Corrective Action Plans

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We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements
We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Impl...
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Shenae Draughn, President.
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2024 – September 30, 2...
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2024 – September 30, 2025 The findings from the September 30, 2025 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2025-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Alice Marie, CFO 507-373-2040 Anticipated Completion Date: Ongoing
II. Finding 2025-002 Lack of Documentation of Quarterly Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has revised its reporting procedures to require that all quarterly reports required under the Assistive Technology Agreement be submitted in writing to...
II. Finding 2025-002 Lack of Documentation of Quarterly Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has revised its reporting procedures to require that all quarterly reports required under the Assistive Technology Agreement be submitted in writing to the DOR Contract Administrator and retained electronically with evidence of timely submission. Documentation may include emailed reports, delivery confirmations, or other records demonstrating compliance with reporting deadlines. Management will maintain a centralized reporting file and review quarterly reporting requirements to ensure all required reports are submitted and retained in accordance with grant requirements. Although program activity associated with the Device Lending and Demonstration Centers and Reuse Centers is currently being procured through a competitive RFP process, CFILC will submit all required quarterly reports beginning with the next reporting cycle, including reports indicating limited or no activity when applicable. Contact Person: M. Lisa Hayes, Executive Director Projected Completion Date: July 30, 2026
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Huma...
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Human Assets department will coordinate with its payroll processing vendor (UKG) to: - Review payroll configuration settings related to bonus payments. - Implement controls to ensure bonus compensation is excluded from grant-related labor distributions. 3. Monitoring and Oversight Reinforcement The VP of Government Grant Compliance will reinforce internal review procedures by: - Providing targeted guidance to the Investor Relations Grant Compliance and Fiscal teams on identifying anomalies in Wage and Hour Reports, including unusual or inflated hourly rates
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete ...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete all tasks before abandoning their position. Before HVC takes on additional grants and duties, the administration (TA and TA Assistant) will learn the processes and portals for the current grants and recurring ones. Create how to guides to include with the new grant binders, for reporting and portal use. Have calendars for each grant. Utilize one big calendar on the wall that includes all the grant reporting periods and the annual requirements for sam.gov (log in requirement). Continue trying to fill positions and delegate workload. Proposed Completion Date: September 30, 2026.
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requ...
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requirements under Uniform Guidance (2 CFR, Part 200.303) Planned Corrective Action: Road Commission is in the process of developing and implementing a written federal policies and procedure addressing the administration of federal awards to ensure compliance with Uniform Guidance (2 CFR, Part 200). The policy will address the following key compliance areas: allowable costs, cash management, procurement, and conflict of interest. The policy shall be reviewed and modified to included all the necessary items outlined in the Uniform Guidance. Contact Person responsible for corrective action: Destain Gingell, Managing Director / CHE, Kathleen Cunningham, Finance Director Anticipated Completion Date: July 30, 2026
Recommendations: The Organization should implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include: - Developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting. - Assigning responsibility f...
Recommendations: The Organization should implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include: - Developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting. - Assigning responsibility for tracking and ensuring timely submission of reports. Additionally, the Organization should conduct a root cause analysis to address any underlying issues and implement corrective actions to prevent future delays. Views of responsible officials and planned corrective actions: Management agrees with the finding and will implement processes to mitigate the risk of future late file reports. Anticipated Completion Date: June 2026
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communi...
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communications Manager completes the annual report before the reporting period deadline. • The Executive Director will review and approve the annual report before the deadline and communicate approval of the annual report to both the Contract Specialist and Communications Manager. • The Contract Specialist will send the annual report to the BIA by the deadline and retain approval forms or records. Anticipated completion date: June 2026.
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate ...
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate documentation to verify primary residence status as part of the CDBG/HOME loan reconciliation workbook process.  Implementing periodic monitoring procedures for loan recipients.  Maintaining documentation in loan files to support compliance throughout the affordability period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and has implemented loan file monitoring procedures to verify occupancy compliance. Name of the contact person responsible for corrective action: Melanie Marquez Planned completion date for corrective action plan: 6/30/2026
Finding 1221502 (2025-003)
Material Weakness 2025
Hips
DC
Views of Responsible Officials: HIPS experienced significant delays in receiving approved budgets, Notice of grant awards (NOGAs) and Purchase Orders (POs) from the grantors. HIPS cannot submit reports without these documents. For these reasons, HIPS could not meet the requirement "timely submission...
Views of Responsible Officials: HIPS experienced significant delays in receiving approved budgets, Notice of grant awards (NOGAs) and Purchase Orders (POs) from the grantors. HIPS cannot submit reports without these documents. For these reasons, HIPS could not meet the requirement "timely submission of required reports". We hope that in the future, HIPS will receive the pre-requisite documentation on time. In addition, the grantors' systems are set in a chronological order and therefore even in instances where HIPS is ready to submit reports HIPS can only submit one month and wait for that month's report to be approved before HIPS can submit the next month. This system,albeit important in grant management, limits HIPS ability to fulfil "timely submission of required reports" requirements. HIPS will improve documentation on this issue.
Finding 1221501 (2025-002)
Material Weakness 2025
Hips
DC
Views of Responsible Officials: As noted in your findings, those instances occurred only prior to December 2024 and no misallocations were noted after that. HIPS implemented a second level of review and approval by the program managers during FY25. HIPS's current payroll and time tracking systems do...
Views of Responsible Officials: As noted in your findings, those instances occurred only prior to December 2024 and no misallocations were noted after that. HIPS implemented a second level of review and approval by the program managers during FY25. HIPS's current payroll and time tracking systems do not have the capacity to implement time tracking at this level of complexity. In FY 26, Supervisors will review and document review of proposed time allocations on the payroll allocations spreadsheets prior to month start to ensure that the allocation correctly matches the proposed schedule, and at month end to assess any changes needed based on actual time worked on various grant activities. We will also search for new software options to improve approval and entry process.
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and...
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melen...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melendez, Executive Director, will be responsible to implement this corrective action by September 30, 2026.
Reference Number: 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Choice Cluster Federal Catalog Number: 14.871 and 14.879 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspec...
Reference Number: 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Choice Cluster Federal Catalog Number: 14.871 and 14.879 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspections) Classification of Finding: Significant Deficiency in Internal Control over Compliance Instance of Noncompliance Authority’s Response & Actions Taken The Authority has made substantial progress in resolving the backlog of Housing Quality Standards (HQS) inspections that originated during the COVID-19 period, when HUD waivers and restricted unit access limited the ability to conduct timely inspections. Since that time, the Authority has reestablished normal inspection operations and significantly improved inspection volume and completion rates. All inspections noted in the audit were completed shortly after the required timeframes, and each unit ultimately passed HQS inspection and met HUD’s requirements for safe, decent, and sanitary housing. These results reflect that there was no impact to housing quality or participant eligibility, but rather timing-related delays within an actively managed inspection pipeline. The instances identified in the audit are largely attributable to timing of the audit sample selection, during which certain inspections were in process and scheduled but had not yet been completed. This does not fully reflect the Authority’s current operational performance or the progress achieved in reducing the inspection backlog. The Authority has established ongoing procedures to prioritize and monitor inspection timeliness, including use of the Emphasys Elite system in coordination with HUD’s PIC system to identify and track units approaching or exceeding inspection deadlines. Units identified as nearing noncompliance are actively scheduled and completed, and the Authority continues to work closely with its third-party HCV contractors to maintain consistent inspection coverage. The Authority continues to enhance oversight, tracking, and contractor accountability to ensure sustained compliance with HUD standards. The enhanced oversight and monitoring resulted in SEMAP fiscal year end 9/30/2025 with High Performer status, and current performance trends show the Authority is well positioned to maintain SEMAP High Performer status for the current fiscal year. Specifically for SEMAP Indicator 12 for Annual HQS Inspections, the Authority achieved 10 out of 10 points for fiscal year end 9/30/2025, which was an improvement from the prior fiscal year of 0 out of 10 points, and currently projected to maintain full points for this indicator with 97% timely annual HQS inspections completed. The key strategies and controls in place are as follows: Tenant-Based Program: 􀁸 Review the report of outstanding HQS Inspections on a weekly basis. 􀁸 Schedule outstanding HQS Inspections in order of aging date. 􀁸 Conduct HQS Inspections prior to the anniversary date of previously completed inspection. 􀁸 Running a monthly report of failed inspections and comparing them with future scheduled inspections to ensure that a second inspection has been scheduled. 􀁸 Running a monthly report to identify units with two failed inspections to ensure all have been abated correctly. 􀁸 Implement weekly monitoring to ensure all units are properly abated and lifted timely when units pass inspections and contracts are properly terminated after being in abatement for 180 days without a cure. The Authority has worked with Emphasys to identify the best ways to sort aged HQS inspections due and generate/schedule in bulk, as well as maximize the Inspector’s workday by routing the tenantbased units in a way that flows in a clear and orderly manner. Similar to the handling of delinquent annual reexaminations, the Authority is checking the data in PIC with the system of records and processing 50058 corrections where inspections have been completed but rejected in PIC due to out of sequence effective dates and any other fatal errors that require corrective action. Anticipated Implementation Date September 30, 2026 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractors Kendra Crawford, Director of Housing Operations
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should...
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should be noted that we are in compliance with the requirements of Ramsey County, Minnesota (the administrator of the ARPA program) as to documentation, reporting and other requirements. Documentation of review of income eligibility is not required by Ramsey County. Action taken in response to finding: We will immediately implement a sign off procedure by staff when they review income eligibility. Name of the contact person responsible for corrective action: Chris Schmidt Planned completion date for corrective action plan: Immediate
Does the Agency Agree: Agree Planned Corrective Action: Processes are in place to identify and record accruals. Accruals are recorded on a regular basis. We will update our year-end checklist to include a new contract review for proper revenue and expense recognition. Contact Name and Title Responsi...
Does the Agency Agree: Agree Planned Corrective Action: Processes are in place to identify and record accruals. Accruals are recorded on a regular basis. We will update our year-end checklist to include a new contract review for proper revenue and expense recognition. Contact Name and Title Responsible for Corrective Action: Elizabeth Butchart, Controller Status: Resolved
Segregation of Duties Auditor’s Recommendations: We recommend that the Authority assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the boa...
Segregation of Duties Auditor’s Recommendations: We recommend that the Authority assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Authority’s Response: The board reviews the reports monthly. A printed payroll report and checks written from meeting to meeting are provided and are approved and initialed. Also provided is a report of the bank statements for the board to review what has been received and what has been paid. Before any bills are paid they are approved at the meeting. If an error is made when inputting a deposit received into the software, the correction is printed and initialed approving the correction.
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Authority should continue to review and accept both proposed adjusting journal ...
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Authority should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. Authority’s Response: The Authority has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the Authority believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the Authority considers such assistance provided by the auditors to be the most cost-effective manner to prepare such information. The Authority will also ensure that in the future all transactions will be properly reflected in the accounting software.
The County has implemented additional internal controls, including a workflow for sharing invoices during 2025 when it was discovered that the grant reporting was not done properly. The County also adopted a new grant policy in March 2026 to provide additional levels of review from the grant applica...
The County has implemented additional internal controls, including a workflow for sharing invoices during 2025 when it was discovered that the grant reporting was not done properly. The County also adopted a new grant policy in March 2026 to provide additional levels of review from the grant application process through closeout of a grant. This further ensures accurate and timely reporting going forward.
WIOA Cluster – Assistance Listing No. 17.258, 17.259, and 17.278 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management document review of subrecipient Single Audit reports when availabl...
WIOA Cluster – Assistance Listing No. 17.258, 17.259, and 17.278 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management document review of subrecipient Single Audit reports when available Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DEDO has implemented procedures to ensure that reviews of subrecipient Single Audit reports are documented annually and maintained in greater detail than the Single Audit review currently incorporated into DEDO's existing risk assessment process. Name(s) of the contact person(s) responsible for corrective action: Travon Earl Planned completion date for corrective action plan: 6/23/26
Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management update and formalize subrecipient monitoring procedu...
Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management update and formalize subrecipient monitoring procedures to align with actual monitoring practices performed and ensure monitoring activities are consistently documented in accordance with Uniform Guidance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHS Financial Services will formalize updates to the Subrecipient Monitoring policy and procedures (currently in draft status) to align with the requirement for monitoring all high-risk subrecipients annually. Name(s) of the contact person(s) responsible for corrective action: Robert Baker Planned completion date for corrective action plan: 9/30/2026
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will remind staff to perform reviews and to ensure that verifications are sent out when necessary. Name of the contact person responsible for corrective action plan: Kayla Matter, HHS Deputy Director Planned completion date for corrective action plan: December 31, 2026
Finding 1221287 (2025-004)
Material Weakness 2025
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesot...
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the County implement procedures to ensure the citizenship, asset, and income verification documentation in the casefiles be retained and that it matches the METS 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 review procedures and show staff proper documentation and entry into METS and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Loni Swenson, Finance Director Planned completion date for corrective action plan: December 31, 2026
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