Corrective Action Plans

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Finding 2025-059 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure revenues and program income generated by non-commercial airports were expended for airport capital or operatin...
Finding 2025-059 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure revenues and program income generated by non-commercial airports were expended for airport capital or operating costs, the local airport system, or other local facilities. Planned Corrective Action MDOT will review existing procedures, including the MDOT Office of Aeronautics Project Manager/Engineering Manual and block grant conditions, to assess whether updates are needed and if resources will be prioritized to help ensure monitoring and oversight efforts are performed relating to revenue and program income requirements. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Bryan Budds, MDOT
Finding 2025-058 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure weekly certified payrolls were obtained from contractors. Planned Corrective Action MDOT will provide training...
Finding 2025-058 Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs, ALN 20.106 Management Views MDOT agrees that it did not ensure weekly certified payrolls were obtained from contractors. Planned Corrective Action MDOT will provide training and guidance to pertinent staff to help ensure contract compliance and that weekly certified payrolls are obtained from contractors. In addition, MDOT will review existing procedures to assess whether updates are needed. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Bryan Budds, MDOT
Finding 2025-062 Child and Adult Care Food Program, ALN 10.558 Management Views MDE agrees with the finding. The COVID-19 SOM travel ban in fiscal year 2020 and MDE being short staffed disrupted the Child and Adult Care Food Program (CACFP) review cycle and contributed to the Review Master Spreadshe...
Finding 2025-062 Child and Adult Care Food Program, ALN 10.558 Management Views MDE agrees with the finding. The COVID-19 SOM travel ban in fiscal year 2020 and MDE being short staffed disrupted the Child and Adult Care Food Program (CACFP) review cycle and contributed to the Review Master Spreadsheet being out of date. Due to the review cycle disruption and extended time frame between reviews, sponsors who had reviews due from 2020 onward were higher risk even if there were no previous serious management problems, fast growth, or other risk factors identified under federal regulation 7 CFR 226.6(m)(6). Planned Corrective Action MDE CACFP staff have worked diligently while short staffed to prioritize reviews out of compliance with the established two-to-three-year rotation per federal regulation 7 CFR 226.6 (m)(6). Reviews completed in fiscal year 2025 targeted reviews out of compliance. For fiscal year 2026, reviews that were to be completed from 2017 through 2020 have been prioritized as higher risk based on the duration between reviews. To complete the reviews more quickly, the MDE Office of Nutrition Services has published an RFP for review contractors to complete out of compliance reviews in all MDE federal nutrition programs. The RFP closed May 8, 2026, with a projected start date of June 2026. The end date is to be determined based on the candidate selected and scope of contract. Currently, progress towards the completion of the fiscal year reviews is discussed biweekly during analyst and departmental manager updates and is monitored quarterly by the departmental manager through completion of the 33 1/3 report. This report indicates that the state agency is working towards the completion of reviews on 33 1/3 of its actively participating sponsors each fiscal year. The departmental manager shares this information with the analyst staff and the MDE CACFP supervisor to ensure the unit is on track with regulations. MDE CACFP has reinstated its current policy and procedure for review prioritization for fiscal year 2026 and expects reviews to be back in compliance with the two-to-three-year rotation by September 30, 2028. MDE created a new application analyst position to assist the departmental manager with program integrity and quality control and MDE is currently in the hiring process. Currently analysts, working with their departmental manager, are prioritizing and triaging reviews in their assigned territory based on length since prior review, along with other high-risk factors. Ongoing, the risk factor(s) of sponsors will be assessed annually by each analyst with input from the departmental manager in an end of fiscal year planning meeting for the upcoming fiscal year review schedule. The risk factor(s) will be entered into the Review Master Spreadsheet by the analysts and monitored for quality control by the new application analyst and the departmental manager quarterly. While the Review Master Spreadsheet was out of date, the fiscal year 2025 completed reviews were recorded in the MDE CACFP review compliance system, GEMS/MARS. The current departmental manager was using this system to generate the GEMS/MARS fiscal year 2025 Review Status report to track compliance. This report shows that although the Review Master Spreadsheet was out of date, reviews had been completed. MDE is currently using the Review Status report to restore fiscal year 2025 on the Review Master Spreadsheet, along with the individual reviewer spreadsheets, and anticipates updates will be completed by September 30, 2026. For ongoing maintenance, analysts and/or the departmental manager will enter the reviews completed on an ongoing basis as reviews are completed and they will be reviewed for quality control by the new application analyst and departmental manager quarterly. Anticipated Completion Date September 30, 2028 Responsible Individual(s) Melissa Lonsberry, MDE Lynn Cavett, MDE
Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program FFAL # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: The Federal requirement related to processing of...
Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program FFAL # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: The Federal requirement related to processing of an application requires the State to provide notice of its decision concerning eligibility and provide timely and adequate notice of the basis for denial or termination of assistance (42 USC 1320c-7(d)). According to the Colorado Department of Health Care Policy and Financing (HCPF), processing standards 8.100.3.D, the County is required to process an initial application for any program not requiring a disability determination no later than 45 days following receipt of application. Our auditors, Eide Bailly, tested eligibility determination and controls over this process for sixty case files. They noted the following in our testing: • Two instances of non-compliance in which the County did not complete the eligibility determination and approve/deny the case within 45 days, and no notice of action was sent to the client within the required timeframe. • Two instances of non-compliance in which it could not be verified whether the notice of action was sent by the County to the client via mail or email Responsible Individuals: Joanne Sprouse, Human Services Director Corrective Action Plan: Summit County Human Services implemented multiple procedures in response to the prior 2024 findings. Those corrective action responses were still in process for the current 2025 period tested and will continue into 2026. During 2025, Summit County Human Services successfully retrained all case managers on application processing protocols, utilizing stateapproved training modules administered through the Staff Development Department. Summit County Human Services strictly follows state-mandated guidelines for processing Medical Assistance applications to ensure that all cases are approved or denied within the 45-day timeframe established by state regulations. To further enhance the accuracy of eligibility determinations for all household members, case managers have also completed the "Case Wrap-Up Training" through CoLearn, an online training platform developed by the State's Staff Development Department. Completion of this training ensures that eligibility determinations are accurate, and that appropriate client correspondence is issued. In 2025 and continuing into 2026, Summit County Human Services has also implemented a weekly review of the county dashboards, specifically the “HCPF Application Timeliness” and “HCPF Renewal Timeliness” dashboards. These dashboards monitor Medicaid application and renewal processing timelines initiated upon receipt by our office. In addition to the dashboard reviews, management meets weekly with the case managers responsible for monitoring the dashboards to identify trends and determine training needs. Furthermore, an additional line was added to the case comment template to ensure review and verification of correct case correspondence issuance. Anticipated Completion Date: Ongoing
6. Finding 2025-006 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulat...
6. Finding 2025-006 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulations. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management is still reviewing and updating the processes and procedures with site personnel to strengthen controls over the refunding of tenant security deposits.
3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulat...
3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulations. b. Action(s) Taken or Planned on the Finding We will review the processes and procedures with site personnel to strengthen controls over the refunding of tenant security deposits.
Finding 2025-002 – Public and Indian Housing Participant Files – Eligibility – Internal Control over Participant Files – Noncompliance and Material Weakness – Public and Indian Housing Program – ALN 14.850 1. Standardized Eligibility Checklist A comprehensive eligibility checklist will be developed ...
Finding 2025-002 – Public and Indian Housing Participant Files – Eligibility – Internal Control over Participant Files – Noncompliance and Material Weakness – Public and Indian Housing Program – ALN 14.850 1. Standardized Eligibility Checklist A comprehensive eligibility checklist will be developed and required for all participant files. This checklist will ensure all required documents (income verification, identification, citizenship status, etc.) are obtained, reviewed, and properly filed before approval. Please see the above attachment regarding the checklist. 2. File Review & Approval Process All resident files will undergo a two-tier review process: • Initial review by the assigned staff member • Secondary review and approval by a supervisor prior to final eligibility determination No file will Be approved without documented supervisory sign-off. 3. Staff Training All staff responsible for eligibility determinations will receive mandatory training on: • Program eligibility requirements • Proper documentation standards • File organization and recordkeeping procedures Refresher training will be conducted annually or as regulations change. 4. Internal Quality Control Audits Monthly random file audits will be conducted to ensure compliance with eligibility requirements and documentation standards. Findings will be documented, and corrective feedback will be provided to staff by supervisor. 5. Written Policies & Procedures Update The agency has updated its written policies and procedures manual to include: • Step-by-step eligibility determination processes • Documentation requirements • File retention and organization standards • Quality control measures All staff will be required to acknowledge and follow updated procedures. 6. File Organization Standardization All resident files (physical and/or electronic) will follow a uniform structure to ensure consistency, accessibility, and completeness. 7. Tracking & Monitoring System A tracking system (manual log or software-based) will be implemented to monitor: • Missing documents • Pending verifications • File status (intake, review, approved) Person Responsible- Shanetta Moye, Deputy Director/COO Anticipated Completion Date - September 30, 2026
In May of 2026, the Institute amended its procedures to (1) require the printing of a schedule of student balances after application of Federal Pell Grant and Loan receipts and (2) for all students with a credit balance within 12 days of the Pell receipt indicating the check number and date of the r...
In May of 2026, the Institute amended its procedures to (1) require the printing of a schedule of student balances after application of Federal Pell Grant and Loan receipts and (2) for all students with a credit balance within 12 days of the Pell receipt indicating the check number and date of the refund to the student on this schedule. This schedule is then to be reviewed for adherence to the required 14-day refund requirement under the Pell program by another staff member.
As reported in the Institutes fiscal 2024 Corrective Action Plan, in May 2025, the Institute revised its current procedures to include having an employee independent from the exit conference process review that any student not enrolled in a new semester or that is enrolled at less than half time sta...
As reported in the Institutes fiscal 2024 Corrective Action Plan, in May 2025, the Institute revised its current procedures to include having an employee independent from the exit conference process review that any student not enrolled in a new semester or that is enrolled at less than half time status has received proper exit conferencing and that exit conferencing has been properly documented. Two of the findings in the current fiscal 2025 occurred prior to the May revision by the Institute of its procedures. The third finding occurred during a period that the independent party performing the review function was on leave due to a death in the family. The Institute recognizes the importance of ensuring that exit conferences are performed timely and properly documented. Management has met with its staff involved in this process to emphasize its importance. Additionally, an additional staff member has been assigned to perform the review procedures if the staff member responsible is not available to timely perform the procedures.
Views of Responsible Officials and Planned Corrective Action The grant administrator for this project retired last year and the current Jetport staff were unable to locate past reports for the requested timeframe. DFA did not respond with any pertinent information. This project was completed in Marc...
Views of Responsible Officials and Planned Corrective Action The grant administrator for this project retired last year and the current Jetport staff were unable to locate past reports for the requested timeframe. DFA did not respond with any pertinent information. This project was completed in March 2025, and all drawdowns were completed by June 30, 2025. The County agrees with the recommendation that Jetport strengthen its internal controls over grant compliance by implementing formal procedures to ensure timely preparation, review, and submission of all required reports. Current Jetport staff have reviewed the process of submitting these reports and will help ensure this does not occur in the future. Management recognizes its responsibility to establish and maintain centralized record retention practices for all grant documentation and implement cross-training or supervisory review processes to mitigate the risk of noncompliance due to staff turnover. We agree with the recommendation and are establishing a centralized grant office and will consistently train the grant administrators that will affect grant accounting reconciliations and oversight. Finding resolution timeline: December 1, 2026 Designation of employee position responsible for meeting this deadline: Jetport Manager, Grants Manager, Grant Accountant
Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and...
Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should expand its financial reporting review procedures to require the documented review and approval of all performance reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: During the fiscal year, the Organization properly implemented procedures that require the documented review of the monthly financial reports, including the corresponding indirect cost calculations. The Organization will expand these policies and procedures to require the documented review and approval of all performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.
Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00...
Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should establish and maintain written internal control procedures that cover the required five components of internal control for each area of compliance for each of its federal programs. The Organization should educate all employees working with federal programs of the Organization’s procedures and monitor compliance with them. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.
Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a disco...
Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a discount but did not have an active sliding fee application for the service date the sliding fee discount was applied. Individual(s) Responsible for Corrective Action: Lori Slicer, Revenue Cycle Manager (organization-wide sliding fee discount monitoring procedure across the medical and dental service lines). Crystal Kinsman, Dental Practice Manager (dental-specific monitoring, with increased sampling of the Dental system given its higher level of manual processing). Heidi Melbostad, Chief Executive Officer and Compliance Officer (sliding fee discount schedule redesign and oversight). Planned Corrective Action: Management is addressing this finding through both an immediate interim action and a comprehensive redesign, together with an ongoing monitoring control. Interim action (completed): the Board approved revised nominal fee levels on 2026-04-27, effective 2026-04-28, establishing Category A as the most favorable discount category, consistent with Section 330(k)(3)(G) of the Public Health Service Act. Full corrective action: management will complete a comprehensive redesign of the Sliding Fee Discount Program, including separate schedules for the medical and dental service lines, data-driven evaluation of tier thresholds and fee levels, and replacement of the percentage-based payment option with a clearer flat-fee structure, for Board review and approval. Ongoing monitoring control: management will establish a documented monitoring procedure over sliding fee discount application across both the medical and dental service lines, including a defined monthly sample drawn from each service line with increased sampling of the Dental system given its higher level of manual processing, verification that an active sliding fee application is on file for each service date, documented review results, timely correction of identified errors, and supervisory sign-off, with error rates reviewed at least quarterly. Anticipated Completion Date: Interim nominal fee revision effective 2026-04-28 (completed). Comprehensive Sliding Fee Discount Program redesign and ongoing monitoring procedure to be Board-approved and operational by 2026-08-24.
Finding 2025-002 – Significant Deficiency Award No.: 21.027 Federal Grantor: U.S. Department of Treasury, Passed-through the County of Butte, Pass-through Grantor’s Number X25534. Compliance Requirement: Procurement, Suspension and Debarment. Condition: The Agency’s procurement policy does not adequ...
Finding 2025-002 – Significant Deficiency Award No.: 21.027 Federal Grantor: U.S. Department of Treasury, Passed-through the County of Butte, Pass-through Grantor’s Number X25534. Compliance Requirement: Procurement, Suspension and Debarment. Condition: The Agency’s procurement policy does not adequately document procurement requirements under the Uniform Guidance or contract provisions under Appendix II to Part 200 of the Uniform Guidance. Criteria: Uniform Guidance, Section 200.318(a) indicates “the recipient or subrecipient must maintain and use documenting procedures for procurement transactions under a Federal award or subaward, including for acquisition of property or services. These documented procurement procedures must be consistent with State, local, and tribal laws and regulations and the standards identified in §§ 200.317 through 200.327”. Required contracting provisions are documented in Appendix II to Part 200 – Contract Provisions for Non-federal Entity Contracts Under Federal Awards. Cause: The Agency’s procurement policy needs to be updated to document the requirements of the Uniform Guidance. Effect: The Agency’s procurement policy does not comply with the requirements of the Uniform Guidance, which could result in procurements that do not comply with the Uniform Guidance and the awarding agency disallowing the federal award and requesting the return of the award. Context: The Agency’s procurement policy complies with many requirements of the Uniform Guidance, but the policy does not comply with certain required provisions, including the thresholds for micro purchases, simplified acquisition threshold and full public procurements and the requirements for sole sourcing procurements under section 200.320. The procurements tested were found to comply with procurement requirements under Uniform Guidance even though the policy did not include all of the required provisions. Recommendation: The Agency should update its procurement policy to reference Uniform Guidance §§ 200.317 through 200.327 and should reference contracting provisions under Appendix II to Part 200 to be in compliance with Uniform Guidance prior to procurements being made under future federal awards. Views of Responsible Officials and Planned Corrective Actions: The procurement policy will be updated to include procurement guidance under Uniform Guidance §§ 200.317 through 200.327 and contracting provisions under Appendix II to Part 200 – Contract Provisions for Non-federal Entity Contracts Under Federal Awards. Title of Responsible Party: Finance Manager Implementation Date: By September 22, 2026
Finding 1218247 (2025-002)
Material Weakness 2025
Valorus
CA
Finding 2025-002 – Incomplete Subrecipient Agreements and Inaccurate Subrecipient SEFA Reporting Subrecipient agreements were executed based on California’s State Administrator of federal funds (CalOES) requirements applicable to second-tier subawards. Based on guidance provided during Federal Grant...
Finding 2025-002 – Incomplete Subrecipient Agreements and Inaccurate Subrecipient SEFA Reporting Subrecipient agreements were executed based on California’s State Administrator of federal funds (CalOES) requirements applicable to second-tier subawards. Based on guidance provided during Federal Grants Advanced Training and the 2025 CalOES Subrecipient Handbook (page 65), entities receiving pass-through funding from the state are required to follow CalOES second-tier subaward requirements. Accordingly, VALOR’s agreements include the elements required for second-tier subawards. Elements of a Second-Tier Subaward (From the 2025 CalOES Subrecipient Handbook) The following elements must be included in a Second-Tier Subaward: • Name of the Subrecipient Organization and the participating agency/organization, • The titles and contact information for the individuals that will serve as the primary contacts,• The timeframe of the agreement (this must cover the Grant Subaward performance period), • The roles and responsibilities (as they relate to the specific Grant Subaward) of the Subrecipient Organization and the participating agency/organization, • Specific information concerning all non-fiscal resources shared between the Subrecipient Organization and the participating agency/organization, • Reporting requirements necessary for the Subrecipient Organization to meet Cal OES reporting requirements, • Signatures of the chief executive or designee of the Subrecipient Organization and the participating agency/organization, including the dates of those signatures, and • Specific information concerning the transfer of any Grant Subaward funds from the Subrecipient Organization to the participating agency/organization. At a minimum, this information must include the total amount of Grant Subaward funds that will be transferred, the process for transferring the Grant Subaward funds (e.g., monthly invoices, payment based on deliverables), what the Grant Subaward funds will be used for, and any match contribution provided by the participating agency/organization. Any funds included in the Second-Tier Subaward must be clearly designated (not itemized) in the Grant Subaward Budget Pages (Cal OES Form 2-106a or b). Additionally, second tier subrecipients are prohibited from charging indirect costs; therefore, indirect cost provisions were not included in the agreements. Based on the above, management believes the subrecipient agreements substantially complied with applicable CalOES requirements. Any omissions identified were administrative in nature and did not impact program performance, allowability of costs, or oversight of subrecipient activities. To strengthen internal controls and ensure full compliance with all applicable grant requirements, beginning January 1, 2027, VALOR’s Director of Operations, Rosemary Gonzales, will include all required elements identified in the finding in future subrecipient agreements. In addition, VALOR will review subrecipient Single Audit reports to verify that applicable grant funding is properly reported on the SEFA. VALOR will also notify subrecipients of the requirement to include these amounts in their future SEFA reporting. Contracts for the current year, 2026, have already been signed.
Finding 2025-001: Material Weaknesses in Internal Control Management’s response: Concur Responsible individual: Finance Manager, Executive Director, Board of Directors Anticipated completion date: March 31, 2026 Management agrees with this finding and will implement the following: • Develop and impl...
Finding 2025-001: Material Weaknesses in Internal Control Management’s response: Concur Responsible individual: Finance Manager, Executive Director, Board of Directors Anticipated completion date: March 31, 2026 Management agrees with this finding and will implement the following: • Develop and implement a formal document retention and destruction policy • Develop and implement a formal periodic close and invoicing policy • Develop and implement a formal conflict of interest policy • Develop and implement a formal internal control policy • Develop and implement a formal whistleblower policy • Develop and implement a formal Board code of ethics policy • Develop and implement a formal reporting schedule • Actively recruit Directors with financial experience to participate in Board oversight
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient t...
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient to Douglas County who is the recipient of the funds. Eide Bailly LLP identified that the Town did not have documented or consistently applied internal controls to ensure compliance with the County’s subrecipient guidance requiring the submission of formal special reports for ALN 21.027. Responsible Individuals: Mark Henderson, Assistant Director of Castle Rock Water Corrective Action Plan: Staff will complete quarterly reports including project progress and estimated project infrastructure costs. The reports will be reviewed by management prior to submission to the recipient of the Federal Funds (Douglas County). Anticipated Completion Date: Ongoing during the period that the Town is a subrecipient of these funds for the project.
Finding 2025-002: Eligibility – Untimely Recertifications Type: Significant Deficiency Condition: During testing of tenant files, the auditor identified fourteen instances in which 2025 annual recertifications were not completed in a timely manner. Recertifications were performed in the subsequent y...
Finding 2025-002: Eligibility – Untimely Recertifications Type: Significant Deficiency Condition: During testing of tenant files, the auditor identified fourteen instances in which 2025 annual recertifications were not completed in a timely manner. Recertifications were performed in the subsequent year, and effective dates were backdated to reflect the current year. Management agrees with the finding and acknowledges the need to strengthen internal controls over tenant file compliance. To address this issue, management will implement a formalized tracking system for annual recertifications to ensure they are completed timely with accurate effective dates. Additionally, supervisory review and approval procedures will be enhanced prior to finalizing tenant rent changes. A. The Compliance Manager will oversee the compliance department and ensure staff complete recertifications prior to required effective dates. B. The Property Manager will conduct weekly meetings with staff to review upcoming recertifications and monitor progress to ensure timeliness. C. Management is in the process of hiring additional staff dedicated to processing recertifications to improve timeliness and compliance. Contact for Corrective Action: Cornelia Reith anticipated Completion date:12/31/26
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommend the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee r...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommend the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that all documentation supporting the sliding discount provided is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: These errors are due to incorrect slide percentage amounts being put into eCW. There is also a known issue within eCW where the eCW changes the slide amount to either 100% or a different slide than was entered. The Organization has found a work around so that the Organization can fix this issue before claims are adjusted. Billing will start reviewing slide documents prior to applying slide to make sure that the percentage entered into eCW is correct for income/family size. These will also be reviewed by the front desk manager and lead patient service representative.
Child Care and Nutrition, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2025. Audit period: October 1, 2024-September 30, 2025 The findings from the September 30, 2025 schedule of findings and questioned costs are discussed below. The findings are nu...
Child Care and Nutrition, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2025. Audit period: October 1, 2024-September 30, 2025 The findings from the September 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2025-001 Internal Accounting Controls Recommendation: We recommend management be aware to the lack of segregation of duties within the accounting functions and provide oversight to ensure the internal control policies and procedures are being implemented by organization staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will continue to review the accounting functions of all affected departments so segregate them as it is cost beneficial. Name of the contact person responsible for corrective action: Sherri Looft, Executive Director Planned completion date for corrective action plan: September 30, 2026. MATERIAL WEAKNESS 2025-002 Annual Financial Reporting Under Generally Accepted Accounting Principles Recommendation: Management should continue to evaluate their internal staff capacity to determine if an internal control policy over the annual financial reporting is beneficial. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization understands this is required communications for the preparation of the financial statements and will continue to work at this area to achieve the overall goal. Name of the contact person responsible for corrective action: Sherri Looft, Executive Director Planned completion date for corrective action plan: September 30, 2026. FINDINGS – FEDERAL AWARD PROGRAMS 2025-003 Internal Accounting Controls Federal Agency: U.S. Department of Agriculture Federal Program: Child and Adult Care Food Program CFDA Number: 10.558 Pass Through Agency: Minnesota Department of Education, Child Nutrition Section Pass Through Number: 1000003400 Award Periods: Year ended September 30, 2025 Recommendation: We recommend management be aware to the lack of segregation of duties within the accounting functions and provide oversight to ensure the internal control policies and procedures are being implemented by organization staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will continue to review the accounting functions of all affected departments so segregate them as it is cost beneficial. Name of the contact person responsible for corrective action: Sherri Looft, Executive Director Planned completion date for corrective action plan: September 30, 2026.
Management recognized the importance of timely bank reconciliations and accurate financial reporting. The District has implemented procedures requiring all bank reconciliations to be completed and reviewed within 30 days of month-end. A reconciliation checklist has been established to ensure all bal...
Management recognized the importance of timely bank reconciliations and accurate financial reporting. The District has implemented procedures requiring all bank reconciliations to be completed and reviewed within 30 days of month-end. A reconciliation checklist has been established to ensure all balance sheet accounts are reviewed and reconciled monthly. Management will also perform periodic reviews of the general ledger throughout the year to identify and correct discrepancies before year-end. In addition, the District will provide additional training to accounting personnel regarding month-end closing procedures and financial reporting requirements.
Management recognized the importance of timely bank reconciliations and accurate financial reporting. The District has implemented procedures requiring all bank reconciliations to be completed and reviewed within 30 days of month-end. A reconciliation checklist has been established to ensure all bal...
Management recognized the importance of timely bank reconciliations and accurate financial reporting. The District has implemented procedures requiring all bank reconciliations to be completed and reviewed within 30 days of month-end. A reconciliation checklist has been established to ensure all balance sheet accounts are reviewed and reconciled monthly. Management will also perform periodic reviews of the general ledger throughout the year to identify and correct discrepancies before year-end. In addition, the District will provide additional training to accounting personnel regarding month-end closing procedures and financial reporting requirements.
Management has implemented changes to the preparation and review process for grant reporting. Management will continue to evaluate its controls regarding current federal awards and requirements to ensure that accurate information is captured, reported, and maintained. Anticipated completion date: Al...
Management has implemented changes to the preparation and review process for grant reporting. Management will continue to evaluate its controls regarding current federal awards and requirements to ensure that accurate information is captured, reported, and maintained. Anticipated completion date: Already implemented and all final grant expenditures included in final annual report for reporting period ending March 31, 2026.
Management will continue to evaluate its controls concerning current federal awards and requirements to ensure that accurate information is captured and reported. Anticipated completion date: Already implemented and all final grant expenditures included in final annual report for reporting period en...
Management will continue to evaluate its controls concerning current federal awards and requirements to ensure that accurate information is captured and reported. Anticipated completion date: Already implemented and all final grant expenditures included in final annual report for reporting period ending March 31, 2026.
The Director of Grants will continue to prepare the reports and then the Superintendent and Corporation Treasurer will review and sign off on the reports to ensure they agree to the underlying details. The Director of Grants will make sure this is done in a timely manner to comply with the reporting...
The Director of Grants will continue to prepare the reports and then the Superintendent and Corporation Treasurer will review and sign off on the reports to ensure they agree to the underlying details. The Director of Grants will make sure this is done in a timely manner to comply with the reporting deadlines for each fiscal year.
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