Corrective Action Plans

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Type of Finding: Significant Deficiency/Noncompliance
Type of Finding: Significant Deficiency/Noncompliance
Compliance Requirement: Allowable Costs/Cost Principles
Compliance Requirement: Allowable Costs/Cost Principles
The Board will strengthen its internal control procedures over federal program expenditures by enhancing the review and approval process to ensure that all costs charged to federal awards are allowable, allocable, reasonable, and adequately supported in accordance with Uniform Guidance requirements ...
The Board will strengthen its internal control procedures over federal program expenditures by enhancing the review and approval process to ensure that all costs charged to federal awards are allowable, allocable, reasonable, and adequately supported in accordance with Uniform Guidance requirements and the terms and conditions of applicable grant awards. In addition, the Board will provide training to fiscal and program staff on Federal cost principles, allowability requirements, and appropriate cost allocation methodologies to improve compliance and consistency in the charging of expenditures to Federal (and State) programs.
Prior to recording the expenditure of the virtual reality headsets on the general ledger, Board management sought guidance on multiple attempts from the Texas Workforce Commission (TWC) Fiscal T/A division regarding the appropriate treatment of the cost, but did not receive a response before payment...
Prior to recording the expenditure of the virtual reality headsets on the general ledger, Board management sought guidance on multiple attempts from the Texas Workforce Commission (TWC) Fiscal T/A division regarding the appropriate treatment of the cost, but did not receive a response before payment was required. However, the Board will continue to work with TWC to determine the appropriate resolution and disposition of the questioned costs and will implement any corrective actions necessary to ensure compliance with Texas Workforce Commission and the Federal requirements as prescribed by the Uniform Guidance.
Marcos Gonzales, Board Financial and Data Analyst
Marcos Gonzales, Board Financial and Data Analyst
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: As a part of the audit process, a reclassification entry was made to move an additional 12 months of reserve funds from the cash swe...
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: As a part of the audit process, a reclassification entry was made to move an additional 12 months of reserve funds from the cash sweep general fund to a separate bookkeeping account. The Hospital had excess cash available to cover the required reserve amount for the fiscal year. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Management will fund the reserve account from the cash sweep general fund and will monitor the separate bookkeeping account throughout the year to ensure the reserve is properly funded throughout the year as required by the loan documents. Anticipated Completion Date: June 30, 2026
EWP Business office Procedure Manual was updated effective 2025 and was submitted to DHHS in March of 2026. Current Procedures is as follows: Business office Procedures. The following procedures will be applied, to the extent that they do no conflict with or contradict the board policies listed abov...
EWP Business office Procedure Manual was updated effective 2025 and was submitted to DHHS in March of 2026. Current Procedures is as follows: Business office Procedures. The following procedures will be applied, to the extent that they do no conflict with or contradict the board policies listed above: 1. Costs will be charged to an award only if the obligation was incurred during the funding period (unless pre-approval by the Federal awarding agency or pass-through grantor agency). 2. All obligations will be liquidated not later than 30 days after the end of the funding period (or specficied by program legislation). 3. Compliance with period of performance requirements will initially be assigned to the individual approving the allowability of the expense/payment. This will be subject to review and approval in the business office as part of the payment processing.
Noncompliance with Grant Reporting Frequency Requirements Auditor Description of Criteria, Condition, and Effect: Per the grant agreement for funds received from the Michigan Department of Environment, Great Lake, and Energy ("EGLE") the Township is required to submit financial status reports on a m...
Noncompliance with Grant Reporting Frequency Requirements Auditor Description of Criteria, Condition, and Effect: Per the grant agreement for funds received from the Michigan Department of Environment, Great Lake, and Energy ("EGLE") the Township is required to submit financial status reports on a monthly basis, but instead submitted their reports on a quarterly basis. The Township failed to file financial status reports as required by the Township's grant agreement with EGLE. As a result of this condition, the Township did not comply fully with the reporting requirements under this federal award. Auditor Recommendation: We recommend that the Township review its procedures for compiling financial data for external reporting purposes and develop a calendar by which grant managers and Township administration are notified of pending due dates. Financial reports should be supported by general ledger reports (which should be retained internally along with a copy of the report) and subjected to review and approval by an independent employee or administrator prior to submission. Corrective Action: The Township will strive to submit required reports to EGLE on a monthly basis as required. Expectation will be established via the grant calendar for this grant to be established as noted in finding 2025-001. Responsible Person: Karen Trombley, Accounting Coordinator Anticipated Completion Date: December 31, 2026
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Opera...
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Anticipated Completion Date: 12/31/2025 Contact: Jackie Oliveira, Director of Affordable Housing
Finding 2025-002 Plan: The Human Resource Director will work with Paylocity to find out why the mapping on the file they provide was incorrect. The Human Resource Director will have Paylocity (our third party payroll provider) make the necessary corrections on their end, so this will not happen agai...
Finding 2025-002 Plan: The Human Resource Director will work with Paylocity to find out why the mapping on the file they provide was incorrect. The Human Resource Director will have Paylocity (our third party payroll provider) make the necessary corrections on their end, so this will not happen again. Anticipated Completion Date: 12/31/2025 Contact: Jill Lesmerises, CFO
Special Tests and Provisions Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Finding Summary: The Hospital did not maintain the required debt service ...
Special Tests and Provisions Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Finding Summary: The Hospital did not maintain the required debt service coverage ratio for the year ended December 31, 2025. Additionally, the Hospital does not have a control process in place to ensure that the monitored debt service coverage ratio is accurate and non-compliance is reported timely. Responsible Individuals: Eric J. Price, CFO Corrective Action Plan: Management has enhanced internal control policies and processes to monitor compliance with debt covenants, including the periodic calculation of debt service coverage ratio, documentation of management review and approval, and timely communication with the lender if noncompliance is identified. Anticipated Completion Date: September 30, 2026
Finding Number: 2025-001 Finding Title: Procurement Controls (Significant Deficiency) Name of Contact Person: Janice Clark, Chief Finance & Operations Officer Corrective actions implemented or in process include the following: 1. Enhanced Procurement Oversight and Centralized Review The Organization...
Finding Number: 2025-001 Finding Title: Procurement Controls (Significant Deficiency) Name of Contact Person: Janice Clark, Chief Finance & Operations Officer Corrective actions implemented or in process include the following: 1. Enhanced Procurement Oversight and Centralized Review The Organization, building on its established procurement policies, implemented stricter headquarters oversight and approval requirements for higher-risk and higher-dollar procurements, including defined approval thresholds for procurement solicitations, evaluation activities, and contract execution. Specialized and international procurements now require additional senior-level review and involvement, regardless of value. 2. Strengthened Vendor Due Diligence and Market Research Procedures The Organization updated procurement procedures to require expanded documentation of vendor due diligence and market research activities, including enhanced validation of vendor qualifications, procurement support documentation, and vendor representations associated with federal procurements. 3. Enhanced Monitoring of Procurement Documentation and Compliance Requirements Management implemented strengthened review procedures over procurement advertisements, vendor certifications, geographic code compliance documentation, and other supporting procurement records. The revised procedures also require additional review and escalation for identified procurement irregularities or inconsistencies. 4. Advance Payment and Approval Controls The Organization implemented revised controls governing advance payments, including enhanced approval requirements for significant prepayments and additional supporting documentation requirements for high-risk payment arrangements. 5. Procurement Evaluation and Technical Assistance The Organization enhanced procurement evaluation oversight by requiring additional Headquarters participation in evaluation activities for procurements exceeding defined thresholds. In addition, the Organization engaged specialized procurement and logistics resources to provide technical assistance and support for international procurement activities. 6. Personnel Actions and Training The Organization took personnel actions in response to the investigation findings and implemented enhanced procurement and compliance training for relevant personnel involved in procurement and grants management activities. Management believes these corrective actions appropriately address the control deficiencies identified in the finding and strengthen the Organization’s internal control over compliance related to procurement activities under federally funded programs. Anticipated Completion Date: Substantially completed as of April 6, 2026, with ongoing monitoring and training activities continuing through fiscal year 2026.
Management agrees with the finding. Policies and procedures as described above will be established and implemented during the current year.
Management agrees with the finding. Policies and procedures as described above will be established and implemented during the current year.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization continues to make improvements to processes and procedures to ensure the accurate documentation and application of sliding fee discounts. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Matt Morrill, CFO, at 970-871-7635.
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management will review procedures to ensure they have the process in place to ensure timely deposit going forward. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: April 2026
Finding 1219022 (2025-002)
Material Weakness 2025
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.157 Management is responsible for maintaining required monthly deposits into the Replacement Reserve account in accordance with the form HUD-9250. Recommendation: The Project should establish and follow a consistent monthly review process t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.157 Management is responsible for maintaining required monthly deposits into the Replacement Reserve account in accordance with the form HUD-9250. Recommendation: The Project should establish and follow a consistent monthly review process to ensure all deposits are made on a timely basis. Action taken in response to finding: Management continues to review and establish processes related to review and approval to ensure monthly replacement reserve deposits are made. The missed July payment was made April of 2026. The Project currently does not have the funds to make the deposit and is working with HUD to resolve. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: December 31, 2026
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The security deposit liability needs to be funded by a security deposit asset equal to or greater than the liability. Recommendation: We recommend management ensure they have controls and processes in place to ensure the security deposi...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The security deposit liability needs to be funded by a security deposit asset equal to or greater than the liability. Recommendation: We recommend management ensure they have controls and processes in place to ensure the security deposit liability account is properly funded at all times. Action taken in response to finding: The property sold on November 30, 2025, and the security deposit cash was transferred to the new owners at that point. The $342 shortage in cash was considered in the sale but was not transferred from operating to the security deposit cash before the sale took place. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: November 30, 2025
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Distributions and payments on surplus cash notes must be within amounts permitted based upon semi-annual surplus cash calculations. Recommendation: Recommend that management account for surplus cash note payments when determining how mu...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Distributions and payments on surplus cash notes must be within amounts permitted based upon semi-annual surplus cash calculations. Recommendation: Recommend that management account for surplus cash note payments when determining how much cash is available for distribution in accordance with the semi-annual surplus cash calculations and review those calculations for accuracy prior to distributions being made. There is no disagreement with the audit finding. Action taken in response to finding: We have surplus cash remaining at December 31, 2025, subsequent to the distributions being made, therefore the finding has corrected itself. Future distributions and payments on surplus cash notes will be monitored closely to ensure they are limited to amounts permitted. Name of the contact person responsible for corrective action: Doug Harrison Planned completion date for corrective action plan: December 31, 2026
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that manage...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that management work with HUD to have the current management agreement approved. There is no disagreement with the audit finding. Action taken in response to finding: We have contacted HUD to obtain an approved management agreement. Name of the contact person responsible for corrective action: Doug Harrison Planned completion date for corrective action plan: December 31, 2026
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION, PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION, HIGHWAY PLANNING AND CONSTRUCTION 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR ...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION, PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION, HIGHWAY PLANNING AND CONSTRUCTION 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 requires the City of Prior Lake (the City) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the highway planning construction grant. The City did not have sufficient controls in place within its highway planning and construction grant to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The City will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – The City’s Finance Director, Nicole Klekner. Planned Completion Date – December 31, 2026. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – The City’s Finance Director, Nicole Klekner, will ensure appropriate controls are in place to verify that any vendor with which the City contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.
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