Corrective Action Plans

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Finding 2025-059 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure revenues and program income generated by non-commercial airports were expended for airport capital or operatin...
Finding 2025-059 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure revenues and program income generated by non-commercial airports were expended for airport capital or operating costs, the local airport system, or other local facilities. Planned Corrective Action MDOT will review existing procedures, including the MDOT Office of Aeronautics Project Manager/Engineering Manual and block grant conditions, to assess whether updates are needed and if resources will be prioritized to help ensure monitoring and oversight efforts are performed relating to revenue and program income requirements. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Bryan Budds, MDOT
Finding 2025-058 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure weekly certified payrolls were obtained from contractors. Planned Corrective Action MDOT will provide training...
Finding 2025-058 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure weekly certified payrolls were obtained from contractors. Planned Corrective Action MDOT will provide training and guidance to pertinent staff to help ensure contract compliance and that weekly certified payrolls are obtained from contractors. In addition, MDOT will review existing procedures to assess whether updates are needed. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Bryan Budds, MDOT
Finding 2025-012 SNAP Cluster, ALN 10.551 and 10.561 and Summer Electronic Benefits Transfer Program for Children, ALN 10.646 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is currently evaluating the two System and Organization Con...
Finding 2025-012 SNAP Cluster, ALN 10.551 and 10.561 and Summer Electronic Benefits Transfer Program for Children, ALN 10.646 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is currently evaluating the two System and Organization Controls (SOC) reports and will document the evaluation and determination of whether a review is required. Based on these evaluations, if MDHHS determines reviews are required, MDHHS will document the SOC report reviews by June 30, 2026. Also, MDHHS will assess the current SOC review process and implement any needed improvements to ensure subservice organizations are properly evaluated, formally documented, and that SOC report reviews are submitted within 60 days of receiving each report, by September 30, 2026. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Tony Weber, MDHHS Veronica Maxson, MDHHS Dani Wager, MDHHS Tim Kubu, MDHHS
Corrective Action Plan Finding No.: 2025 - 004 Condition: During testing of expenditures claimed under the Education Stabilization Fund program we identified $41,157 of expenditures that were included in a reimbursement request were not supported by allowable program expenditures. Subsequent to the ...
Corrective Action Plan Finding No.: 2025 - 004 Condition: During testing of expenditures claimed under the Education Stabilization Fund program we identified $41,157 of expenditures that were included in a reimbursement request were not supported by allowable program expenditures. Subsequent to the reimbursement request and receipt of grant funds, the checks issued as payment to vendors were voided as the vendors did not provide goods or services. These expenditures were determined to be unsupported and resulted in questioned costs. Plan: Administration will not create and hold checks for goods and services not yet rendered under a grant award, as this can lead to unsupported expenditures, should the goods or services not be provided or the checks are voided and not timely reported. The encumbrance process will be used appropriately, and payments will be made once the goods or services have been rendered. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Dr. Rena Whitten, Superintendent
Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program FFAL # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: The Federal requirement related to processing of...
Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program FFAL # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: The Federal requirement related to processing of an application requires the State to provide notice of its decision concerning eligibility and provide timely and adequate notice of the basis for denial or termination of assistance (42 USC 1320c-7(d)). According to the Colorado Department of Health Care Policy and Financing (HCPF), processing standards 8.100.3.D, the County is required to process an initial application for any program not requiring a disability determination no later than 45 days following receipt of application. Our auditors, Eide Bailly, tested eligibility determination and controls over this process for sixty case files. They noted the following in our testing: • Two instances of non-compliance in which the County did not complete the eligibility determination and approve/deny the case within 45 days, and no notice of action was sent to the client within the required timeframe. • Two instances of non-compliance in which it could not be verified whether the notice of action was sent by the County to the client via mail or email Responsible Individuals: Joanne Sprouse, Human Services Director Corrective Action Plan: Summit County Human Services implemented multiple procedures in response to the prior 2024 findings. Those corrective action responses were still in process for the current 2025 period tested and will continue into 2026. During 2025, Summit County Human Services successfully retrained all case managers on application processing protocols, utilizing stateapproved training modules administered through the Staff Development Department. Summit County Human Services strictly follows state-mandated guidelines for processing Medical Assistance applications to ensure that all cases are approved or denied within the 45-day timeframe established by state regulations. To further enhance the accuracy of eligibility determinations for all household members, case managers have also completed the "Case Wrap-Up Training" through CoLearn, an online training platform developed by the State's Staff Development Department. Completion of this training ensures that eligibility determinations are accurate, and that appropriate client correspondence is issued. In 2025 and continuing into 2026, Summit County Human Services has also implemented a weekly review of the county dashboards, specifically the “HCPF Application Timeliness” and “HCPF Renewal Timeliness” dashboards. These dashboards monitor Medicaid application and renewal processing timelines initiated upon receipt by our office. In addition to the dashboard reviews, management meets weekly with the case managers responsible for monitoring the dashboards to identify trends and determine training needs. Furthermore, an additional line was added to the case comment template to ensure review and verification of correct case correspondence issuance. Anticipated Completion Date: Ongoing
#2025-006 FINDING: Reporting Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will reconcile individual program expenditure activity to the completed SF425 report and establish deadlines for filing submissions within the grant agreement timelines. The...
#2025-006 FINDING: Reporting Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will reconcile individual program expenditure activity to the completed SF425 report and establish deadlines for filing submissions within the grant agreement timelines. The Business Manager will follow the recommendation of the auditor. Anticipated Completion Date: Ongoing
#2025-005 FINDING: Payroll Testing Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will continue to review payroll prior to payroll being paid. The Payroll/Accountant will double check all timesheets before entering and double check payrate against c...
#2025-005 FINDING: Payroll Testing Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will continue to review payroll prior to payroll being paid. The Payroll/Accountant will double check all timesheets before entering and double check payrate against contract amount. Anticipated Completion Date: Ongoing
Segregation of Duties
Segregation of Duties
Name of Contact Person: Chelsey Traeger, City Clerk
Name of Contact Person: Chelsey Traeger, City Clerk
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
CASE FILE REVIEWS 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 Depar...
CASE FILE REVIEWS 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 Recommendation: It is recommended the Agency perform case file reviews on a more representative sample of the total clients served and that adequate documentation be retained of those reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Waylon Welvaert, Finance Manager Planned completion date for corrective action plan: December 31, 2026
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: Minneso...
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 Agency 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 Agency 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: Waylon Welvaert, Finance Manager Planned completion date for corrective action plan: December 31, 2026
3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure all replacement reserve withdrawals are supported with a HUD-signed Form HUD-9250 prior to releasing funds, the rec...
3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure all replacement reserve withdrawals are supported with a HUD-signed Form HUD-9250 prior to releasing funds, the recommendation to repay the $3,970 withdrawal, and the recommendation to obtain HUD approval for the 2024 unauthorized withdrawals of $39,282 or pay the amounts back to the reserve. b. Action(s) Taken or Planned on the Finding Management stated that a correction was processed to return the $3,970 to the replacement reserve account, with the repayment clearing in October 2025. The prior year unauthorized withdrawal remains unresolved, as management does not have the funds to repay the $39,282. Management will also strengthen internal controls to ensure all future withdrawals are fully supported with HUD-signed Form HUD-9250 approvals.
The Crete Public Schools Board of Education and Superintendent continually evaluate the distribution of duties to employees and closely monitor federal program finances. The Chief Financial Officer will continue to separate duties to the greatest extent possible with available staff. The Director of...
The Crete Public Schools Board of Education and Superintendent continually evaluate the distribution of duties to employees and closely monitor federal program finances. The Chief Financial Officer will continue to separate duties to the greatest extent possible with available staff. The Director of Federal Programs will assist in strengthening internal controls by actively participating in the preparation and review of grant expenditures, reimbursement requests, budget-to-actual reports, and supporting documentation to ensure transactions are accurate, properly approved, and comply with federal grant requirements. The Director of Federal Programs will also monitor federal program activities, review exception reports, and provide an additional layer of oversight for federally funded transactions. The District will continue to evaluate opportunities to implement additional compensating controls as staffing and resources permit.
Project Legal Name: Evangeline Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113- EE041 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Te...
Project Legal Name: Evangeline Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113- EE041 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to reimburse the project for overpaid management fee in the amount of $466 and implement procedures to ensure that the management fee paid does not exceed the amount determined in accordance with the management agreement. b. Action(s) Taken or Planned on the Finding Management will repay the property and update our procedures to correctly calculate management fees.
2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to deposit $21,146 into the replacement reserve account or obtain evidence of HUD approval. b. Action(s) Taken or Planned on the Finding Management a...
2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to deposit $21,146 into the replacement reserve account or obtain evidence of HUD approval. b. Action(s) Taken or Planned on the Finding Management acknowledges that two replacement reserve withdrawals dated February 14, 2025 were processed prior to obtaining HUD's written approval. This occurred due to a temporary lapse in oversight during a staff absence. We will attempt to retroactively obtain HUD approval for the withdrawal.
Management's Response and Planned Corrective Action: This finding relates primarily to the submission of annual grant reports SF-271 and SF-425, which are required by the FAA to be filed each year. The SF-271 (Outlay Report and Request for Reimbursement) are used to report project expenditures and r...
Management's Response and Planned Corrective Action: This finding relates primarily to the submission of annual grant reports SF-271 and SF-425, which are required by the FAA to be filed each year. The SF-271 (Outlay Report and Request for Reimbursement) are used to report project expenditures and request reimbursement of federal funds. It shows how much of the grant has been spent (outlays) and how much reimbursement is being requested from the funding agency. SF-425 (Federal Financial Report) provides a comprehensive summary of the financial status of a grant, including total expenditures, federal funds used, recipient cost share (if applicable), and remaining balances, to ensure proper accountability and compliance with grant requirements. Although these reports were submitted after the established due dates, management maintained the reporting requirements as an active and ongoing priority. These reports were regularly discussed during monthly coordination meetings involving Airport staff and the FAA Airports District Office (ADO), as well as during weekly internal staff meetings. During these regular discussions with the FAA ADO, the Airport was not advised that it was out of compliance with reporting deadlines. Rather, the FAA consistently indicated that reports should be submitted as soon as practicable. The Airport remained aware of its reporting obligations and their importance, particularly in support of ongoing efforts to secure funding for the terminal expansion project. Notwithstanding the above, management acknowledges that formal tracking mechanisms and documented follow-up procedures can be strengthened to ensure earlier identification and resolution of incomplete or missing grant data. To address this, management will enhance internal controls over grant reporting to ensure timely and complete submissions. Improvements will include implementing calendar-based tracking tools and structured notification procedures, with reminders and follow-up communications beginning at the FAA fiscal year-end (September 30) and continuing through the reporting due date (December 31). Additionally, management will coordinate with the FAA and MDOT to secure reliable access to the FAA’s Delphi System, where the data necessary to complete these reports resides. Communication with both the FAA ADO and MDOT will be further strengthened during the critical period leading up to reporting deadlines to ensure that any missing or incomplete information is promptly identified and addressed. Regular internal discussions regarding grant reporting status will also continue to support timely resolution of outstanding items. Management believes these corrective actions will mitigate the risk of delayed or incomplete reporting and strengthen overall compliance with grant requirements. Responsible Party for Corrective Action: Mark Bishop, Chief Financial Officer Anticipated Completion Date: June 2026.
Segregation of Duties
Segregation of Duties
Name of Contact Person: Connie Wold, City Treasurer
Name of Contact Person: Connie Wold, City Treasurer
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Finding 2025-001 - Internal Controls and Accounting for Capital Fund Grants – Cash Management and Special Tests and Provisions – Noncompliance and Significant Deficiency Capital Fund Grant Program ALN #14.872 Public and Indian Housing ALN #14.850 Corrective Action Plan: The Housing Authority of the ...
Finding 2025-001 - Internal Controls and Accounting for Capital Fund Grants – Cash Management and Special Tests and Provisions – Noncompliance and Significant Deficiency Capital Fund Grant Program ALN #14.872 Public and Indian Housing ALN #14.850 Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year September 30, 2026: a. Accounting staff will be sent to Capital Fund Training. b. Funds will be drawn and paid within 3 days of receipt. c. Funds will be drawn from appropriate BLI and distributed to the eligible line number. d. Grant end dates will be monitored to prevent loss of funding. Person Responsible: Joseph L Regan, Chief Financial Officer Anticipated Completion Date: September 30, 2026
INVOICE CODING - Criteria: Costs are necessary and reasonable for the performance of the federal award and allocable under the principles of 2 CFR 200, Subpart E. Condition: One invoice charged to the grant in the amount of $1,955 should have been allocated to a different grant. Context: Internal co...
INVOICE CODING - Criteria: Costs are necessary and reasonable for the performance of the federal award and allocable under the principles of 2 CFR 200, Subpart E. Condition: One invoice charged to the grant in the amount of $1,955 should have been allocated to a different grant. Context: Internal control review procedures did not correctly identify that the invoice was charged to the incorrect grant. Effect: Cost was charged to the wrong grant. Cause: Error in invoice coding. Recommendation: Review procedures should be enhanced to ensure approved costs are charged to the appropriate grant. Corrective Action: This mistake of grant attribution was subsequently corrected completely. The issue was attributable to a manual process that has been replaced by electronic processing. The electronic procurement system significantly reduces and in most cases eliminates data entry and manual translation between procurement and posting to a particular grant. Adequate review and oversight processes are in place and this issue does not reflect a systemic failure. Responsible Party: Claudine Lurvey, VP of Finances.
Action Taken: The Department has taken immediate corrective action to address the deficiencies identified in the files audited. All noted discrepancies are being reviewed and are in the process of being corrected, and revised Form HUD-50058 submissions will be completed and transmitted, where requir...
Action Taken: The Department has taken immediate corrective action to address the deficiencies identified in the files audited. All noted discrepancies are being reviewed and are in the process of being corrected, and revised Form HUD-50058 submissions will be completed and transmitted, where required. The Department maintains established procedures, systems, and internal controls designed to support compliance with applicable HUD requirements. To further strengthen these controls, enhancements are currently underway to improve the timeliness of processing activities, ensure accurate and thorough income verification, and enforce proper application of abatements. Additionally, the Department is implementing more robust quality control (QC) measures to verify that all required documentation is consistently obtained, reviewed, and retained. To reinforce oversight, the Department is expanding its existing QC and Housing and Community Development (HCD) review processes. This includes the implementation of a front-line supervisory review of a representative sample of recertifications prior to the submission of Form HUD-50058. This added layer of review is intended to proactively identify and correct potential errors, ensuring accuracy, completeness, and full regulatory compliance. If the Department of Housing and Urban Development has questions regarding this plan, please call Nathan Kogon, Director at (786) 469-4120. The process to start correcting the issue discussed above is currently underway, and significant progress is expected for the next fiscal year end audit.
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