the contract administrator as early as possible.
B. Any such other information as specified in the Statement of Work, Attachment A
shall be developed and submitted by the Grantee as required by the Contract
Administrator.
C. Reports and information shall be submitted to the Contract Administrator at:
Ali Cosgrove, CosgroveA2@michigan.gov
D. The Contract Administrator shall evaluate the reports submitted as described in
Attachment C, Items A. and B. for their completeness and adequacy.
E. The Grantee shall permit the Department or its designee to visit and to make an
evaluation of the project as determined by the Contract Administrator
ATTACHMENT E
PROGRAM SPECIFIC REQUIREMENT
Oakland County Health Division, St. Joseph Mercy Oakland Hospital, McLaren Hospital,
Oakland Community Health Network and Honor Community Health will partner to address the
need for increased access to primary care and mental health services by creating an Urgent
Primary and Behavioral Health Center (UPBHC) in Pontiac.
The center will provide a combination of in-person and telehealth service, including 12 hours of
walk-in and virtual visits and 12 hours of virtual visits 7 days a week for urgent medical and
mental health services.
The center will provide an integrated response aimed to triage, coordinate treatment, provide
mental health interventions, bridge prescriptions, conduct medical interventions, and follow-up
with individuals at risk is needed.
The center will be open to all individuals in Pontiac and surrounding areas in Oakland county
who are experiencing medical concerns including medication assistance, elevated levels of
anxiety, depression, substance use, other mental health issues, and/or coordinated care.
Individuals will be provided service regardless of their ability to pay.
The center will provide integrated services on an urgent basis with same day appointments with
a Primary Care Provider (PCP).
Mental health triage by a behavioral health consultant will be available if needed, as well as
referrals to a psychiatric nurse practitioner.
If a mental health medication refill is required, a bridge prescription will be made by the
psychiatric nurse practitioner until the patient sees their regular mental health provider.
The behavioral health consultant will coordinate care with the treating mental health professional
and obtain consent for coordination of care. If the patient does not have a mental health
professional, the behavioral health consultant will make a referral. They will also conduct a
follow-up appointment within 48 hours if there were mental health concerns.
For patients with physical health concerns, a medical assistant will follow up within 48 hours.
GRANT REVIEW SIGN-OFF – Health & Human Services/Health Division
GRANT NAME: Pontiac Integrated Urgent Care 2025 APP00174
FUNDING AGENCY: Michigan Department of Health and Human Services
DEPARTMENT CONTACT: Stacey Smith/248 452-2151
STATUS: Grant - Application (Greater than $50,000)
DATE: 08/01/2024
Please be advised that the captioned grant materials have completed the internal grant review. Below are the returned
comments.
The Board of Commissioners’ liaison committee resolution and grant application package (which should include this sign-
off and the grant application with related documentation) should be downloaded into Civic Clerk to be placed on the next
agenda(s) of the appropriate Board of Commissioners’ committee(s) for grant acceptance by Board resolution.
DEPARTMENT REVIEW
Management and Budget:
Approved – Sheryl Johnson (07/12/2024)
Human Resources:
Approved by Human Resources. No position impact. -Heather Mason (07/10/2024)
Risk Management:
Approved. Contract allows the County to self-insure and removes additional insured requirement. - Robert
Erlenbeck (07/10/2024)
Corporation Counsel:
Approved. Corp Counsel conducted legal review of attached documents AND application emailed by SS to me
on 8.1.24. Corp Counsel finds no unresolved legal issues at this time. – Heather Lewis (08/01/2024)
[Completed grant application is attached]
Facesheet for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
__________________________________________________________________________
1.Demographic Information
a.Demographic Information Name Oakland County Department of Health and Human Services/ Health Division
b.Organizational Unit
c.Address 1200 N. Telegraph Rd.
d.Address 2 34 East
e.City Pontiac State MI Zip 48341-1032
f.Federal ID Number 38-6004876 Reference No.136200362 Unique Entity Id.HZ4EUKDD7A
B4
g.Agency's fiscal year (beginning month and day)October-01
h.Agency Type
Private, Non-Profit Public
1.Select the appropriate radio button to indicate the agency method of accounting.
Accrual
Cash
Modified Accrual
2.Program / Service Information
a.Program / Service Information Name Pontiac Integrated Urgent Care - 2025
b.Is implementing agency same as Demographic Information Yes No
c.Implementing Agency Name
d.Project Start Date Oct-01-2024 End Date Sep-30-2025
e.Amount of Funds Allocated $1,000,000.00 Project Cost $1,000,000.00
__________________________________________________________________________
Page: 1 of 12
3.Certification / Contacts Information
a.Authorized Official
Name David T. Woodward
Title County Commissioner
Mailing Address 1200 N. Telegraph Rd.
City Pontiac State MI Zip 48341
Telephone (248) 452-2151 Fax
E-mail Address Woodwardd@oakgov.com
b.Financial Officer
Name Michelle Coburn
Title Accountant
Mailing Address 2100 Pontiac Lk Rd
City Waterford State MI Zip 48328
Telephone (248) 858-5468 Fax
E-mail Address coburnm@oakgov.com
c.Project Director
Name Stacey Sledge
Title Administrator
Mailing Address 1200 N Telegraph 34E
City Pontiac State MI Zip 48341
Telephone (248) 452-2151 Fax
E-mail Address sledges@oakgov.com
Facesheet for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
__________________________________________________________________________
__________________________________________________________________________
Page: 2 of 12
Certifications for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
__________________________________________________________________________
4.Assurances and Certifications
A. SPECIAL CERTIFICATIONS
a By checking this box, the individual or officer certifies that the individual or officer is authorized to approve
this grant application for submission to the Department of Health and Human Services on behalf of the
responsible governing board, official or Grantee.
b By checking this box, the individual or officer certifies that the individual or officer is authorized to sign the
agreement on behalf of the responsible governing board, official or Grantee.
B. State of Michigan Information Technology Information Security Policy
1.By checking the following boxes, the Grantee acknowledges compliance with State of Michigan Information
Technology Information Security Policy* and provides the following assurances:
a.The Grantee Project Director will be notified within 24 hours when its users are terminated or transferred
or immediately if after an unfriendly separation.
b.The Grantee Project Director will annually review and certify user accounts to verify the user’s access is
still required and the user is assigned the appropriate permissions.
c.The Grantee Project Director will remove user’s access within 48 hours of notification when users are
terminated or transferred, or immediately if after an unfriendly separation.
d.After 120 days of inactivity, when the user attempts to log into their account they will receive a message
stating their account has been deactivated, and the user will have to request the account be reinstated.
*Policy available at https://www.michigan.gov/documents/dmb/1340_193162_7.pdf
__________________________________________________________________________
Page: 3 of 12
Narrative for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
__________________________________________________________________________
5.Program Synopsis
The COVID-19 pandemic affected everyone, however, it disproportionately impacted communities with high social
vulnerabilities such low income, homelessness, unemployment, limited access to mental and physical health. One of
those communities in Oakland County is the city of Pontiac. The pandemic exacerbated the need for access to primary
care and mental health services. Oakland County Health Division, St. Joseph Mercy Oakland Hospital, McLaren Hospital,
Oakland Community Health Network and Honor Community Health will partner to address the need for increased access
to primary care and mental health services by creating an Urgent Primary and Behavioral Health Center (UPBHC) in
Pontiac. The center will provide a combination of 12 hours of walk-in and virtual visits, 7 days a week for urgent medical
and mental health services. We believe that an integrated response aimed to triage, coordinate treatment, provide mental
health interventions, bridge prescriptions, conduct medical interventions, and follow-up with individuals at risk is needed.
The COVID-19 pandemic has increased demand for both physical and mental health services. The COVID-19 pandemic
has negatively affected many people’s mental health and created new barriers for people already suffering from mental
illness and substance use disorders. During the pandemic, the proportion of adults that report symptoms of anxiety or
depressive disorder has increased from 11% to over 40% of adults nationally. The pandemic has also disproportionately
affected the health of communities of color. Black (48%) and Hispanic or Latino (46%) adults are more likely to report
symptoms of anxiety and/or depression than White adults (41%) (The Implications of COVID-19 for Mental Health and
Substance Use). Approximately 21% of adults in Pontiac report poor mental health.
A COVID-19 diagnosis can exacerbate mental health issues. Once diagnosed with COVID-19, individuals are
quarantined, which causes social isolation and separation from family members, roommates, or other social supports.
Prior studies have shown increases in depression, acute stress disorder, Post Traumatic Stress Disorder (PTSD), anxiety,
insomnia, and cognitive impairment with quarantine. Individuals with pre-existing mental illnesses exhibited even greater
risk of anxiety, depression, anger, and other mental health symptoms following quarantine. In Michigan during 2020,
alcohol sales increased 41% and marijuana purchases nearly doubled since the beginning of the pandemic. The use of
alcohol and other substances have also been shown to increase with unemployment.
According to the report “preparing Michigan for the Behavioral Health Impact of COVID-19, April 6, 2020 “Primary Care
Providers (PCPs) are important community gatekeepers for mental health issues, prescribing 79% of antidepressants and
treating 60% of individuals receiving care for depression in the US. Due to efforts to slow the transmission of COVID-19,
outpatient health care visits have dramatically decreased, including a 49% decrease in primary care visits and 30%
decrease in behavioral health visits. This decline in medical care visits may reflect delayed help-seeking by patient or
decrease access to treatment, resulting in worsening mental health symptoms.”
An integrated urgent care would improve access to primary care and mental health services. It would be open to all
individuals seeking service, regardless of ability to pay, and offer both in person and telehealth visits to limit barriers to
seeking care. Having both primary and behavioral health care on staff would increase the likelihood that people with
mental health needs would get diagnosis and treatment, since primary care providers are often the first to detect mental
health concerns.
The target population would be individuals in the Pontiac area that are experiencing medical concerns including
medication assistance, elevated levels of anxiety, depression, substance use, or other mental health issues. These
individuals may also need coordination of care. The target population would include Medicaid enrollees and Medicaid
eligible, those underinsured or uninsured, people that are low income, as well as those commercially insured.
The center would provide integrated services on an urgent basis with same day appointments with a Primary Care
Provider (PCP). Mental health triage by a behavioral health consultant is also available if needed, as well as referrals to a
psychiatric nurse practitioner. If a mental health medication refill is required, then a bridge prescription will be made by the
psychiatric nurse practitioner until the patient sees their regular mental health provider. The behavioral health consultant
will coordinate care with the treating mental health professional and obtain consent for coordination of care. If the patient
does not have a mental health professional, the behavioral health consultant will make a referral. They will also conduct a
follow-up appointment within 48 hours if there were mental health concerns. For patients with physical health concerns, a
medical assistant will follow up within 48 hours.
__________________________________________________________________________
Page: 4 of 12
Narrative for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
__________________________________________________________________________
6.Program Target Area
Counties project will serve (check all that apply):
Alcona Alger Allegan
Alpena Antrim Arenac
Baraga Barry Bay
Benzie Berrien Branch
Calhoun Cass Charlevoix
Cheboygan Chippewa Clare
Clinton Crawford Delta
Dickinson Eaton Emmet
Genesee Gladwin Gogebic
Grand Traverse Gratiot Hillsdale
Houghton Huron Ingham
Ionia Iosco Iron
Isabella Jackson Kalamazoo
Kalkaska Kent Keweenaw
Lake Lapeer Leelanau
Lenawee Livingston Luce
Mackinac Macomb Manistee
Marquette Mason Mecosta
Menominee Midland Missaukee
Monroe Montcalm Montmorency
Muskegon Newaygo Oakland
Oceana Ogemaw Ontonagon
Osceola Oscoda Otsego
Ottawa Presque Isle Roscommon
Saginaw St. Clair St. Joseph
Sanilac Schoolcraft Shiawassee
Tuscola Van Buren Washtenaw
Wayne Wexford Out Wayne
__________________________________________________________________________
Page: 5 of 12
Work Plan for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
__________________________________________________________________________
FOR OFFICE USE ONLY: Version # ______ APP # ______
7.Workplan
Objective :By February 2024, create a new welcoming, relaxed and safe integrated walk-
in/urgent care center.
Activity :Honor Community Heath will purchase materials and supplies for new
integrated space.
Responsible Staff :Honor Community Health
Date Range :10/01/2024 - 02/28/2025
Expected Outcome :Move in to the new welcoming, relaxed and safe integrated walk-in/urgent care
center.
Measurement :Facility 100% operational for provisions of client services
Activity :Begin issuing compensation payments (salary and fringes) to Behavioral Health
staff to increase capacity in the integrated walk-in/urgent care center.
Responsible Staff :Oakland Community Health Network
Date Range :10/01/2024 - 09/30/2025
Expected Outcome :Compensation paid to Master's Level Clinicians, Screeners and Supervisors to
increase capacity in the integrated walk-in/urgent care center.
Measurement :Staff onboarded and quantitative increase in the integrated walk-in/urgent care
center capacity.
__________________________________________________________________________
Page: 6 of 12
Budget Detail for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
________________________________________________________________________________________________________________
Line Item Qty Rate Units UOM Total Amount
DIRECT EXPENSES
Program Expenses
1 Salary & Wages
2 Fringe Benefits
3 Employee Travel and Training
4 Supplies & Materials
5 Subawards – Subrecipient Services
Subrecipient Agency -Oakland Community Health
Network
Notes : OCHN- Increase capacity of Master Level
Clinicians
Contact Details : Oakland Community Health
Network
5505 Corporate Dr #2614,
Troy,MI,48098,
Phone : 2488581210
0.0000 0.000 0.000 500,000.00 500,000.00
Subrecipient Agency -Honor Community Health
Notes : Honor Community Health to build new
space for integrated urgent care
Contact Details : Honor Community Health
461 West Huron,
Pontiac,MI,48341,
Phone : 2487247600
0.0000 0.000 0.000 500,000.00 500,000.00
________________________________________________________________________________________________________________
Page: 7 of 12
Budget Detail for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
________________________________________________________________________________________________________________
Line Item Qty Rate Units UOM Total Amount
Total for Subawards – Subrecipient Services 1,000,000.00 1,000,000.00
6 Contractual - Professional Services
7 Communications
8 Grantee Rent Costs
9 Space Costs
10 Capital Expenditures - Equipment & Other
11 Client Assistance - Rent
12 Client Assistance - All Other
13 Other Expense
Total Program Expenses 1,000,000.00 1,000,000.00
TOTAL DIRECT EXPENSES 1,000,000.00 1,000,000.00
INDIRECT EXPENSES
Indirect Costs
1 Indirect Costs
2 Cost Allocation Plan
Total Indirect Costs 0.00 0.00
TOTAL INDIRECT EXPENSES 0.00 0.00
TOTAL EXPENDITURES 1,000,000.00 1,000,000.00
________________________________________________________________________________________________________________
Page: 8 of 12
Budget Summary for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
________________________________________________________________________________________________________________
Category Total Amount Narrative
DIRECT EXPENSES
Program Expenses
1 Salary & Wages 0.00 0.00
2 Fringe Benefits 0.00 0.00
3 Employee Travel and Training 0.00 0.00
4 Supplies & Materials 0.00 0.00
5 Subawards – Subrecipient Services 1,000,000.00 1,000,000.00
6 Contractual - Professional Services 0.00 0.00
7 Communications 0.00 0.00
8 Grantee Rent Costs 0.00 0.00
9 Space Costs 0.00 0.00
10 Capital Expenditures - Equipment & Other 0.00 0.00
11 Client Assistance - Rent 0.00 0.00
12 Client Assistance - All Other 0.00 0.00
13 Other Expense 0.00 0.00
Total Program Expenses 1,000,000.00 1,000,000.00
TOTAL DIRECT EXPENSES 1,000,000.00 1,000,000.00
INDIRECT EXPENSES
Indirect Costs
1 Indirect Costs 0.00 0.00
________________________________________________________________________________________________________________
Page: 9 of 12
Budget Summary for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
________________________________________________________________________________________________________________
Category Total Amount Narrative
2 Cost Allocation Plan 0.00 0.00
Total Indirect Costs 0.00 0.00
TOTAL INDIRECT EXPENSES 0.00 0.00
TOTAL EXPENDITURES 1,000,000.00 1,000,000.00
________________________________________________________________________________________________________________
Page: 10 of 12
Source of Funds for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
________________________________________________________________________________________________________________
Source of Funds
Category Total Amount Cash Inkind Narrative
1 Source of Funds
MDHHS State Agreement 1,000,000.00 1,000,000.00 0.00 0.00
Fees and Collections - 1st and 2nd
Party
0.00 0.00 0.00 0.00
Fees and Collections - 3rd Party 0.00 0.00 0.00 0.00
Local 0.00 0.00 0.00 0.00
Non-MDHHS State Agreements 0.00 0.00 0.00 0.00
Federal 0.00 0.00 0.00 0.00
Other 0.00 0.00 0.00 0.00
In-Kind 0.00 0.00 0.00 0.00
Federal Cost Based
Reimbursement
0.00 0.00 0.00 0.00
Total Source of Funds 1,000,000.00 1,000,000.00 0.00 0.00
Totals 1,000,000.00 1,000,000.00 0.00 0.00
________________________________________________________________________________________________________________
Page: 11 of 12
Miscellaneous for Pontiac Integrated Urgent Care - 2025
Agency: Oakland County Department of Health and Human Services/ Health Division
Application: Pontiac Integrated Urgent Care - 2025
8/1/2024
__________________________________________________________________________
11.Supporting documentation, if required
Attachment Title Attachment
__________________________________________________________________________
Page: 12 of 12