Corrective Action Plans

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Finding 1224628 (2025-004)
Material Weakness 2025
Lack of Segregation of Duties Condition Found: The City has a limited number of office personnel, which prevents an ideal segregation of duties for controls over financial reporting. Planned Corrective Action: Due to limited staffing, the City is unable to fully segregate duties. To mitigate the ass...
Lack of Segregation of Duties Condition Found: The City has a limited number of office personnel, which prevents an ideal segregation of duties for controls over financial reporting. Planned Corrective Action: Due to limited staffing, the City is unable to fully segregate duties. To mitigate the associated risks, management, the Mayor, and the City Council will continue to provide oversight of financial activities. This includes review of financial reports, bank reconciliations, and other key accounting records. The City will also consider enhancing documentation of oversight and review procedures where feasible. Anticipated Completion Date: Ongoing – oversight activities performed throughout the fiscal year. Responsible Official: City Administrator / Finance Officer
Finding 1224627 (2025-003)
Material Weakness 2025
Finding 2025-001 & 2025-003 – Preparation of the Financial Statements Condition Found: The City does not have a system of internal controls that would enable management to conclude the financial statements and related disclosures are complete and presented in accordance with the generally accepted a...
Finding 2025-001 & 2025-003 – Preparation of the Financial Statements Condition Found: The City does not have a system of internal controls that would enable management to conclude the financial statements and related disclosures are complete and presented in accordance with the generally accepted accounting principles which could lead to material errors that may not be identified and corrected by the City. As such, management requested external auditor to prepare a draft of the financial statements, including the related footnote disclosures. Planned Corrective Action: The City will continue to rely on its external auditors to prepare the draft financial statements and related footnote disclosures due to cost and staffing considerations. Management will review the completed financial statements and disclosures provided by the auditors and accept responsibility for their accuracy and completeness prior to issuance. Anticipated Completion Date: Ongoing – implemented annually as part of the year-end financial reporting process. Responsible Official: City Administrator / Finance Officer
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Supplemental Nutrition Assistance Program Cluster & Medical Assistance Assistance Listing Numbers: 10.561 and 93.778 Federal Award Identification Numbers and Years: 252MN101S2514 – 2025 & 2505MN5ADM – 2025 Passed Thro...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Supplemental Nutrition Assistance Program Cluster & Medical Assistance Assistance Listing Numbers: 10.561 and 93.778 Federal Award Identification Numbers and Years: 252MN101S2514 – 2025 & 2505MN5ADM – 2025 Passed Through Entity: Minnesota Department of Human Services Pass Through Number: H55250010 & H58260061 & H55255048 Compliance Requirement: Allowable Activities Award Period: 2025 Recommendation: We recommend that the County review its procedures and control to ensure all RMS listings sent to the State properly exclude those necessary individuals no longer working in the programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will increase coordination with human resources to obtain data on employee turnover as timely as possible and also ensure that the listings are reviewed prior to submission going forward. Name of the contact person responsible for corrective action: Tiffinie Miller, Deputy Director of Employment & Economic Assistance Planned completion date for corrective action plan: December 31, 2026
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Numbers: 93.778 Federal Award Identification Numbers and Years: 2505MN5ADM – 2025 Passed Through Entity: Minnesota Department of Human Services Pass Through Number: H55255048 Comp...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Numbers: 93.778 Federal Award Identification Numbers and Years: 2505MN5ADM – 2025 Passed Through Entity: Minnesota Department of Human Services Pass Through Number: H55255048 Compliance Requirement: Special Provisions Award Period: 2025 Recommendation: We recommend that the County reviews its polices and controls to ensure there is a formally documented control that ensures all required training of LCTS fiscal site contacts is completed and the documentation of the completions of the training is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will share the Minnesota DHS previously recorded “LCTS Fiscal & Cost Schedule” training video with all new Fiscal Site Contacts that prepare cost schedules. County staff will then follow-up with the new Fiscal Site Contacts with a brief quiz to ensure they watched the training video and know how to capture only applicable costs in the cost schedule reports. Then, the LCTS Training Verification Form will be completed, signed by the applicable parties, and emailed to the LCTS Project Manager at Minnesota DHS. The communications sharing the training video, responses to the brief quiz, and LCTS Training Verification Form will be maintained as documentation of the completion of the required trainings. Name of the contact person responsible for corrective action: Lucas Chase, Audit Manager Planned completion date for corrective action plan: December 31, 2026
The Organization is aware of the lack of segregation of duties caused by the limited size of its staff, and will continue to use other controls, where practical to compensate for this limitation.
The Organization is aware of the lack of segregation of duties caused by the limited size of its staff, and will continue to use other controls, where practical to compensate for this limitation.
Finding Number: 2025-002 Planned Corrective Action: Management has implemented enhanced cash management and grant monitoring procedures, including strengthened review of draw requests, improved documentation requirements, and closer reconciliation of grant expenditures to amounts drawn. In addition,...
Finding Number: 2025-002 Planned Corrective Action: Management has implemented enhanced cash management and grant monitoring procedures, including strengthened review of draw requests, improved documentation requirements, and closer reconciliation of grant expenditures to amounts drawn. In addition, the Organization is undertaking process improvements to streamline grant accounting and reporting activities, improve the timeliness of expense recognition, and enhance overall oversight of federal awards. Management expects these actions will strengthen compliance with federal cash management requirements and reduce the risk of future occurrences. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Alison Roca, Chief Financial Officer
Name of Contact Person: Nathanael Carver Management Response: In FY24, the County’s Information Technology Department implemented enhanced procedures under the Computer and Internet Use Policy to strengthen the security of County and State data. These updates include restricting unused network ports...
Name of Contact Person: Nathanael Carver Management Response: In FY24, the County’s Information Technology Department implemented enhanced procedures under the Computer and Internet Use Policy to strengthen the security of County and State data. These updates include restricting unused network ports, limiting network access by non-County devices, enforcing stronger password requirements, and requiring all IT-related support requests to be submitted through a centralized ticketing system. Automatic time-out procedures were implemented across all County workstations. In addition, staff were reminded of their responsibility to secure workstations when unattended. Compliance is reinforced through random verification checks conducted by DSS supervisors and IT staff to confirm users have properly logged out of their workstations. Further review identified that the specific instance in question involved a workstation assigned to a contracted worker. In response, targeted training was provided to both the contractor and the contracting organization to ensure a clear understanding of County security expectations and procedures. These actions demonstrate the County’s commitment to strengthening controls, addressing identified gaps, and maintaining ongoing compliance with data security requirements. Proposed Completion Date: Immediately
2025-002 – Reporting Requirements Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. Action Taken: We have reviewed our project set up process and modified it to capture all federal projects upon initiation to ena...
2025-002 – Reporting Requirements Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. Action Taken: We have reviewed our project set up process and modified it to capture all federal projects upon initiation to enable accurate monitoring and tracking of accumulated expenditures on a fiscal year basis so we can timely determine if the Organization meets the threshold for a Single Audit.
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recogni...
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recognizes that consistent execution and documentation of these controls were not fully adhered to in all instances. Management will formally re-communicate federal disbursement approval requirements to all relevant personnel, i ncluding principal investigators, department heads, and finance staff. This will include mandatory training sessions on federal compliance and approval protocols and distribution of updated written procedures outlining required approval l evels and documentation standards. To reduce reliance on manual processes, the University will configure the financial system/workilow to require multiple l evels of electronic approval prior to payment processing and restrict disbursement processing until all required a pprovals are completed and documented within the system. Management will implement ongoing monitoring procedures to ensure compliance, including monthly reviews of a sample of federal disbursements by the Controller's Office or Grants Accounting, quarterly compliance reporting to the CFO and senior leadership, and documentation of review results and corrective follow-up actions. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in Decem...
After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in December 2025.
Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit ...
Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will work with program managers to improve eligibility verification documentation. Name of the contact person responsible for corrective action: Heather Goodwin Planned completion date for corrective action plan: December 31, 2026
KHDA will hire a CPA to oversee this process.
KHDA will hire a CPA to oversee this process.
The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the ...
The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the annual financial reporting. The City has also struggled with vacancies in key positions, as well as challenges in completing successful recruitments to fill the positions; staff are exploring options for third party assistance with financial reporting functions.
Management concurs that stronger documentation surrounding the collection and monitoring of Continuum of Care program income would have strengthened internal controls and the audit trail. The finding relates to a program that has since been discontinued. Throughout the audit period, all program inco...
Management concurs that stronger documentation surrounding the collection and monitoring of Continuum of Care program income would have strengthened internal controls and the audit trail. The finding relates to a program that has since been discontinued. Throughout the audit period, all program income that was collected was used for allowable program purposes; however, management acknowledges that documentation supporting assessment, collection, monitoring, and reconciliation procedures should have been more comprehensive. Although this activity is no longer part of the Organization's operations, Ability1st has strengthened its overall documentation standards. Should the Organization administer future programs involving program income, written policies and procedures will be implemented prior to program implementation and will include: • documented fee assessment methodology; • collection and deposit procedures; • reconciliation requirements; • supervisory review; • record retention standards; and • periodic internal monitoring. Management believes these procedures will provide an appropriate level of accountability and compliance with federal requirements should program income be collected in the future. Responsible Official: Executive Director Implementation Date: Completed for discontinued program; procedures will be implemented before any future program income activity.
Management agrees with the recommendations. During 2025, DVCH’s front desk staff started to assume more responsibility for conducting the sliding fee categorization. This additional staff had training and is gaining experience. Management will ensure training, monitoring, auditing, and supervision i...
Management agrees with the recommendations. During 2025, DVCH’s front desk staff started to assume more responsibility for conducting the sliding fee categorization. This additional staff had training and is gaining experience. Management will ensure training, monitoring, auditing, and supervision is adequate to ensure registration properly documents the signed sliding fee attestation form. DVCH expects to adopt a software solution for sliding fee categorization in 2026. The software solution will make common errors less common by automating several manual processes. If the Health Resources and Services Administration has questions regarding this plan, please call Ryan Taylor, Chief Financial Officer, at taylorr@dvch or 267-240-2578.
Corrective Action Plan Finding No: 2025-002 Condition: During the audit, the City did not verify that the contractor or subcontractor submitted the required certified payrolls for work performed under the federally assisted construction contract. As a result, the City did not maintain or review suff...
Corrective Action Plan Finding No: 2025-002 Condition: During the audit, the City did not verify that the contractor or subcontractor submitted the required certified payrolls for work performed under the federally assisted construction contract. As a result, the City did not maintain or review sufficient documentation to demonstrate compliance with wage rate requirements for all applicable weeks during the audit period. Management’s Plan: The City recognizes the need to improve internal controls related to grant disbursements for labor provided by our contractors. The project this past year included participation from multiple federal funding agencies and payments by the City as well as direct payments to contractors by the funding agencies. We have already added additional procedures and checkpoints to provide for adequate documentation related to certified payrolls. In addition, the City is planning to procure a grant tracking system to automate tracking the details for every project. Anticipated Date of Completion: 12/31/26 Name of Contact Person: Cheri Grieco, Finance Director
Corrective Action Plan Finding No: 2025-001 Condition: During the audit, our procedures indicated that capital expenditures were primarily reviewed at an individual invoice level to determine whether they exceeded the capitalization threshold. We also noted that communication between the City’s fina...
Corrective Action Plan Finding No: 2025-001 Condition: During the audit, our procedures indicated that capital expenditures were primarily reviewed at an individual invoice level to determine whether they exceeded the capitalization threshold. We also noted that communication between the City’s finance department and engineers or other City staff responsible for managing grants and capital projects is not consistently formalized. Management’s Plan: Management is committed to strengthening coordination and oversight of the City’s grant-funded capital projects through centralizing project tracking via grant/project management software, implementing rigorous compliance monitoring, and improving intradepartmental communication. By centralizing our grants through the course of their lifespans, we intend to better track the progress of our grant projects and budgets and with the inclusion of grant document storage, to enhance compliance across departments. We will also designate coordination teams consisting of liaisons across administration, finance, engineering, public works, and grant writers to ensure internal alignment. Anticipated Date of Completion: 4/30/2027 Name of Contact Person: Cheri Grieco, Finance Director
Finding 2025-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating...
Finding 2025-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the project and related expenses submitted to FEMA for reimbursement. Resolution: Management will develop and implement additional internal controls to ensure that adequate documentation is retained to evidence the design and operating effectiveness of controls over FEMA-related expenditures. These internal controls will be designed to ensure that expenses included in FEMA grant applications are complete, accurate, and allowable in accordance with program requirements. Specifically, management will implement a reconciliation process comparing detailed application expenses to the corresponding final paid invoices or payroll expenditures. As part of this process, each expense will be reviewed and annotated to confirm its allowability under FEMA guidelines. The reconciliation will be subject to review and approval by the Cottage Health Vice President of Finance prior to submission of the FEMA application. Evidence of this review and approval will be formally documented and retained. Contact Person: Lawrence Thomas, Vice President of Finance Anticipated Completion Date: December 31, 2026 (The entity has not incurred expenditures under the FEMA program subsequent to the period under audit. Accordingly, the corrective actions described above will be implemented on a prospective basis, contingent upon the entity incurring future FEMA-related expenditures).
Name of contact person: Melissa Labra, Income Maintenance Administrator II Caseworkers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Casework...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Caseworkers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Caseworkers will receive training on the work number (TWN) in NCFAST learning gateway. Workers will be retrained on NCFAST evidence for resources to ensure procedures are being followed for evidence on dashboard to match the supporting documentation used as verifications. Workers will be retrained on determining who to count in the needs unit and adequate case file documentation. Workers will be retrained on the proper use of Medicaid Forced Eligibility. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Proposed Completion Date: August 31, 2026
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files t...
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files tested: • In one patient file selected for testing, the sliding fee discount applied was incorrect due to the patient’s income not being entered correctly in Epic, resulting in an inaccurate FPL calculation and associated discount classification. • In one patient file selected for testing, based on support provided and the SFDS, an incorrect discount class was applied, and the County was not able to provide documentation demonstrating how annual income/household size supported the applied discount classification. Hennepin County’s Corrective Action Planned in Response to Finding: Develop a required form for all case aides to use and uniformly determine “annual income”. The EPIC Financial Assistance Module (FAM) recently implemented will maintain record of patient financial calculations / conversations and will include upload of the financial income form. Determination of the proper patient discount is automated in FAM and will reduce chance of incorrect rate setting. Hennepin County Employee Responsible for the CAP: Baye D Diouf, Chief Financial Officer Planned Completion Date for CAP: September 30, 2026
Current policy and procedure in place will be followed. The Daily meal count sheets will be reconciled to the dummary spreadsheet and the reimburement claims, including a second review prior to submitting the claim for reinburement.
Current policy and procedure in place will be followed. The Daily meal count sheets will be reconciled to the dummary spreadsheet and the reimburement claims, including a second review prior to submitting the claim for reinburement.
U.S. Department of Housing and Urban Development MATERIAL WEAKNESS Segregation of Duties Recommendation: When this condition exists, management’s and the board’s close supervision and review of accounting information is the best means of preventing or detecting errors and fraud. Explanation of disag...
U.S. Department of Housing and Urban Development MATERIAL WEAKNESS Segregation of Duties Recommendation: When this condition exists, management’s and the board’s close supervision and review of accounting information is the best means of preventing or detecting errors and fraud. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We agree and will continue to monitor financial results and accounting information as hiring additional employees is not practical. Name(s) of the contact person(s) responsible for corrective action: Donald Bly Planned completion date for corrective action plan: In process
In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization...
In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee policy.
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations re...
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations regarding ethical behavior through training and communications. HealthXP proactively reports and investigates allegations of fraud and raises awareness of the actions to be taken when fraud is suspected. The HealthXP Global Internal Audit and Investigations team shares lessons learned from its work. Given the challenging operating environments in which HealthXP implements its programs, fraud remains an ongoing risk that HealthXP actively monitors, investigates, and mitigates.
Action To Be Taken: To ensure federal compliance for the Corona virus Relief Fund (ALN 21.019), the organization will implement a secondary review process. After the Executive Director prepares the federal financial reports, a designated member of the Board Finance Committee will review the supporti...
Action To Be Taken: To ensure federal compliance for the Corona virus Relief Fund (ALN 21.019), the organization will implement a secondary review process. After the Executive Director prepares the federal financial reports, a designated member of the Board Finance Committee will review the supporting documentation (General Ledger and invoices) for accuracy before the report is submitted to the granting agency.•Responsible Party: Executive Director and Board Finance Committee. Anticipated Completion Date: February 28, 2026.
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