Corrective Action Plans

Browse how organizations respond to audit findings

Total CAPs
64,113
In database
Filtered Results
10,482
Matching current filters
Showing Page
24 of 420
25 per page

Filters

Clear
Active filters: Significant Deficiency
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. 14.155 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 has made all required deposits to the residual receipts account as of May 2025 and the cash account was whole before the sale that took place on November 30, 2025. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: May 31, 2025
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.
Management Response: Management acknowledges Finding 2025-005 and agrees that the deficiency in accounting for expenses covered under the resource sharing agreement constitutes a material weakness in internal control over financial reporting and compliance. Misclassification of individual expense ca...
Management Response: Management acknowledges Finding 2025-005 and agrees that the deficiency in accounting for expenses covered under the resource sharing agreement constitutes a material weakness in internal control over financial reporting and compliance. Misclassification of individual expense categories by $70,223 affected the accuracy of category-level reporting and increased the risk of budget overages or noncompliance where federal awards and resource sharing agreements contain line-item spending limitations or require accurate reporting by cost category. Although the error did not necessarily affect total expenditures, incorrect classification can impair oversight, distort budget-to-actual monitoring, and reduce the reliability of information used for internal and external reporting. Management determined that the root causes included insufficiently detailed written guidance for coding transactions under the resource sharing agreement, inconsistent use of account mappings between the general ledger and agreement budget categories, and inadequate review of category-level coding before expenditures were finalized and reported. Existing procedures addressed expense processing generally, but they did not provide enough direction on how shared-service or agreement-covered costs should be classified into the proper expense categories for budget monitoring and reporting. To address this material weakness, management is implementing a corrective action plan focused on improving category-level classification and reporting for expenses covered under the resource sharing agreement. The plan includes four key actions: revising written accounting procedures to define category descriptions, coding rules, and decision standards; creating a standardized crosswalk between general ledger accounts and agreement budget categories; requiring supervisory review of category coding before final reporting; and implementing periodic budget-to-actual monitoring to identify unusual balances, potential overages, and coding trends that may indicate misclassification. Under the revised process, each expense charged under the resource sharing agreement will be recorded using the approved chart-of-accounts mapping and supported by documentation sufficient to identify the nature of the cost, the applicable budget category, and the reason the selected classification is appropriate. If a transaction involves a cost type that does not clearly align to an established category, accounting personnel will be required to elevate the transaction for review before posting or reporting. Any manual reclassification entries affecting agreement categories will require documented justification and supervisory approval. In addition, management will compare recorded expenditures to budgeted amounts by category on a recurring basis so that unusual fluctuations, coding anomalies, or category overages can be investigated and corrected before financial or grant reporting is finalized. Management will also provide targeted training to accounting, finance, and grants personnel responsible for recording or reviewing resource sharing agreement activity. Training will address the relationship between GAAP-based accounting records, agreement-specific budget categories, and federal compliance expectations for accurate, current, and complete financial reporting and comparison of expenditures to budget amounts. Management will supplement this training with periodic reviews of classification trends and exception items so that recurring coding issues can be identified and corrected through additional guidance, process changes, or retraining as needed. Management believes these corrective actions directly address the auditors’ recommendation to review current policies and procedures for compliance with GAAP and federal regulations. Responsibility for implementation will rest primarily with the Finance Director, in coordination with accounting and grants personnel involved in resource sharing agreement reporting. Management expects the enhanced coding guidance, account crosswalk, review controls, and category-level monitoring procedures to improve the accuracy of expense classification, strengthen budget oversight, and reduce the risk of misstatements or noncompliance related to resource sharing agreement expenditures in future periods. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Revise and adopt written accounting procedures for expenses covered under the resource sharing agreement, including category definitions, coding rules, and documentation standards for classification decisions. Finance Director; Accounting Manager June 30, 2026 Approved procedures; updated accounting manual; staff distribution records. Develop and implement a standardized crosswalk between general ledger accounts and resource sharing agreement budget categories, including guidance for common transaction types and reclassification scenarios. Accounting Manager; Finance Director July 15, 2026 Approved account crosswalk; coding reference guide; sample mapped transactions. Require documented supervisory review of category coding for resource sharing agreement transactions before final reporting, including review of manual reclasses and higher-risk expense categories. Finance Director Effective immediately Reviewer signoff on category reports; approved reclassification support; supervisory review documentation. Provide targeted training to accounting, finance, and grants personnel on category-level expense classification, use of the crosswalk, and reporting requirements under the resource sharing agreement Compliance Officer; Finance Director August 31, 2026 Training materials; attendance logs; completed acknowledgements or knowledge checks. and applicable federal regulations. Perform monthly budget-to-actual category reviews for resource sharing agreement expenditures to identify unusual balances, potential overages, and coding anomalies requiring investigation or correction. Accounting Manager; Finance Director Monthly, beginning July 31, 2026 Monthly budget-to-actual reports; exception logs; documented follow-up and corrections. Perform quarterly monitoring of a sample of resource sharing agreement transactions to verify correct category coding, consistency with the approved crosswalk, and compliance with agreement and federal reporting requirements. Compliance Officer; Finance Director Quarterly, beginning September 30, 2026 Quarterly monitoring reports; sample testing documentation; corrective action follow-up records
Item 2025.003 - Cash Management Recommendation The Organization should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting, a grant and contracts consulting firm....
Item 2025.003 - Cash Management Recommendation The Organization should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting, a grant and contracts consulting firm. A drawdown policy will be established for the July 2026 Board Meeting for approval.
Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly appli...
Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly applied a sliding fee discount to a patient account, resulting in a discount that was not consistent with the Organization's sliding fee discount policy. Individual(s) Responsible for Corrective Action: Andrew Barter, CEO Planned Corrective Action: The identified error resulted from a contracted third-party billing company applying a sliding fee discount that was inconsistent with Little Rivers Health Care's Sliding Fee Discount Program policy. Upon identification of the finding, the account was reviewed and corrected to ensure the patient received the appropriate discount. To prevent future occurrences, Little Rivers Health Care re-instituted its monthly monitoring and review procedures in May 2026. These monitoring activities had been conducted consistently through the fall of 2025 and include periodic audits of patient accounts receiving sliding fee discounts, verification of discount calculations, and oversight of third-party billing activities. Findings from these reviews are documented, and corrective action is taken promptly when discrepancies are identified. In addition, the contracted billing company has been reminded of the organization's sliding fee discount requirements and expectations for compliance. To provide ongoing oversight and validation of compliance with the Sliding Fee Discount Program, Little Rivers Health Care has also implemented quarterly review meetings involving the Billing Manager, Controller, and Chief Executive Officer. These meetings have been formally scheduled, with the first occurrence set for July 20, 2026. The quarterly reviews will evaluate monitoring results, validate adherence to policy requirements, identify trends or potential risks, and ensure continuous compliance with program requirements. Anticipated Completion Date: May 20, 2026 (Corrective action completed), for reinstatement of monthly monitoring procedures. Quarterly compliance review meetings with the Billing Manager, Controller, and CEO are scheduled to commence on July 20, 2026, and will continue on an ongoing basis as part of the Organization's continuous compliance monitoring process.
Authority Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor and has initiated corrective actions to strengthen compliance with Housing Quality Standards (HQS) inspection requirements and related abatement procedures. Management identified that staff...
Authority Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor and has initiated corrective actions to strengthen compliance with Housing Quality Standards (HQS) inspection requirements and related abatement procedures. Management identified that staffing turnover and transition-related training gaps contributed to delays in the timely processing and enforcement of failed inspection reinspections and landlord abatements during the audit period. In response, the Authority has implemented enhanced monitoring and supervisory review procedures over failed inspections and reinspection timelines to ensure compliance with HUD requirements. Management has reinforced staff training related to HQS enforcement, reinspection tracking, and Housing Assistance Payment (HAP) abatement procedures. In addition, the Authority is utilizing system generated tracking reports and management oversight tools to identify failed inspections approaching required corrective action deadlines and to ensure timely follow-up and enforcement actions are completed. The Authority believes these corrective measures will strengthen internal controls over compliance and help ensure continued adherence to HUD Housing Quality Standards requirements and related special tests and provisions compliance requirements. Isaiah Norris, Vice President of the Housing Choice Vouchers Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2026.
Authority's Response and Planned Corrective Plan: The Authority accepts the auditor’s recommendation. Management acknowledges the importance of maintaining complete and readily available tenant file documentation to support eligibility determinations and ongoing program compliance for the Housing Vo...
Authority's Response and Planned Corrective Plan: The Authority accepts the auditor’s recommendation. Management acknowledges the importance of maintaining complete and readily available tenant file documentation to support eligibility determinations and ongoing program compliance for the Housing Voucher Cluster. The documents noted as unavailable during the audit relate to file maintenance and documentation retention. Management does not believe the exceptions indicate that the sampled households were ineligible for assistance; however, the Authority recognizes that required documentation must be consistently maintained and available for audit review. In response, the Authority will implement a corrective action plan that includes increased supervisory review of tenant files, enhanced file completion checklists, periodic internal quality control reviews, and additional staff training on required eligibility documentation, including consent forms, lead-based paint documentation, HAP contracts, and tenancy addenda. The Authority will also strengthen monitoring procedures to ensure missing or incomplete documents are identified and corrected timely. Management will assign responsibility for periodic file review to Housing Choice Voucher leadership and will document follow-up actions taken. These procedures are intended to improve internal controls over tenant file maintenance and ensure continued compliance with HUD requirements, Uniform Guidance, and the applicable compliance supplement. Isaiah Norris, Vice President of the Housing Choice Vouchers Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2026.
Persons responsible for corrective action: Keith Morrow, Health Services Chief Executive Officer Corrective action planned: Developed and implemented process by which Business Services staff in Health Services review documents provided by non-Ponca Native Americans upon initial request for services ...
Persons responsible for corrective action: Keith Morrow, Health Services Chief Executive Officer Corrective action planned: Developed and implemented process by which Business Services staff in Health Services review documents provided by non-Ponca Native Americans upon initial request for services and on an annual basis to follow to confirm and verify their capacity to receive health services from the Ponca Tribe. Steps have been taken to see the staff verifying are independent from those who initially collect such documents. Additionally, confirmed such process is consistent with existing verification review of Ponca members requesting services. Implementation date: December 1, 2025.
Finding 2025-002 Condition: Two vendors were awarded a contract without a competitive procurement process. The school did not maintain any documentation in the files regarding why a competitive procurement process was not performed. Corrective Action Planned: Southbridge Public Schools is actively c...
Finding 2025-002 Condition: Two vendors were awarded a contract without a competitive procurement process. The school did not maintain any documentation in the files regarding why a competitive procurement process was not performed. Corrective Action Planned: Southbridge Public Schools is actively creating procedures for all procurements in compliance with Massachusetts General Laws and Federal Regulations. This procedure will be in place for any procurements utilizing federal grant funding. Anticipated Completion Date: July 31, 2026 Contact: Matthew Robidoux – Business Manager
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.
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
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
In May of 2026, the Institute amended its procedures to (1) require the printing of a schedule of student balances after application of Federal Pell Grant and Loan receipts and (2) for all students with a credit balance within 12 days of the Pell receipt indicating the check number and date of the r...
In May of 2026, the Institute amended its procedures to (1) require the printing of a schedule of student balances after application of Federal Pell Grant and Loan receipts and (2) for all students with a credit balance within 12 days of the Pell receipt indicating the check number and date of the refund to the student on this schedule. This schedule is then to be reviewed for adherence to the required 14-day refund requirement under the Pell program by another staff member.
As reported in the Institutes fiscal 2024 Corrective Action Plan, in May 2025, the Institute revised its current procedures to include having an employee independent from the exit conference process review that any student not enrolled in a new semester or that is enrolled at less than half time sta...
As reported in the Institutes fiscal 2024 Corrective Action Plan, in May 2025, the Institute revised its current procedures to include having an employee independent from the exit conference process review that any student not enrolled in a new semester or that is enrolled at less than half time status has received proper exit conferencing and that exit conferencing has been properly documented. Two of the findings in the current fiscal 2025 occurred prior to the May revision by the Institute of its procedures. The third finding occurred during a period that the independent party performing the review function was on leave due to a death in the family. The Institute recognizes the importance of ensuring that exit conferences are performed timely and properly documented. Management has met with its staff involved in this process to emphasize its importance. Additionally, an additional staff member has been assigned to perform the review procedures if the staff member responsible is not available to timely perform the procedures.
Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a disco...
Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a discount but did not have an active sliding fee application for the service date the sliding fee discount was applied. Individual(s) Responsible for Corrective Action: Lori Slicer, Revenue Cycle Manager (organization-wide sliding fee discount monitoring procedure across the medical and dental service lines). Crystal Kinsman, Dental Practice Manager (dental-specific monitoring, with increased sampling of the Dental system given its higher level of manual processing). Heidi Melbostad, Chief Executive Officer and Compliance Officer (sliding fee discount schedule redesign and oversight). Planned Corrective Action: Management is addressing this finding through both an immediate interim action and a comprehensive redesign, together with an ongoing monitoring control. Interim action (completed): the Board approved revised nominal fee levels on 2026-04-27, effective 2026-04-28, establishing Category A as the most favorable discount category, consistent with Section 330(k)(3)(G) of the Public Health Service Act. Full corrective action: management will complete a comprehensive redesign of the Sliding Fee Discount Program, including separate schedules for the medical and dental service lines, data-driven evaluation of tier thresholds and fee levels, and replacement of the percentage-based payment option with a clearer flat-fee structure, for Board review and approval. Ongoing monitoring control: management will establish a documented monitoring procedure over sliding fee discount application across both the medical and dental service lines, including a defined monthly sample drawn from each service line with increased sampling of the Dental system given its higher level of manual processing, verification that an active sliding fee application is on file for each service date, documented review results, timely correction of identified errors, and supervisory sign-off, with error rates reviewed at least quarterly. Anticipated Completion Date: Interim nominal fee revision effective 2026-04-28 (completed). Comprehensive Sliding Fee Discount Program redesign and ongoing monitoring procedure to be Board-approved and operational by 2026-08-24.
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient t...
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient to Douglas County who is the recipient of the funds. Eide Bailly LLP identified that the Town did not have documented or consistently applied internal controls to ensure compliance with the County’s subrecipient guidance requiring the submission of formal special reports for ALN 21.027. Responsible Individuals: Mark Henderson, Assistant Director of Castle Rock Water Corrective Action Plan: Staff will complete quarterly reports including project progress and estimated project infrastructure costs. The reports will be reviewed by management prior to submission to the recipient of the Federal Funds (Douglas County). Anticipated Completion Date: Ongoing during the period that the Town is a subrecipient of these funds for the project.
Finding 2025-004: Eligibility- Inconsistent Tenant Rent Across Documentation Type: Significant Deficiency Condition: During testing of tenant files, two instances where the tenant rent on the rent roll/rent change notice (Subsidy Adjustment Notice) did not agree to the tenant rent on the Tenant Inco...
Finding 2025-004: Eligibility- Inconsistent Tenant Rent Across Documentation Type: Significant Deficiency Condition: During testing of tenant files, two instances where the tenant rent on the rent roll/rent change notice (Subsidy Adjustment Notice) did not agree to the tenant rent on the Tenant Income Certification. Management agrees with the finding. Management will implement a secondary review process to reconcile tenant rent amounts across all documentation before finalizing rent changes or submitting files to the PHA. A. Management will coordinate with Compliance Manager to establish a review process to ensure tenant rent amounts are reconciled and consistent across the TIC, rent roll, and all subsidy adjustment notices prior to submission to the public housing authority. Contact for Corrective Action: Cornelia Reith anticipated Completion date:12/31/26
Finding 2025-002: Eligibility – Untimely Recertifications Type: Significant Deficiency Condition: During testing of tenant files, the auditor identified fourteen instances in which 2025 annual recertifications were not completed in a timely manner. Recertifications were performed in the subsequent y...
Finding 2025-002: Eligibility – Untimely Recertifications Type: Significant Deficiency Condition: During testing of tenant files, the auditor identified fourteen instances in which 2025 annual recertifications were not completed in a timely manner. Recertifications were performed in the subsequent year, and effective dates were backdated to reflect the current year. Management agrees with the finding and acknowledges the need to strengthen internal controls over tenant file compliance. To address this issue, management will implement a formalized tracking system for annual recertifications to ensure they are completed timely with accurate effective dates. Additionally, supervisory review and approval procedures will be enhanced prior to finalizing tenant rent changes. A. The Compliance Manager will oversee the compliance department and ensure staff complete recertifications prior to required effective dates. B. The Property Manager will conduct weekly meetings with staff to review upcoming recertifications and monitor progress to ensure timeliness. C. Management is in the process of hiring additional staff dedicated to processing recertifications to improve timeliness and compliance. Contact for Corrective Action: Cornelia Reith anticipated Completion date:12/31/26
View of Responsible Officials: Management carried out an after-action review to identify root cause of delays in completing the 2024 audit and timely filing of the single audit report packet. We implemented strict timeline in completing the 2024 year-end financial closing process and accounts reconc...
View of Responsible Officials: Management carried out an after-action review to identify root cause of delays in completing the 2024 audit and timely filing of the single audit report packet. We implemented strict timeline in completing the 2024 year-end financial closing process and accounts reconciliation. An overall Audit Coordinator was appointed and worked closely with the business process leads while Regional and Country Managers helped ensure completion of the 2024 field offices and affiliates audit reports prior to start of the global audit fieldwork. While timely submission of the 2024 Single Audit package remained a high priority, staff bandwidth constraints required additional time to ensure all audit requests were thoroughly supported and addressed. Management is continuing to strengthen processes and coordination mechanisms to improve timeliness going forward, including better workload planning, earlier engagement with key stakeholders, and ongoing monitoring of audit readiness milestones.
Contact Person Patricia Heraty, Accountant Corrective Action Plan Management plans to review its internal control procedures to ensure a quality control review is performed to verify all required documentation and calculations are maintained in the tenant files. Planned Completion Date for CAP Immed...
Contact Person Patricia Heraty, Accountant Corrective Action Plan Management plans to review its internal control procedures to ensure a quality control review is performed to verify all required documentation and calculations are maintained in the tenant files. Planned Completion Date for CAP Immediately.
Recommendation: We recommend that the college review its processes and internal controls related to SAP and ensure procedures are in place to ensure students who are not meeting SAP requirements are properly identified and disbursed aid in accordance with the institution’s SAP policy. Explanation of...
Recommendation: We recommend that the college review its processes and internal controls related to SAP and ensure procedures are in place to ensure students who are not meeting SAP requirements are properly identified and disbursed aid in accordance with the institution’s SAP policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since December 2025, the College has worked with the SIS Managed Services team (Anthology now Ellucian) to update its SAP policy and ensure compliance with federal regulations. The new SAP policy was fully implemented effective during the Winter 2026 term. As an internal control, at the end of each term when SAP is evaluated, the results are pre-screened by the Coordinator of Financial Aid with oversight from the Director of Financial Aid to ensure accuracy before results are posted live in the system. Additionally, the College has clarified its understanding of Anthology’s treatment of students who are newly enrolled at the College or who have changed into a different program version. These students are designated with a not-calculated SAP which represents a blank or null status until the conclusion of the term when the students receive a passing or failing grade and can be evaluated by the SAP standards. Steps also have been taken to ensure that prior enrollments are linked to ensure integrity of the application of SAP standards based on the cumulative pace, GPA and maximum timeframe. As a further measure to ensure the integrity of awarding Title IV funds only to eligible students, the College has placed students with prior ineligible SAP statuses in a hold group within the SIS and identified these students as not meeting Disbursement Approval Criteria (DAC) thus causing any attempt to disburse funds to them to fail. Name(s) of the contact person(s) responsible for corrective action: Sarajane Viemeister and Denise Reid-Strachan. Planned completion date for corrective action plan: June 30, 2027.
« 1 22 23 25 26 420 »