Corrective Action Plans

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FINDING – Federal Award Finding 2025-001: Agency: U.S. Department of Health and Human Services (CSBG) Program: Community Service Block Grant (AL No. 93.569) Significant Deficiency and Noncompliance over Allowable Costs / Period of Performance Repeat Finding: No Condition: During our testing over all...
FINDING – Federal Award Finding 2025-001: Agency: U.S. Department of Health and Human Services (CSBG) Program: Community Service Block Grant (AL No. 93.569) Significant Deficiency and Noncompliance over Allowable Costs / Period of Performance Repeat Finding: No Condition: During our testing over allowable costs, we identified 2 transactions in the amount of $38,225 that were incurred in fiscal years 2022 and 2023; however, those costs were recorded as federal expenditure and revenue in fiscal year 2025. The current CSBG grant covering fiscal year 2025 covers the period October 1, 2024 – September 30, 2025, as such, those costs were recorded outside of the period of performance and as such are unallowable. Recommendation: We recommend that management strengthen controls over the timing of federal expenditure recognition to ensure costs are recorded in the proper period of performance. Additionally, the entity should implement procedures to review and reconcile expected expenses to actual invoices received on a periodic basis to ensure all vendor invoices have been timely received. Auditee Response and Corrective Action Plan: UPO has recently implemented two methods for procuring goods and services to address the noted condition. Use of the P-Card for micropurchases and the Purchase Request for larger purchases. P-Card purchases will allow recurring vendor invoices and payments to be captured in real time and recorded in the appropriate billing and funding period. Mandatory use of Purchase Request/PO for all other purchases, to allow the program and finance team to monitor invoices and obligations, and record them within the funding period.
Management’s Action Plan: Management concurs with the findings. The deficiency was due to a lapse in management oversight related to the review and approval of independent contractor timesheets. To strengthen internal controls and ensure compliance with federal requirements, management has implement...
Management’s Action Plan: Management concurs with the findings. The deficiency was due to a lapse in management oversight related to the review and approval of independent contractor timesheets. To strengthen internal controls and ensure compliance with federal requirements, management has implemented corrective actions through the full implementation of a new enterprise resource planning system, Fusion. Under this process, all timecards are now entered, reviewed, and approved directly within Fusion and cannot be processed for payment unless they have been formally approved by appropriate management personnel. This ensures proper documentation, accountability, and adherence to internal control policies. Name of Person Responsible for the Plan: Katherine Hill, Manager of Accounting Jason Lynn, Vice President of Finance and Controller Anticipated Completion Date of the Plan: Completed – fully implemented with the rollout of the Fusion system (May 2025).
Corrective action plan: Dallas County HCVP will expand inspection capacity by hiring additional full-time and contractual inspectors, including an Inspector Supervisor to ensure timely completion of all inspections. Additionally, the Housing Supervisor will review inspection status regularly to ensu...
Corrective action plan: Dallas County HCVP will expand inspection capacity by hiring additional full-time and contractual inspectors, including an Inspector Supervisor to ensure timely completion of all inspections. Additionally, the Housing Supervisor will review inspection status regularly to ensure compliance with HUD­related inspection schedules. Increasing staffing levels will allow the program to meet HUD-required timeframes consistently and reduce the likelihood of delays. Implementation dates: September 30, 2026 Responsible persons: Kesete Yohannes, Assistant Director of Housing
Corrective Action Plan: Dallas County HCVP leadership addressed EIV compliance during the April 2026 and May 2026 monthly staff meetings and will continue to emphasize the requirement. Review of meetings agendas dated April 22, 2026, and May 20, 2026, confirm that EIV compliance was discussed. Addit...
Corrective Action Plan: Dallas County HCVP leadership addressed EIV compliance during the April 2026 and May 2026 monthly staff meetings and will continue to emphasize the requirement. Review of meetings agendas dated April 22, 2026, and May 20, 2026, confirm that EIV compliance was discussed. Additionally, the HCVP Housing Supervisor issued an email to all staff reiterating the requirement to retain EIV reports for all transactions, including but limited to recertifications, interims, and relocations. Implementation Date: June 11, 2026 Responsible Party: Kesete Yohannes, Assistant Director of Housing
Audit Finding Reference Number: 2025 – 003 Finding: NERACOOS submitted FFATA reports for the initial subaward agreements; however, the reports were not updated timely for subsequent subaward amendments. Specifically, amended subaward amounts and amendment dates were not reported timely and accuratel...
Audit Finding Reference Number: 2025 – 003 Finding: NERACOOS submitted FFATA reports for the initial subaward agreements; however, the reports were not updated timely for subsequent subaward amendments. Specifically, amended subaward amounts and amendment dates were not reported timely and accurately in SAM.gov. Corrective Action Plan: Develop a subaward amendment tracking log to record all subaward modifications, including amendment dates, revised subaward amounts, and FFATA reporting due dates. The log will be updated each time a subaward amendment is executed. Establish a written procedure requiring that any subaward amendment triggering a change in amount or key data be reported in SAM.gov within the required timeframe (no later than the end of the month following the month in which the obligation or award was made). Designate a staff member responsible for FFATA reporting compliance and assign a backup to ensure coverage during absences. Implement a quarterly reconciliation between executed subaward agreements/amendments and SAM.gov reporting records to identify and remediate any unreported or inaccurate entries. Provide training to relevant Finance and Grants Management staff on FFATA reporting requirements under 2 CFR Section 200.332 and SAM.gov reporting procedures. Retroactively update SAM.gov for any subaward amendments identified during the audit as not having been reported or reported inaccurately. Responsible Official: Jake Kritzer, Executive Director Anticipated Completion Date: August 31, 2026 (retroactive corrections); ongoing quarterly reconciliation beginning July 2026
Poverty and Social Reform Institute Dba Leaps and Bounds Family Services has updated the policies and procedures for the agency to reflect the Uniform Guidance requirements regarding the process and controls used to administer federal awards. These changes address the issue of non-compliance by form...
Poverty and Social Reform Institute Dba Leaps and Bounds Family Services has updated the policies and procedures for the agency to reflect the Uniform Guidance requirements regarding the process and controls used to administer federal awards. These changes address the issue of non-compliance by formally addressing the roles and responsibilities in writing of who at the agency is responsible for insuring that the Uniform Guidance is followed. The updated policy covers the areas of: allowable costs, cash management, procedures, and conflicts of interest. The new policy will be presented and reviewed for approval at the July 22nd, 2026, board meeting. We believe this corrective action plan will address the non-compliance and bring the agency into full compliance moving forward.
Actions Planned - The Authority is not in position to hire additional staff members for the sole purpose of eliminated the segregation of duties finding from our audit. The Airport Office Adminstrator communicates with the Executive Director and commission members regarding all major account transac...
Actions Planned - The Authority is not in position to hire additional staff members for the sole purpose of eliminated the segregation of duties finding from our audit. The Airport Office Adminstrator communicates with the Executive Director and commission members regarding all major account transactions, including the recording of recurring and non-recurring jounral entry adjustments. The commission meets monthly and closely monitors the financial information provded to them. Official responsible: Airport Office Administrator Planned Completion Date - On-going monitoring Disagreement with Finding - none, the Authority concurs with the finding. Plan to Monitor - The Authority is aware of the situation and will monitor, as it deems appropriate. Monitoring will include commission member oversight for the interim and year-end reporting.
Description of Finding: The organization did not complete and submit its Single Audit within the required timeframe due to special projects (mortgage sales) that dramatically limited staff bandwidth in key financial management positions, resulting in delays in audit coordination and reporting and th...
Description of Finding: The organization did not complete and submit its Single Audit within the required timeframe due to special projects (mortgage sales) that dramatically limited staff bandwidth in key financial management positions, resulting in delays in audit coordination and reporting and the timing of commencing the audit.Statement of Concurrence: The organization concurs with this finding.Corrective Action: The organization has resolved the underlying cause of this finding by streamlining the data collection process related to mortgage sales transactions. Furthermore, the organization is in the process of reorganizing the financial department to streamline workflows. The Staff Accountant in partnership with the Director of Finance & Administration are responsible for oversight of financial reporting, compliance with Uniform Guidance (2 CFR Part 200), and coordination of the Single Audit process.Corrective actions implemented include:• Departmental reorganization is underway to streamline workflows and provide clear ownership of departmental responsibilities (including single audit compliance) between Staff Accountant and Director of Finance and Administration.• Development of a formal audit timeline and internal milestones to ensure timely audit initiation, completion, and submission.• Strengthening of internal controls over financial reporting and audit documentation.• Ongoing communication and coordination with external auditors to ensure compliance with federal audit requirements. These actions ensure that future Single Audits will be completed and submitted timely in accordance with Uniform Guidance.Status of Finding: This finding resulted from unexpected special projects that limited financial staff bandwidth as well as fragmented workflows, which have both been addressed. Corrective action is in process.Projected Completion Date: Corrective action completed as of 6/5/2026, with ongoing monitoring incorporated into standard financial management procedures.
Noncompliance with Grant Reporting Frequency Requirements Auditor Description of Criteria, Condition, and Effect: Per the grant agreement for funds received from the Michigan Department of Environment, Great Lake, and Energy ("EGLE") the Township is required to submit financial status reports on a m...
Noncompliance with Grant Reporting Frequency Requirements Auditor Description of Criteria, Condition, and Effect: Per the grant agreement for funds received from the Michigan Department of Environment, Great Lake, and Energy ("EGLE") the Township is required to submit financial status reports on a monthly basis, but instead submitted their reports on a quarterly basis. The Township failed to file financial status reports as required by the Township's grant agreement with EGLE. As a result of this condition, the Township did not comply fully with the reporting requirements under this federal award. Auditor Recommendation: We recommend that the Township review its procedures for compiling financial data for external reporting purposes and develop a calendar by which grant managers and Township administration are notified of pending due dates. Financial reports should be supported by general ledger reports (which should be retained internally along with a copy of the report) and subjected to review and approval by an independent employee or administrator prior to submission. Corrective Action: The Township will strive to submit required reports to EGLE on a monthly basis as required. Expectation will be established via the grant calendar for this grant to be established as noted in finding 2025-001. Responsible Person: Karen Trombley, Accounting Coordinator Anticipated Completion Date: December 31, 2026
Authority's Response and Planned Corrective Action: The Authority acknowledges the deficiencies identified in the Section 8 Housing Choice Vouchers program and has implemented internal control procedures to ensure compliance with federal regulations. The Auditor selected two files out of 17 leased u...
Authority's Response and Planned Corrective Action: The Authority acknowledges the deficiencies identified in the Section 8 Housing Choice Vouchers program and has implemented internal control procedures to ensure compliance with federal regulations. The Auditor selected two files out of 17 leased units in the Audit period. In one, the Rent Reasonableness verification documentation was missing. HHA staff will review all 17 newly leased units from the Audit period to assure compliance. In addition, HHA has implemented a system for all new lease ups to assure full compliance with Rent Reasonableness documentation. This includes the Assistant Director of Management reviewing all files before a unit is leased. Marc A. Recko, Executive Director was designated to be responsible for implementing this corrective action by September 30, 2026.
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Opera...
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Anticipated Completion Date: 12/31/2025 Contact: Jackie Oliveira, Director of Affordable Housing
Special Tests and Provisions Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Finding Summary: The Hospital did not maintain the required debt service ...
Special Tests and Provisions Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Finding Summary: The Hospital did not maintain the required debt service coverage ratio for the year ended December 31, 2025. Additionally, the Hospital does not have a control process in place to ensure that the monitored debt service coverage ratio is accurate and non-compliance is reported timely. Responsible Individuals: Eric J. Price, CFO Corrective Action Plan: Management has enhanced internal control policies and processes to monitor compliance with debt covenants, including the periodic calculation of debt service coverage ratio, documentation of management review and approval, and timely communication with the lender if noncompliance is identified. Anticipated Completion Date: September 30, 2026
Finding Number: 2025-001 Finding Title: Procurement Controls (Significant Deficiency) Name of Contact Person: Janice Clark, Chief Finance & Operations Officer Corrective actions implemented or in process include the following: 1. Enhanced Procurement Oversight and Centralized Review The Organization...
Finding Number: 2025-001 Finding Title: Procurement Controls (Significant Deficiency) Name of Contact Person: Janice Clark, Chief Finance & Operations Officer Corrective actions implemented or in process include the following: 1. Enhanced Procurement Oversight and Centralized Review The Organization, building on its established procurement policies, implemented stricter headquarters oversight and approval requirements for higher-risk and higher-dollar procurements, including defined approval thresholds for procurement solicitations, evaluation activities, and contract execution. Specialized and international procurements now require additional senior-level review and involvement, regardless of value. 2. Strengthened Vendor Due Diligence and Market Research Procedures The Organization updated procurement procedures to require expanded documentation of vendor due diligence and market research activities, including enhanced validation of vendor qualifications, procurement support documentation, and vendor representations associated with federal procurements. 3. Enhanced Monitoring of Procurement Documentation and Compliance Requirements Management implemented strengthened review procedures over procurement advertisements, vendor certifications, geographic code compliance documentation, and other supporting procurement records. The revised procedures also require additional review and escalation for identified procurement irregularities or inconsistencies. 4. Advance Payment and Approval Controls The Organization implemented revised controls governing advance payments, including enhanced approval requirements for significant prepayments and additional supporting documentation requirements for high-risk payment arrangements. 5. Procurement Evaluation and Technical Assistance The Organization enhanced procurement evaluation oversight by requiring additional Headquarters participation in evaluation activities for procurements exceeding defined thresholds. In addition, the Organization engaged specialized procurement and logistics resources to provide technical assistance and support for international procurement activities. 6. Personnel Actions and Training The Organization took personnel actions in response to the investigation findings and implemented enhanced procurement and compliance training for relevant personnel involved in procurement and grants management activities. Management believes these corrective actions appropriately address the control deficiencies identified in the finding and strengthen the Organization’s internal control over compliance related to procurement activities under federally funded programs. Anticipated Completion Date: Substantially completed as of April 6, 2026, with ongoing monitoring and training activities continuing through fiscal year 2026.
PLANNED CORRECTIVE ACTION The Division will communicate to all units conducting USDA Foods inventory counts the requirement that inventory reports must include documented evidence of review prior to submission. The Division's Social Services department will incorporate verification of documented inv...
PLANNED CORRECTIVE ACTION The Division will communicate to all units conducting USDA Foods inventory counts the requirement that inventory reports must include documented evidence of review prior to submission. The Division's Social Services department will incorporate verification of documented inventory review into its quarterly internal oversight process to ensure compliance with this requirement on an ongoing basis. ANTICIPATED COMPLETION DATE 10/1/26 RESPONSIBLE CONTACT PERSON Julie Luft, NW Social Services Director
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.
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