Corrective Action Plans

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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
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
We will establish policies and procedures to ensure all reports are reviewed and approved by management. We are introducing Program Management Standards on October 1, 2025. After implementation, we will work on the technology for how to document reviews.
We will establish policies and procedures to ensure all reports are reviewed and approved by management. We are introducing Program Management Standards on October 1, 2025. After implementation, we will work on the technology for how to document reviews.
The District will train food service administrative staff regarding adequate internal controls involving monthly downloads of the Department of Social and Health Services DSHS direct certifications, including training at least 2 administrative staff members in order to ensure compliance in the absen...
The District will train food service administrative staff regarding adequate internal controls involving monthly downloads of the Department of Social and Health Services DSHS direct certifications, including training at least 2 administrative staff members in order to ensure compliance in the absence of the primary staff member performing the necessary internal control. Should Supply Chain Assistance funds become available in the future, the District will retrain food service administrative staff regarding the tracking of qualifying food products to reconcile to the funds received, and complete that tracking prior to the end of the qualifying fiscal year.
View Audit 366821 Questioned Costs: $1
Time and Effort Documentation Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a method to track actual time spent on various programs to support time allocated to federal award programs. Explanation of disagreement with audit finding: There is no disagreement with the ...
Time and Effort Documentation Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a method to track actual time spent on various programs to support time allocated to federal award programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will verify that actual time is tracked to comply with the requirements. Name of the contact person responsible for corrective action: Nicole Benson Planned completion date for corrective action plan: December 31, 2025
Timely Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the Authority develop a process to ensure that rent reasonableness calculations are completed prior to becoming effective Explanation of disagreement with audit finding: There is no disagreement with ...
Timely Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the Authority develop a process to ensure that rent reasonableness calculations are completed prior to becoming effective Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will train individuals doing the calculations to ensure calculations are completed timely and enforce processes to verify rent reasonableness calculations are done. Name of the contact person responsible for corrective action: Nicole Benson Planned completion date for corrective action plan: December 31, 2025
2024-005 Improve Internal Controls Over Procurement Management Response and Corrective Action Plan (DPW): Management concurs with the finding. The City acknowledges that one procurement, a rental for a piece of equipment under the SLFRF program for ARPA Replacement Roads and Sidewalks, lacked suffic...
2024-005 Improve Internal Controls Over Procurement Management Response and Corrective Action Plan (DPW): Management concurs with the finding. The City acknowledges that one procurement, a rental for a piece of equipment under the SLFRF program for ARPA Replacement Roads and Sidewalks, lacked sufficient supporting documentation to demonstrate compliance with federal procurement standards. The City is committed to strengthening internal controls to ensure all federally funded procurements comply with 2 CFR 200.317–200.327, Treasury’s SLFRF Compliance and Reporting Guidance, and applicable state and local procurement laws. Planned Implementation Date: 12/17/2025 Person Responsible for Corrective Action: Julianne Pelletier
Management’s Corrective Action Plan In response to finding 2024-001, management will improve the reporting timeliness of grant details by the identified timeframe. Management intends to implement a monitoring process to ensure compliance with the reporting requirements of the grants. This would incl...
Management’s Corrective Action Plan In response to finding 2024-001, management will improve the reporting timeliness of grant details by the identified timeframe. Management intends to implement a monitoring process to ensure compliance with the reporting requirements of the grants. This would include adherence to meeting the reporting timelines. Individual Responsible for Corrective Action Plan Nicole DuPont Director of Strategic Development & Grants (269) 986-0077 Anticipated Completion Date: October 1, 2025
Finding #2024-001 – Significant Deficiency and Other Noncompliance. Federal Award: U. S. Department of Housing and Urban Development, Passed through Texas Department of Housing and Community Affairs, Assistance Listing #: 14.239, Contract number: 92230123418, Contract period: 07/14/23 – Grant agreem...
Finding #2024-001 – Significant Deficiency and Other Noncompliance. Federal Award: U. S. Department of Housing and Urban Development, Passed through Texas Department of Housing and Community Affairs, Assistance Listing #: 14.239, Contract number: 92230123418, Contract period: 07/14/23 – Grant agreement expires 30 years from the date of completion. Condition and context: Our testing included a sample of 5 of the 31 subcontractors for two months of the year for timely submission of weekly certified payroll reports. Two of the five subcontractors did not submit certified payroll reports in a timely manner. Recommendation: Provide additional oversight of the submission of certified payroll reports by subcontractors to ensure compliance. Planned corrective action: New Hope Housing, Inc. and Affiliates has contracted with Camden to ensure compliance with timely submission of weekly certified payroll reports. Camden performs the activities of a general contractor in addition to its compliance role. The real estate development team of New Hope Housing, Inc. has started a new process to monitor and review Camden's reports prior to the approval of each construction draw submitted by Camden. The process also includes a new layer of monthly review by the Vice President of Real Estate Development of New Hope Housing, Inc (who is responsible for procurement and management of subcontractors) and the Chief Financial Officer of New Hope Housing, Inc. Responsible officer: John Peavy, Chief Financial Officer of New Hope Housing, Inc. Estimated completion date: We have implemented this new process as of August 18, 2025.
By expanding our internal and contracted accounting capacity and updating internal controls and accounting processes to include these new roles in the monthly and annual workflow, the Organization will be in better position to perform timely reconciliations and adjustments to federal grant activity,...
By expanding our internal and contracted accounting capacity and updating internal controls and accounting processes to include these new roles in the monthly and annual workflow, the Organization will be in better position to perform timely reconciliations and adjustments to federal grant activity, ensuring timely filling of the data collection form and single audit package.
Criteria: Federal and state grant agreements typically require recipients to maintain effective internal controls over financial reporting. These include accurate and timely submission of required reports; proper documentation and retention of supporting records and review and approval processes to ...
Criteria: Federal and state grant agreements typically require recipients to maintain effective internal controls over financial reporting. These include accurate and timely submission of required reports; proper documentation and retention of supporting records and review and approval processes to ensure compliance and accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment: To prevent miscoding of expenses, we implemented a change in the prior fiscal year to allocate all CACFP-related expenses to a distinct program code. This ensures that CACFP costs are tracked independently and not charged to direct programs. Root Cause Reconciliation of the reimbursement from USDA can vary on the reimbursement of the cost of food. Where there is less cost than reimbursement we are reconciling the overage to staff wages of kitchen staff and supplies for the kitchen at the end of the year instead of monthly. Action Taken Reconciliation of the monthly reimbursement amount from CACFP to the food expenses will be reviewed each month by the 10th (for the following month) and reconciliation to the appropriate programs will be journal entries and included in the monthly review of revenue and expenses.
Condition: The Association’s controls were not effective to ensure it was recognizing revenue and unearned revenue for reimbursement-based programming in the same period the expenditure occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...
Condition: The Association’s controls were not effective to ensure it was recognizing revenue and unearned revenue for reimbursement-based programming in the same period the expenditure occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment During the previous year, fiscal staff have received additional training on processing of receivables for accrual accounting, eliminating errors in the recognition of revenue in reimbursement grant funding. Root Cause Oversight in the reconciliation steps of moving money to unearned revenue at the end of the year. Action Taken Research and training have taken place for fiscal staff to better understand the unearned revenue documentation and process. Additional training and support will be implemented at year end recognizing all revenue and account balances.
Criteria: The Association is required by a US Department of Agriculture (USDA) loan agreement to fund a reserve account at the sum of $204 each month until a balance of $64,500 is achieved (see Note 4 to the financial statements). Additionally, funds withdrawn from the reserve fund must be approved ...
Criteria: The Association is required by a US Department of Agriculture (USDA) loan agreement to fund a reserve account at the sum of $204 each month until a balance of $64,500 is achieved (see Note 4 to the financial statements). Additionally, funds withdrawn from the reserve fund must be approved in advance by USDA. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment: The Fiscal Manager has reviewed the loan requirements. Root Cause Due to large turnover in the fiscal team and the lack of knowledge of loan requirements. Action Taken Fiscal Manager has reviewed loan documents and requirements making ourselves familiar with the reserve account requirements. This concern was found in late 2024 and was corrected immediately with transfers happening in October 2024. Moving forward the transfer to the reserve account happened on a monthly basis in conjunction with the mortgage payment. OCCDA has met the account balance requirements for the reserve accounts which currently have $65,392.10.
Conservation and Rehabilitation of Natural Resources on Military Installations – Assistance Listing No. 12.005 Recommendation: CLA recommends for the Organization to place emphasis on stronger controls around the timely filing of required reports, such as retaining a monthly checklist of required re...
Conservation and Rehabilitation of Natural Resources on Military Installations – Assistance Listing No. 12.005 Recommendation: CLA recommends for the Organization to place emphasis on stronger controls around the timely filing of required reports, such as retaining a monthly checklist of required reconciliations and reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in October 2024 following FY 2022 & 2023 Audits, including creating a calendar of required reconciliations and reports for all agreements. We also updated our procedure for review, approval, and documentation of Federal Financial Reports. We intend to add an additional and stronger control by adding performance and financial report schedules as part of our internal project software (Asana). Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2025
Bladenboro Housing Authority Corrective Action Plan For the Year Ended December 31, 2024 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2024-001 Name of Contact Person: Becky Tatum Interim Director Corrective Action: Manageme...
Bladenboro Housing Authority Corrective Action Plan For the Year Ended December 31, 2024 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2024-001 Name of Contact Person: Becky Tatum Interim Director Corrective Action: Management will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. Proposed Completion Date: Immediately
Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that ACS review all participant files to ensure proper documentation is retained supporting the eligibility of a...
Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that ACS review all participant files to ensure proper documentation is retained supporting the eligibility of applicants. We noted that there is currently a process in place to review files to ensure that only eligible participants are being served, but we recommend that a process is implemented and documented to ensure that there is proper review and approval of all applicants prior to the individual receiving services and that this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This will be grant dependent as many of the grant's ACS has the grantors retain the documentation and do a secondary review of eligibility. The Self-Help grant is a grant that is direct to the organization, and two people will review and document on the participation form they have reviewed the eligibility of the participants. Name(s) of the contact person(s) responsible for corrective action: Nasreen Sajady Planned completion date for corrective action plan: This will begin September 2025 and continue for the remainder of the programs needing a secondary review.
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