Corrective Action Plans

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MEDICAL ASSISTANCE - LACK OF CASEFILE DOCUMENTATION Recommendation: It is recommended the County implement procedures to ensure all required documentation is: maintained on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response...
MEDICAL ASSISTANCE - LACK OF CASEFILE DOCUMENTATION Recommendation: It is recommended the County implement procedures to ensure all required documentation is: maintained on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure all required documentation is maintained on file. Name of the contact person responsible for corrective action plan: Kathleen Ryan, County Auditor Planned completion date for corrective action plan: December 31, 2026
Finding Number: 2025-006 Finding Title: Eligibility - MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Ashley VanOverbeke – Eligibility Supervisor Chantelle Fogelson – Eligibility Supervisor Correct...
Finding Number: 2025-006 Finding Title: Eligibility - MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Ashley VanOverbeke – Eligibility Supervisor Chantelle Fogelson – Eligibility Supervisor Corrective Action Planned: The planned corrective action is to continue reminding and reviewing with staff on a regular basis and at unit meetings the need to utilize checklists with all applications and renewals, so all required documentation is on file, verify income and asset requirements, and complete case transfers correctly. Supervisors and/or Lead Workers will also complete case reviews for accuracy. Anticipated Completion Date: December 31, 2026
Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Felicia Chester, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program elegibility requirements. Ma...
Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Felicia Chester, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program elegibility requirements. Mangement has established a checklist for applications and will establish checklists for move-ins and move-outs. Proposed Completion Date: Immediately
1) Revisit our training materials provided to our Patent Access Representatives upon being hired and revise such materials to emphasize sliding fee requirements more thoroughly. Provide testing to new hires after training to establish if training was effective. a. Anticipated completion on date: 10/...
1) Revisit our training materials provided to our Patent Access Representatives upon being hired and revise such materials to emphasize sliding fee requirements more thoroughly. Provide testing to new hires after training to establish if training was effective. a. Anticipated completion on date: 10/31/2026 for revisions, ongoing with new hire training. 2) Establish front desk (Patient Access Coordinator) supervisor “recap” trainings establishing the requirements for sliding fee designations. During this training, allow for on-hands role playing of scenarios conducted both at group and individual levels. a. Anticipated completion date: 10/31/2026 3) Establish routine spot audits. Our Patient Access Coordinator will do spot audits on a monthly routine, and more a formal process at the CFO level completed quarterly. a. Anticipated completion date: Ongoing
Corrective Action Plan: All files for the House of Joseph Residence are now reviewed on a quarterly basis by the case manager and the program director, and a checklist has been created so that case managers can confirm that all necessary documents are contained within a given client’s file. New inco...
Corrective Action Plan: All files for the House of Joseph Residence are now reviewed on a quarterly basis by the case manager and the program director, and a checklist has been created so that case managers can confirm that all necessary documents are contained within a given client’s file. New income certifications, which are part of the checklist for documents that need to be in a client’s file, have been completed as well and the two files lacking documentation to support the annual income reported by the tenant have been corrected. Contact Person Responsible for Corrective Action: Eugene Halus (COO), John Bates (Deputy Director, Programs), and Eugene Watson (Program Manager) Anticipated Completion Date of Corrective Action: Corrections were completed in August 2026.
Corrective Action Plan: The Organization had discovered the issue of one of the tenants of House of Joseph Residence exceeding 30% of the area median income when we assisted him in applying for Medicaid in early 2026, for which he was initially denied due to income. The individual in question was wo...
Corrective Action Plan: The Organization had discovered the issue of one of the tenants of House of Joseph Residence exceeding 30% of the area median income when we assisted him in applying for Medicaid in early 2026, for which he was initially denied due to income. The individual in question was working part-time, and we had him scale back his working hours accordingly so that in the future he would not exceed the threshold of the 30% area median income going forward and eventually qualify for Medicaid. We also emphasized with the tenant the consequences of exceeding the 30% limit as well. Contact Person Responsible for Corrective Action: Eugene Halus (COO), John Bates (Deputy Director, Programs), and Eugene Watson (Program Manager) Anticipated Completion Date of Corrective Action: Completed in early 2026.
Auditor’s Recommendation: It is recommended that Hearts for the Invisible Charlotte Coalition develop and implement a suspension and debarment procedure to review the eligibility of vendors before entering into contracts. Training should be provided to all relevant staff to ensure awareness and comp...
Auditor’s Recommendation: It is recommended that Hearts for the Invisible Charlotte Coalition develop and implement a suspension and debarment procedure to review the eligibility of vendors before entering into contracts. Training should be provided to all relevant staff to ensure awareness and compliance with Federal requirements. Additionally, periodic monitoring and internal audits should be conducted to ensure adherence to the established procedures. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding and agrees with the recommendation. Hearts for the Invisible Charlotte Coalition is in the process of developing and implementing a formal suspension and debarment procedure, which is intended to be implemented in October 2026. Furthermore, periodic reviews will be instituted to monitor adherence to these requirements and to prevent the recurrence of this issue.
Finding 2025-003 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Mount Sinai ...
Finding 2025-003 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Mount Sinai has taken corrective actions to address this issue. During 2025, the Health System created a process to ensure a vendor is not considered suspended or debarred. All existing vendors in the vendor master file, as well as all newly onboarded vendors through our credentialing process, are screened monthly through our designated sanction screening provider. In addition, we have implemented a new monthly manual control to review, confirm, and reconcile our vendor master against the files submitted to our sanction-screening provider. Our Internal Audit team also performs periodic, independent sanction screening checks on a sample of vendors to validate the accuracy and completeness of the third party screening results. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: December 31, 2025.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster - Section 8 Housing Choice Vouchers, Mainstream Vouchers, and Emergency Housing Vouchers Programs Federal Assistance Listing Numbers: 14.871 & 14.879 Noncompliance - E. Eligibility - Tena...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster - Section 8 Housing Choice Vouchers, Mainstream Vouchers, and Emergency Housing Vouchers Programs Federal Assistance Listing Numbers: 14.871 & 14.879 Noncompliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately nine hundred forty (940) Housing Voucher Cluster units. Of a sample size of twenty two (22) tenant files, the following information was unavailable for examination at the time of audit: • Lead based paint forms were missing in two (2) files • Verification of income were miscalculated in two (2) files Our sample size is statistically valid. Known Questioned Costs: $8,028* * Represents HAP attributable to two (2) tenant files for which the Authority could not demonstrate compliance with eligibility requirements. The questioned costs do not represent amounts determined to be ineligible but rather costs associated with miscalculation for verification of income. Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Ann Malfavon, Executive Director, is responsible for implementing this corrective action by December 31, 2026.
The Town of Farmington subsequently verified the vendors through Sam.Gov and none of them were suspended or disbarred. Going forward, the Town plans to include a clause in all vendor contracts ensuring that they are not suspended or disbarred, along with continuing to verify this information on the ...
The Town of Farmington subsequently verified the vendors through Sam.Gov and none of them were suspended or disbarred. Going forward, the Town plans to include a clause in all vendor contracts ensuring that they are not suspended or disbarred, along with continuing to verify this information on the Sam.gov website.
Finding 1236916 (2025-003)
Material Weakness 2025
CONTROLS OVER ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2505MN5ADM and 2505MN5MAP, 2025 Pass-Through Agency: Minnesota De...
CONTROLS OVER ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2505MN5ADM and 2505MN5MAP, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5ADM and 2505MN5MAP Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the County increase review over casefiles and ensure that there are performed on a periodic basis throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action plan: Anne Broskoff, Human Services Director Planned completion date for corrective action plan: December 31, 2026
CASEFILE REVIEW (PRIOR YEAR 2024-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Commu...
CASEFILE REVIEW (PRIOR YEAR 2024-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2405MN5ADM, 2405MN5MAP Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2025 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025
ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal...
ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2501MNTANF Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that the County ensure every page is scanned in. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure each application is scanned in with every page. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025
CASEFILE REVIEW (PRIOR YEAR 2024-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Commu...
CASEFILE REVIEW (PRIOR YEAR 2024-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2405MN5ADM, 2405MN5MAP Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2025 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025
Views of Responsible Officials and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Joel Johnson, Ex...
Views of Responsible Officials and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Joel Johnson, Executive Director, is responsible for implementing this corrective action by December 31, 2026.
The County will continue to monitor supervisory review procedures to ensure the completeness of applicant files
The County will continue to monitor supervisory review procedures to ensure the completeness of applicant files
The County will continue to monitor supervisory review procedures to ensure the completeness of applicant files
The County will continue to monitor supervisory review procedures to ensure the completeness of applicant files
The County will continue to monitor supervisory review procedures to ensure the completeness of applicant files
The County will continue to monitor supervisory review procedures to ensure the completeness of applicant files
Condition and Context: The District did not establish controls to identify and monitor applicable federal reporting requirements associated with its federal awards. As a result, the District did not submit its Single Audit reporting package to the Federal Audit Clearinghouse by the required deadline...
Condition and Context: The District did not establish controls to identify and monitor applicable federal reporting requirements associated with its federal awards. As a result, the District did not submit its Single Audit reporting package to the Federal Audit Clearinghouse by the required deadline of March 31, 2026. Recommendation: The District should establish procedures to identify applicable Federal compliance requirements upon acceptance of Federal awards, monitor cumulative Federal expenditures to determine when a Single Audit is required, assign responsibility for monitoring reporting deadlines, and maintain a compliance calendar to ensure timely submission of all required Federal reports and the Single Audit reporting package. Contact Name: Carrissa Anderson, Business Administrator Corrective Action Planned: The District accepts the recommendation and will improve internal controls over reporting. The District has added this to our annual calendar to ensure proper reporting to the Federal Audit Clearinghouse. Anticipated Completion Date: Immediately.
Finding 2025-004: Temporary Assistance for Needy Families, Assistance Listing No. 93.558, U.S. Department of Health and Human Services Passed through Colorado Department of Human Services Compliance Requirement: Activities Allowed and Unallowed, Allowable Costs/Cost Principles, Eligibility Grant No....
Finding 2025-004: Temporary Assistance for Needy Families, Assistance Listing No. 93.558, U.S. Department of Health and Human Services Passed through Colorado Department of Human Services Compliance Requirement: Activities Allowed and Unallowed, Allowable Costs/Cost Principles, Eligibility Grant No.: Not applicable Type of Finding: Internal Control (material weakness) and Compliance (material noncompliance) Recommendation: The County should strengthen internal controls over TANF-funded contracts to ensure costs charged to TANF are allowable and adequately supported. The County should establish and enforce contractor documentation requirements and contract terms sufficient to demonstrate TANF eligibility and allowable services, implement monitoring procedures to verify support before payment or reimbursement, and retain required records in accordance with applicable retention requirements. Action Taken: Action Taken: Our office has experienced significant turnover over the past year, and this contract was established under the previous Director. Since then, we have updated our procedures for TANF-funded contracts. All TANF contracts are now reviewed by the Department of Social Services Attorney and by the State before our office enters into any agreement with outside agencies.
The Department of Children and Family Services management agrees with the findings and will reinforce existing policies and procedures to ensure that all required documents are properly retained and signed. The Department will continue to work collaboratively with the Courts to improve the timelines...
The Department of Children and Family Services management agrees with the findings and will reinforce existing policies and procedures to ensure that all required documents are properly retained and signed. The Department will continue to work collaboratively with the Courts to improve the timeliness and completeness of court documentation. In addition, the Department will strengthen supervisory oversight and internal review processes to ensure that eligibility and re-determination documentation is completed, reviewed, and signed within the required timeframes.
Name of Auditee: Wayland Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2025 CAP Prepared by: Brian Boggia, Executive Director Phone: (408) 655-6310 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2025-001 (a) C...
Name of Auditee: Wayland Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2025 CAP Prepared by: Brian Boggia, Executive Director Phone: (408) 655-6310 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2025-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendations, please see below for action taken. (b) Action taken - The Authority will obtain the required citizenship documentation. (c) Planned implementation date of corrective action - Completed by December 31, 2026.
Corrective Action Plan Assistance Listing Number 21.029 COVID-19 Coronavirus Capital Projects Fund U.S. Department of the Treasury Missouri Department of Economic Development Program Year 2024 Finding #2025-003 – Statement of Condition: The Cooperative was unable to provide evidence that vendors use...
Corrective Action Plan Assistance Listing Number 21.029 COVID-19 Coronavirus Capital Projects Fund U.S. Department of the Treasury Missouri Department of Economic Development Program Year 2024 Finding #2025-003 – Statement of Condition: The Cooperative was unable to provide evidence that vendors used in covered transactions were not suspended, debarred, or otherwise excluded. Response: Due to the current year finding, management set a goal to ensure the Missouri ARPA Broadband Infrastructure Grant Program guidelines related to debarred or suspended vendors are being met. To meet these guidelines management has compared the current vendor list to Excluded Parties List System found on SAM.GOV and found none of the currently used vendors on the list. Management has added this verification step to its new vendor process and will conduct annual self-assessment to ensure vendor eligibility documentation is current and up to date. The completion date for the above-mentioned corrective action was February 10, 2026.
Recommendation: ll is recommended County management implements a review process in place to ensure the information added into the METS and MAXIS systems malches supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in ...
Recommendation: ll is recommended County management implements a review process in place to ensure the information added into the METS and MAXIS systems malches supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will add a review process to ensure the casefile eligibility determinations match the supporting documentation provided. Name of the contact person responsible for corrective action plan: Tabitha Kremmin, Community Human Services Director Planned completion date for corrective action ptan: December 31, 2026
CASEFILE REVIEWS Recommendation: It is recommended the County implement procedures to ensure proper documentation in the casefiles and that it matches the information input into the eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. A...
CASEFILE REVIEWS Recommendation: It is recommended the County implement procedures to ensure proper documentation in the casefiles and that it matches the information input into the eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will retain documentation related to applicable federal requirements. Name of the contact person responsible for corrective action plan: Kelly Christianson, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2026
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