Corrective Action Plans

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CORRECTIVE ACTION PLAN Concerning Finding 2025-001 - Procurement Contact Person Responsible for Corrective Action: Darcy K. Labbe, Superintendent Corrective Action: The Eagle Lake Sewer District will take the following actions to address finding 2025-001. A procurement policy was drawn up and implem...
CORRECTIVE ACTION PLAN Concerning Finding 2025-001 - Procurement Contact Person Responsible for Corrective Action: Darcy K. Labbe, Superintendent Corrective Action: The Eagle Lake Sewer District will take the following actions to address finding 2025-001. A procurement policy was drawn up and implemented on February 23, 2026. Anticipated Completion Date: A procurement policy was signed by the Board of Trustees and implemented on February 23, 2026.
Corrective Action Plan Finding No.: 2025 - 005 Condition: ECHO did not maintain a listing of capital equipment acquired with Federal funds. During testing of equipment purchased under the Education Stabilization Program, we noted that management was unable to provide a complete inventory identifying...
Corrective Action Plan Finding No.: 2025 - 005 Condition: ECHO did not maintain a listing of capital equipment acquired with Federal funds. During testing of equipment purchased under the Education Stabilization Program, we noted that management was unable to provide a complete inventory identifying equipment purchased with Federal awards or documenting the information required by the Uniform Guidance. As a result, ECHO could not demonstrate that equipment acquired with Federal funds was properly tracked and monitored. Plan: ECHO will establish procedures to record and maintain an inventory of capital equipment acquired with Federal and non-federal grant funds. The inventory lists will be maintained by the Director of Finance and Operations. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Dr. Rena Whitten, Superintendent
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
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
Project Legal Name: Booth Residence, Inc., A Georgia Corporation HUD Project No.: 061-11293 Audit Firm: CohnReznick LLP Period covered by the audit: 10/01/24-9/03/25 (day before sale) Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory ...
Project Legal Name: Booth Residence, Inc., A Georgia Corporation HUD Project No.: 061-11293 Audit Firm: CohnReznick LLP Period covered by the audit: 10/01/24-9/03/25 (day before sale) 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 implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and notes that the property was sold on September 4, 2025 to an unrelated party, therefore we consider this finding closed and no further action required.
6. Finding 2025-006 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulat...
6. Finding 2025-006 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulations. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management is still reviewing and updating the processes and procedures with site personnel to strengthen controls over the refunding of tenant security deposits.
5. Finding 2025-005 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 that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...
5. Finding 2025-005 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 that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.
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.
Project Legal Name: Evangeline Booth Residence, Inc., A Florida Corporation HUD Project No.: 063-EE011-WAH 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 Fina...
Project Legal Name: Evangeline Booth Residence, Inc., A Florida Corporation HUD Project No.: 063-EE011-WAH 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 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 review the project budget to determine if nonessential costs can be cut (or request a loan from the owner) to ensure that the replacement reserve is funded in accordance with the terms of the regulatory agreement and the recommendation to obtain from HUD a waiver for the missing replacement reserve deposits if possible, or fund the missing deposits. b. Action(s) Taken or Planned on the Finding Due to significant delays in receipt of PRAC funds for over a year, management suspended making the deposits to the reserve until PRAC funding was replenished. Management also borrowed funds from the replacement reserve in 2024 which funds were repaid during the year ended September 30, 2024 once past-due PRAC funds were received. Due to ongoing issues with PRAC funding, management continues to be behind on making the monthly deposits during the year ended September 30, 2025.
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 that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...
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 that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.
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 change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulat...
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 change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulations. b. Action(s) Taken or Planned on the Finding We will review the processes and procedures with site personnel to strengthen controls over the refunding of tenant security deposits.
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 implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...
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 implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.
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.
4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to reimburse the amount due to the project and establish procedures to ensure reimbursement for shared costs and related receivables are made timely ...
4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to reimburse the amount due to the project and establish procedures to ensure reimbursement for shared costs and related receivables are made timely in accordance with established policy. b. Action(s) Taken or Planned on the Finding We will implement procedures to ensure shared costs are reimbursed on a consistent and regular basis.
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 that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...
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 that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.
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.
Project Legal Name: Catherine Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113-EE021 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 Terr...
Project Legal Name: Catherine Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113-EE021 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 implement procedures to ensure the funds are deposited into the correct account and to ensure that the replacement reserve is funded in accordance with the terms of the regulatory agreement. b. Action(s) Taken or Planned on the Finding North TX A/C refunded two months deposit of $5,464 to the property as of September 30, 2025. One month deposit was correctly deposited into the replacement reserve account, the second missed deposit was not deposited into the replacement reserve account. We will correct the deposit and move to the replacement reserve account.
Project Legal Name: William Booth Residence, Inc., A North Carolina Corporation HUD Project No.: 053-EE107 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 Fina...
Project Legal Name: William Booth Residence, Inc., A North Carolina Corporation HUD Project No.: 053-EE107 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 implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations None
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: SECTION 202, ASSISTANCE LISTING NUMBER 14.157 During 2024, the Project overpaid management fees to the management company. Recommendation: The management company should repay the $388 to the Project. Action Taken: The Project agrees with ...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: SECTION 202, ASSISTANCE LISTING NUMBER 14.157 During 2024, the Project overpaid management fees to the management company. Recommendation: The management company should repay the $388 to the Project. Action Taken: The Project agrees with the finding. The management company repaid the management fees to the Project in January 2026. If the Department of Housing and Urban Development has questions regarding this plan, please call Ling Han at 651-757-3038.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: In 1 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before pa...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: In 1 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment. The finding was corrected in January 2026. If the Department of Housing and Urban Development has questions regarding this plan, please call Ling Han at 651-645-7271.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Condition: The Project's replacement reserve cash balance was underfunded at December 31, 2025. Recommendation: The Project should deposit $360 into the replacement reserve account. Action Taken: The Project agrees with the finding. Management deposited $3...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Condition: The Project's replacement reserve cash balance was underfunded at December 31, 2025. Recommendation: The Project should deposit $360 into the replacement reserve account. Action Taken: The Project agrees with the finding. Management deposited $360 into the replacement reserve account in February 2026. If the Department of Housing and Urban Development has questions regarding this plan, please call Ling Han at 651-757-3038.
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