Corrective Action Plans

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The delegates from the board did receive the 40-hour training prior to entering the board but were unable to provide certification proof. Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do ...
The delegates from the board did receive the 40-hour training prior to entering the board but were unable to provide certification proof. Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, Board members will prepare a memo with self-attestation of completion for our records.
Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, staff will prepare a memo with self-attestation of completion for our records.
Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, staff will prepare a memo with self-attestation of completion for our records.
Finding Number: 2024-004 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks, Accounting & Support Services Supervisor - Main Contact Persons involved: Kim Giese, Fiscal Officer and Joan Stordalen, Social Services S...
Finding Number: 2024-004 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks, Accounting & Support Services Supervisor - Main Contact Persons involved: Kim Giese, Fiscal Officer and Joan Stordalen, Social Services Supervisor Corrective Action Planned: Regarding the DHS-3220.3 Local Collaborative Time Study (LCTS) Cost Schedule, it was discovered that the Sexual Reproductive Health Services Grant Award was not accurately reported on the LCTS Cost Schedule due to the misguidance from MN Department of Health (MDH) and the interpretation of Watonwan County. After clarification from MDH, all SRHS funds will be reported as state funds only and should not be reflected on the LCTS reporting. Fiscal Officer will amend the last 4 quarters of the LCTS reporting to reflect that change. Moving forward, we will retain documentation from MDH showing SRHS funds are state only funds, regardless of what our grant agreement shows, and ensure that this funding source is not reported on the LCTS reporting in the future. Fiscal Officer will continue to complete the quarterly LCTS reporting, while the Accounting & Support Services Supervisor will review and sign off on it. Regarding the late submission of the 2024 Annual Collaborative Report. This report is emailed and completed by the LCTS Coordinator. Watonwan County's LCTS Coordinator is our Social Services Supervisor. To ensure on time submission of the Annual Collaborative Report, that is due on April 30 each year, a reminder will be added to both the Social Services Supervisor and the Accounting & Support Services Supervisor's Outlook calendars for a reminder beginning April ist giving time to complete and submit the report prior to April 30th. Anticipated Completion Date: 9/12/2025 - Reporting 4/30/2026 - Late Submission
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Verification of Citizenship/assets: We will have discussions at our next unit meeting about makin...
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Verification of Citizenship/assets: We will have discussions at our next unit meeting about making sure all health care cases have their citizenship verified. We will also have training on the policy regarding verifying vehicles if there is more than one in the household. Anticipated Completion Date: 9/15/25 we will have the unit meeting
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Timelines: This error occurred from a worker that is no longer in our agency. It was discovered af...
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jodi Halvorson Corrective Action Planned: Timelines: This error occurred from a worker that is no longer in our agency. It was discovered after the worker left that the application was filed away without processing. This is not our policy, and we will be discussing the importance of program timelines in our unit meeting. Verification of Citizenship status (error with SSN entry): This case was received from a previous county. The SSN was entered incorrectly which did not produce citizenship verification in the system. It was noted that there was a birth certificate on file, but METS case files do not get transferred between counties, so we did not have the birth certificate. The SSN was corrected which was able to ping the verification of the citizenship. Going forward, for the next 3 months we will be looking at each case that is transferred into our county to make sure the citizenship has been verified and if not, request the birth certificate or other verification. After the initial 3 months, we plan to do random case checks. Anticipated Completion Date: 9/15/25 we will have the unit meeting and discuss timelines 12/31/25 will be our 3-month goal of checking transferred in cases for citizenship
2024-003: Water and Waste Disposal Systems for Rural Communities Reporting Corrective Action Plan: The Village is actively working with USDA personnel to submit the required reporting documents. Going forward, these will be submitted once available. Reponsible person: Sheila Schreiner Anticipated co...
2024-003: Water and Waste Disposal Systems for Rural Communities Reporting Corrective Action Plan: The Village is actively working with USDA personnel to submit the required reporting documents. Going forward, these will be submitted once available. Reponsible person: Sheila Schreiner Anticipated completetion date: Ongoing
CASEFILE REVIEW (2023-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County...
CASEFILE REVIEW (2023-005) Recommendation: It is recommended the County review case files on a periodic basis throughout the year and document the reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS (2023-009) Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with...
SSIS ACTIVITIES ALLOWED/ALLOWABLE COSTS (2023-009) Recommendation: It is recommended that the County implement procedures to document review of disbursements when not able to show an electronic approval in the SSIS system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to document review for all SSIS disbursements. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
FOSTER CARE REPORTING (2023-008) Recommendation: It is recommended that the County implement procedures to review the foster care report and retain evidence of the review on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in respons...
FOSTER CARE REPORTING (2023-008) Recommendation: It is recommended that the County implement procedures to review the foster care report and retain evidence of the review on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will start printing a coversheet for the Fiscal Supervisor to sign and retain physical evidence of the review being done. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
SLFRF SUSPENSION AND DEBAREMENT (2023-011) Recommendation: It is recommended that the County ensure properly language related to suspension and debarment is included in the contract, or other records are kept on file to support a verification was done. Explanation of disagreement with audit finding:...
SLFRF SUSPENSION AND DEBAREMENT (2023-011) Recommendation: It is recommended that the County ensure properly language related to suspension and debarment is included in the contract, or other records are kept on file to support a verification was done. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work at this area and internal controls to achieve the overall goal. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
Condition: The Organization did not have the appropriate controls in place over FFATA reporting and did not file the required reports. Further, while the Organization had written procedures over cash management, they were outdated and did not reflect the current staffing model. Planned Corrective Ac...
Condition: The Organization did not have the appropriate controls in place over FFATA reporting and did not file the required reports. Further, while the Organization had written procedures over cash management, they were outdated and did not reflect the current staffing model. Planned Corrective Action: Reporting was completed in SAM.gov in May 2025 for subrecipient subaward amount based on the award period running from calendar periods of July to June. Written internal MMTC procedures regarding cash management will be updated and will include the current staff. Contact person responsible for corrective action: Alan Kowalewski Anticipated Completion Date: 10/31/2025
Auditee’s Response and Planned Corrective Action The Adams Housing Authority has received approval for HUD to switch banks for the HCV program. The Authority will obtain a signed depository agreement from the new bank Planned Implementation Date of Corrective Action: September 1, 2025 Person Respons...
Auditee’s Response and Planned Corrective Action The Adams Housing Authority has received approval for HUD to switch banks for the HCV program. The Authority will obtain a signed depository agreement from the new bank Planned Implementation Date of Corrective Action: September 1, 2025 Person Responsible for Corrective Action: William Schrade, Executive Director
Auditee’s Response and Planned Corrective Action The Adams Housing Authority will be providing training from a 3rd party for all employees on proper documentation and checklists needed for all voucher files. Planned Implementation Date of Corrective Action: September 8, 2025 Person Responsible for C...
Auditee’s Response and Planned Corrective Action The Adams Housing Authority will be providing training from a 3rd party for all employees on proper documentation and checklists needed for all voucher files. Planned Implementation Date of Corrective Action: September 8, 2025 Person Responsible for Corrective Action: William Schrade, Executive Director
The property manager attended a couple of multifamily housing specialist training courses and received certification. The required update to the gross rents, annually based on the OCAF, will be corrected in tenants' files moving forward. The Housing Authority has put a quality control system in plac...
The property manager attended a couple of multifamily housing specialist training courses and received certification. The required update to the gross rents, annually based on the OCAF, will be corrected in tenants' files moving forward. The Housing Authority has put a quality control system in place to ensure the tenants' files are in compliance. We expect to be in compliance moving forward.
The outstanding balance currently reflected in the books represents unreconciled funds resulting from the transfer of assets and liabilities during the conversion of the Public Housing Program to the RAD Project-Based Rental Assistance (PBRA) Program. These funds were carried forward following the t...
The outstanding balance currently reflected in the books represents unreconciled funds resulting from the transfer of assets and liabilities during the conversion of the Public Housing Program to the RAD Project-Based Rental Assistance (PBRA) Program. These funds were carried forward following the transition of ownership and operations from the PHA to Athens Housing Management, LLC, as the new ownership entity. By HUD RAD guidance, including the RAD Notice Revision 4 (H-2019-09/PIH-2019-23), when a public housing project converts to PBRA under RAD, the PHA is required to transfer assets and liabilities to the new ownership entity to ensure continuity and financial integrity of the property. Specifically, Attachment 1A to the RAD Notice outlines the obligation to transfer project-specific assets and liabilities from the public housing ledger to the new entity, including cash, receivables, and project-level obligations. The amounts in question were initially anticipated to be reconciled as part of that process. However, due to the complexity of the transition and lack of adequate internal controls at the time, the residual balance has remained unreconciled for the past five fiscal years. These amounts are not expected to be repaid or resolved in FY 2025. As such, this is a one-time, non-recurring issue, and corrective action is underway. Staff will formally seek HUD’s approval and submit a resolution to the Boards of both the Housing Authority (the management entity) and Athens Housing Management LLC (the ownership entity), requesting that the outstanding balance be written off. This action will appropriately clear the books of legacy items tied to the conversion and align the accounting records of both entities. This write-off recommendation aligns with best practices in governmental accounting for long-standing inter-entity balances that are no longer collectible or relevant to current operations. Additional internal controls have since been implemented to prevent recurrence, including improved cash management oversight, inter-entity reconciliation protocols, and timely financial reporting.
U. S. Department of Health and Human Services Health Center Program – Assistance Listing No. 93.224/93.527 Recommendation: It is recommended that the Agency provide additional training to staff on the calculation and recording of sliding fee adjustments to ensure sliding fee adjustments are correctl...
U. S. Department of Health and Human Services Health Center Program – Assistance Listing No. 93.224/93.527 Recommendation: It is recommended that the Agency provide additional training to staff on the calculation and recording of sliding fee adjustments to ensure sliding fee adjustments are correctly applied to all eligible patients. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To address the eligibility compliance issues identified by CLA, the client will implement a corrective action plan centered on enhancing staff training and reinforcing procedural accuracy. All front-line and billing personnel will undergo targeted training sessions focused on the proper application of the Sliding Fee Scale (SFS) discount. This training will cover key eligibility criteria, including accurate income assessment against the 200% federal poverty level threshold, correct interpretation and application of CPT codes, and verification of insurance status prior to discount application. Special emphasis will be placed on real-world scenarios, such as identifying when a CPT code should be billed at no charge or when a patient’s insurance coverage disqualifies them from SFS eligibility. Name(s) of the contact person(s) responsible for corrective action: Jessica Rogers, Director of Finance. Planned completion date for corrective action plan: December 31, 2025.
Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Amy Waldvogel, Financial Assistance Supervisor Corrective Action Planned: The supervisor will periodically pull random cases and verify all required verifications are notat...
Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Amy Waldvogel, Financial Assistance Supervisor Corrective Action Planned: The supervisor will periodically pull random cases and verify all required verifications are notated and on file. The required verification for programs will be reviewed at unit meetings and employee/supervisor meetings. Anticipated Completion Date: Completion date of 10/31/2025, there will be ongoing reviews to continue accuracy of benefits for Morrison County residents.
Finding reference: 2024-002 Description of Finding: The required inspections for two (2) tenants out of a sample of forty (40) were not completed timely. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: The Authority’s Field Services Manager is no...
Finding reference: 2024-002 Description of Finding: The required inspections for two (2) tenants out of a sample of forty (40) were not completed timely. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: The Authority’s Field Services Manager is now printing system generated reports to distribute to inspectors for review. Inspectors are required to review to identify any units that are in need of inspections outside of those that have already been scheduled. Those reports are downloaded and saved to monthly file folders for oversight of that process. Name of Contact Person: Curtis Lokey, Director of Finance, 432-752-4893, clokey@chahousing.org
Maxton Housing Authority Corrective Action Plan for the year ended December 31, 2024 Section II - Financial Statement Findings Finding 2024-001 Name of Contact Person: Teresa Bethea, Executive Director Corrective Action: We will monitor budgeted expenditures and make budget amendments as necessary. ...
Maxton Housing Authority Corrective Action Plan for the year ended December 31, 2024 Section II - Financial Statement Findings Finding 2024-001 Name of Contact Person: Teresa Bethea, Executive Director Corrective Action: We will monitor budgeted expenditures and make budget amendments as necessary. Proposed Completion Date: Immediately Section III - Federal Award Findings and Questioned Costs Finding 2024-002 Name of Contact Person: Teresa Bethea, Executive Director Corrective Action: Management will review the recertification process and plan to monitor recertifications. Proposed Completion Date: Immediately
Finding 1153789 (2024-005)
Material Weakness 2024
CONTROLS OVER REPORTING – C&TC ANNUAL REPORT Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM and 2405MN5MAP, 2024 Pass-Through ...
CONTROLS OVER REPORTING – C&TC ANNUAL REPORT Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM and 2405MN5MAP, 2024 Pass-Through Agency: Brown-Nicollet Community Health Services Pass-Through Number: 2405MN5ADM and 2405MN5MAP Award Period: Year-Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the County have a secondary person review these reports before they are submitted to DHS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action plan: Anne Broskoff, Human Services Director Planned completion date for corrective action plan: December 31, 2025
Finding 1153786 (2024-004)
Material Weakness 2024
RANDOM MOMENT STUDY EMPLOYEES LISTING Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM and 2405MN5MAP, 2024 Pass-Through Agency:...
RANDOM MOMENT STUDY EMPLOYEES LISTING Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM and 2405MN5MAP, 2024 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2405MN5ADM and 2405MN5MAP Award Period: Year-Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the County review the RMS listings and employees within the department and account codes to ensure the proper employees are included on the listing and general ledger accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a person ensure account coding is made to the correct accounts. Name of the contact person responsible for corrective action plan: Anne Broskoff, Human Services Director Planned completion date for corrective action plan: December 31, 2025
Finding 1153783 (2024-003)
Material Weakness 2024
CONTROLS OVER ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM and 2405MN5MAP, 2024 Pass-Through Agency: Minnesota De...
CONTROLS OVER ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM and 2405MN5MAP, 2024 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2405MN5ADM and 2405MN5MAP Award Period: Year-Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the County increase review over casefiles and ensure that there are performed on a periodic basis throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action plan: Anne Broskoff, Human Services Director Planned completion date for corrective action plan: December 31, 2025
1. Description: There were discrepancies noted on the HUD‐50058 forms used to determine eligibility for the Housing Choice Voucher Program. (Finding 2023‐003). 2. Analysis: The Uniform Guidance and the compliance statement must be adhered to and complied with when determining eligibility for partici...
1. Description: There were discrepancies noted on the HUD‐50058 forms used to determine eligibility for the Housing Choice Voucher Program. (Finding 2023‐003). 2. Analysis: The Uniform Guidance and the compliance statement must be adhered to and complied with when determining eligibility for participation in the Housing Choice Voucher Program. 3. Corrective Action: The Bloomfield Housing Agency design and implement control procedures with respect to eligibility determinations that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. 4. Implementation Date: Ongoing
View Audit 366862 Questioned Costs: $1
Finding 2024-002: Significant Deficiency – Reporting Repeat of Prior Year Finding 2023-002 Condition: The annual report understated current period expenditures and total cumulative expenditures. Corrective Action: The differences in the reporting are a cumulative effect from incorrect reporting from...
Finding 2024-002: Significant Deficiency – Reporting Repeat of Prior Year Finding 2023-002 Condition: The annual report understated current period expenditures and total cumulative expenditures. Corrective Action: The differences in the reporting are a cumulative effect from incorrect reporting from March 2023. The Administrator was unable to make changes to the 2023 report, so that affected the 2024 report. The Administrator will have Auditor-Treasurer review the final report before submitting. Person Responsible For Corrective Action: Rebecca Young, Administrator Anticipated Completion Date: April 30, 2025
Comments on findings and recommendations The organization concurs with the finding and the auditor’s recommendation. We acknowledge that while the missing file was an isolated incident, internal controls over document retention need improvement to ensure all required tenant files are preserved and r...
Comments on findings and recommendations The organization concurs with the finding and the auditor’s recommendation. We acknowledge that while the missing file was an isolated incident, internal controls over document retention need improvement to ensure all required tenant files are preserved and retrievable. Actions taken or planned The organization is in the process of implementing an electronic document management system with automatic backup features. Additionally, a formal file retention policy is being developed, which will include supervisory review prior to any deletion or purging of files. Staff responsible for document handling will receive training to reinforce compliance with the policy. Anticipated completion date September 30, 2025
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