Corrective Action Plans

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Finding 1224390 (2025-001)
Material Weakness 2025
Fraser
MN
Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: During testing instances were identified where statistical information submitted via the required annual reports were inaccurate. In addition, there was no documented review of the reports prior to submission. Resp...
Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: During testing instances were identified where statistical information submitted via the required annual reports were inaccurate. In addition, there was no documented review of the reports prior to submission. Responsible Individuals: Lucas Kunach, Miranda Gilmore, Jim Olson Corrective Action Plan: We have designated a member of management to review the reporting materials prior to submission for accuracy and tie to detail support. Anticipated Completion Date: Already in place
Finding No. 2025-001 Significant Deficiency in Internal Control over Compliance, Other Matters Condition The Organization had revisions to the SEFA and management’s review and approval process did not detect the following errors that were identified during the audit procedures performed: - An incorr...
Finding No. 2025-001 Significant Deficiency in Internal Control over Compliance, Other Matters Condition The Organization had revisions to the SEFA and management’s review and approval process did not detect the following errors that were identified during the audit procedures performed: - An incorrect de minimis indirect cost rate was used and charged to a federal award. - Approximately $65,000 of federal expenditures were omitted from the initial SEFA. - Subrecipient costs from the prior year were charged to the current year due to incomplete accruals in the prior year. As a result, the SEFA was not complete or accurate prior to submission for audit. Planned Corrective Action: Management concurs with the findings and related recommendations. While the Organization completed its federal award activity in May 2025 and does not currently anticipate additional federal award activity, it recognizes the importance of compliance with grant reporting requirements, including the accurate preparation of the Schedule of Expenditures of Federal Awards (SEFA). In response to this finding, the Organization has taken the following corrective actions: Indirect Cost Rate: Updated our grant setup checklist to ensure the correct de minimis indirect cost rate is applied. The Organization has initiated and is currently processing the repayment of the overcharged indirect costs to the primary awardee. SEFA Completeness & Year-End Cutoff: Implemented a formal year-end SEFA reconciliation procedure. This includes a secondary review by the Director, Accounting to cross-reference general ledger federal expenditures against grant award agreements and to verify that all subrecipient accruals are recorded in the proper fiscal period. These improvements in our review and approval functions are designed to prevent future reporting omissions and ensure timely, accurate SEFA preparation should the Organization be subject to Single Audit requirements in the future. Anticipated Completion Date: July 31, 2026 Name of Contact Person: Melinda O’Leary, Chief Financial Officer & Vice President If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Melinda O’Leary, Chief Financial Officer & Vice President at 571-483-1324.
The Platte County has implemented procedures to ensure when an entity is selected by Board Resolution/Motion, to be paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or disbarred and such procedure will be documented. The procedure to have the entity verif...
The Platte County has implemented procedures to ensure when an entity is selected by Board Resolution/Motion, to be paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or disbarred and such procedure will be documented. The procedure to have the entity verified is included in the Board minutes.
After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in Decem...
After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in December 2025.
Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit ...
Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will work with program managers to improve eligibility verification documentation. Name of the contact person responsible for corrective action: Heather Goodwin Planned completion date for corrective action plan: December 31, 2026
2025-001 – ALN 14.872 – Public Housing Capital Fund Program – Period of Performance The Authority has developed and implemented the necessary standard operating procedures to verify the timing of drawdowns relative to obligations and actual payments and periodically review drawdown and expenditure r...
2025-001 – ALN 14.872 – Public Housing Capital Fund Program – Period of Performance The Authority has developed and implemented the necessary standard operating procedures to verify the timing of drawdowns relative to obligations and actual payments and periodically review drawdown and expenditure records to proactively identify and correct discrepancies. Person Responsible for Correction of Finding: Krista Bolemon, Executive Director Projected Completion Date: December 31, 2026
KHDA will hire a CPA to oversee this process.
KHDA will hire a CPA to oversee this process.
KHDA will hire a CPA to oversee this process.
KHDA will hire a CPA to oversee this process.
Regarding the debarment status, the Policy has been updated to include that and says : Compliance with this Policy. KHDA Management shall maintain oversight to ensure that contractors and vendors perform in accordance with the terms, conditions, and specifications of contracts or purchase orders. Vi...
Regarding the debarment status, the Policy has been updated to include that and says : Compliance with this Policy. KHDA Management shall maintain oversight to ensure that contractors and vendors perform in accordance with the terms, conditions, and specifications of contracts or purchase orders. Violations of this policy may result in disciplinary action, up to and including termination. KHDA will hire a CPA firm to oversee this process.
The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the ...
The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the annual financial reporting. The City has also struggled with vacancies in key positions, as well as challenges in completing successful recruitments to fill the positions; staff are exploring options for third party assistance with financial reporting functions.
Additional time was needed to complete accurate fiscal records for the year ended June 30, 2025. Monthly closings and fiscal records reconciliations for the year ending June 30, 2026, are timely being conducted. Timely filing of the Data Collection form for the year ended June 30, 2026 is anticipate...
Additional time was needed to complete accurate fiscal records for the year ended June 30, 2025. Monthly closings and fiscal records reconciliations for the year ending June 30, 2026, are timely being conducted. Timely filing of the Data Collection form for the year ended June 30, 2026 is anticipated.
Management concurs that formalizing contract management procedures will further strengthen organizational oversight. Since FY2025, Ability1st has made significant investments in improving grant administration and compliance management. These improvements include: • centralized grant files; • enhance...
Management concurs that formalizing contract management procedures will further strengthen organizational oversight. Since FY2025, Ability1st has made significant investments in improving grant administration and compliance management. These improvements include: • centralized grant files; • enhanced tracking of reporting deadlines and deliverables; • standardized internal monitoring tools; • expanded written policies and procedures; • improved coordination between program staff, accounting personnel, and executiveleadership; • implementation of CIL Suite to improve documentation, reporting, and participantrecord management; • strengthened Board financial reporting; and • ongoing collaboration with the Organization's accounting firm to ensure compliance with federal, state, and local funding requirements. Management recognizes that compliance is an evolving process and remains committed to continuously improving internal controls as funding requirements expand and organizational capacity grows. Responsible Official: Executive Director Implementation Date: Ongoing. Ability1st is committed to continuous improvement and recognizes that strong financial stewardship is essential to fulfilling our mission. Management believes the corrective actions already implemented significantly strengthen the Organization's internal control environment and position Ability1st for improved compliance, financial reporting, and audit readiness in future years.
Management concurs with this finding and appreciates the opportunity to provide additional context regarding the circumstances that contributed to the delayed audit reporting. During the audit period, Ability1st experienced an unprecedented transition in its financial management infrastructure. The ...
Management concurs with this finding and appreciates the opportunity to provide additional context regarding the circumstances that contributed to the delayed audit reporting. During the audit period, Ability1st experienced an unprecedented transition in its financial management infrastructure. The Organization unexpectedly lost its long-term accounting support, engaged multiple accounting providers during the transition period, and ultimately retained a new accounting firm while simultaneously completing two fiscal years of audit activity. Despite these significant administrative challenges, the Organization continued uninterrupted delivery of critical independent living, housing, mental health, disaster recovery, youth transition, and accessibility services throughout its seven-county service area. Staff remained focused on meeting contractual obligations and serving individuals with disabilities while rebuilding financial systems. Since that time, Ability1st has implemented substantial improvements, including: • engaging a permanent external accounting firm; • strengthening month-end closing procedures; • improving reconciliations and financial reporting; • establishing regular fiscal monitoring meetings; • improving coordination among management, accounting personnel, and auditors; • developing standardized financial schedules for grant reporting; • improving documentation supporting accounting transactions; and • implementing earlier audit preparation timelines. Management believes these improvements have significantly strengthened the Organization's financial reporting process and will greatly improve future compliance with federal reporting deadlines. Responsible Official: Executive Director Implementation Date: Substantially complete; ongoing monitoring throughout FY2026 and beyond.
Management concurs that stronger documentation surrounding the collection and monitoring of Continuum of Care program income would have strengthened internal controls and the audit trail. The finding relates to a program that has since been discontinued. Throughout the audit period, all program inco...
Management concurs that stronger documentation surrounding the collection and monitoring of Continuum of Care program income would have strengthened internal controls and the audit trail. The finding relates to a program that has since been discontinued. Throughout the audit period, all program income that was collected was used for allowable program purposes; however, management acknowledges that documentation supporting assessment, collection, monitoring, and reconciliation procedures should have been more comprehensive. Although this activity is no longer part of the Organization's operations, Ability1st has strengthened its overall documentation standards. Should the Organization administer future programs involving program income, written policies and procedures will be implemented prior to program implementation and will include: • documented fee assessment methodology; • collection and deposit procedures; • reconciliation requirements; • supervisory review; • record retention standards; and • periodic internal monitoring. Management believes these procedures will provide an appropriate level of accountability and compliance with federal requirements should program income be collected in the future. Responsible Official: Executive Director Implementation Date: Completed for discontinued program; procedures will be implemented before any future program income activity.
Finding type: Significant deficiency. Federal award: 21.027 Coronavirus State and Local Fiscal Recovery Funds and 14.251 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants. Passthrough organization: 21.027 (Vermont Agency of Commerce and Community Development, Town ...
Finding type: Significant deficiency. Federal award: 21.027 Coronavirus State and Local Fiscal Recovery Funds and 14.251 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants. Passthrough organization: 21.027 (Vermont Agency of Commerce and Community Development, Town of Windsor, and Vermont Housing & Conservation Board); 14.251 (Vermont Housing & Conservation Board). Condition: Organization's draft schedule of expendiures of federal awards was missing certain awards. Management concurrence: Management concurs with this finding. Corrective action plan: The proper recording of all grants passed through WWHT will be identified upon the signing of the grant agreement to ensure which party is responsible for reporting of Federal funds. The SEFA will be created after confirmation that all Federal grants have been recorded. Name of contact person: Sandy Garland, Finance Director. Projected completion date: December 31, 2026.
Management agrees with the recommendations. During 2025, DVCH’s front desk staff started to assume more responsibility for conducting the sliding fee categorization. This additional staff had training and is gaining experience. Management will ensure training, monitoring, auditing, and supervision i...
Management agrees with the recommendations. During 2025, DVCH’s front desk staff started to assume more responsibility for conducting the sliding fee categorization. This additional staff had training and is gaining experience. Management will ensure training, monitoring, auditing, and supervision is adequate to ensure registration properly documents the signed sliding fee attestation form. DVCH expects to adopt a software solution for sliding fee categorization in 2026. The software solution will make common errors less common by automating several manual processes. If the Health Resources and Services Administration has questions regarding this plan, please call Ryan Taylor, Chief Financial Officer, at taylorr@dvch or 267-240-2578.
Corrective Action Plan Finding No: 2025-002 Condition: During the audit, the City did not verify that the contractor or subcontractor submitted the required certified payrolls for work performed under the federally assisted construction contract. As a result, the City did not maintain or review suff...
Corrective Action Plan Finding No: 2025-002 Condition: During the audit, the City did not verify that the contractor or subcontractor submitted the required certified payrolls for work performed under the federally assisted construction contract. As a result, the City did not maintain or review sufficient documentation to demonstrate compliance with wage rate requirements for all applicable weeks during the audit period. Management’s Plan: The City recognizes the need to improve internal controls related to grant disbursements for labor provided by our contractors. The project this past year included participation from multiple federal funding agencies and payments by the City as well as direct payments to contractors by the funding agencies. We have already added additional procedures and checkpoints to provide for adequate documentation related to certified payrolls. In addition, the City is planning to procure a grant tracking system to automate tracking the details for every project. Anticipated Date of Completion: 12/31/26 Name of Contact Person: Cheri Grieco, Finance Director
Corrective Action Plan Finding No: 2025-001 Condition: During the audit, our procedures indicated that capital expenditures were primarily reviewed at an individual invoice level to determine whether they exceeded the capitalization threshold. We also noted that communication between the City’s fina...
Corrective Action Plan Finding No: 2025-001 Condition: During the audit, our procedures indicated that capital expenditures were primarily reviewed at an individual invoice level to determine whether they exceeded the capitalization threshold. We also noted that communication between the City’s finance department and engineers or other City staff responsible for managing grants and capital projects is not consistently formalized. Management’s Plan: Management is committed to strengthening coordination and oversight of the City’s grant-funded capital projects through centralizing project tracking via grant/project management software, implementing rigorous compliance monitoring, and improving intradepartmental communication. By centralizing our grants through the course of their lifespans, we intend to better track the progress of our grant projects and budgets and with the inclusion of grant document storage, to enhance compliance across departments. We will also designate coordination teams consisting of liaisons across administration, finance, engineering, public works, and grant writers to ensure internal alignment. Anticipated Date of Completion: 4/30/2027 Name of Contact Person: Cheri Grieco, Finance Director
Finding 2025-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating...
Finding 2025-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the project and related expenses submitted to FEMA for reimbursement. Resolution: Management will develop and implement additional internal controls to ensure that adequate documentation is retained to evidence the design and operating effectiveness of controls over FEMA-related expenditures. These internal controls will be designed to ensure that expenses included in FEMA grant applications are complete, accurate, and allowable in accordance with program requirements. Specifically, management will implement a reconciliation process comparing detailed application expenses to the corresponding final paid invoices or payroll expenditures. As part of this process, each expense will be reviewed and annotated to confirm its allowability under FEMA guidelines. The reconciliation will be subject to review and approval by the Cottage Health Vice President of Finance prior to submission of the FEMA application. Evidence of this review and approval will be formally documented and retained. Contact Person: Lawrence Thomas, Vice President of Finance Anticipated Completion Date: December 31, 2026 (The entity has not incurred expenditures under the FEMA program subsequent to the period under audit. Accordingly, the corrective actions described above will be implemented on a prospective basis, contingent upon the entity incurring future FEMA-related expenditures).
Name of contact person: Melissa Labra, Income Maintenance Administrator II Caseworkers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Casework...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Caseworkers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Caseworkers will receive training on the work number (TWN) in NCFAST learning gateway. Workers will be retrained on NCFAST evidence for resources to ensure procedures are being followed for evidence on dashboard to match the supporting documentation used as verifications. Workers will be retrained on determining who to count in the needs unit and adequate case file documentation. Workers will be retrained on the proper use of Medicaid Forced Eligibility. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Proposed Completion Date: August 31, 2026
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct income evidence into NCFAST. Caseworkers will receive training on determining the correct base period to use for income calculations Cas...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct income evidence into NCFAST. Caseworkers will receive training on determining the correct base period to use for income calculations Caseworkers will receive training on the work number (TWN) in NCFAST learning gateway. Caseworkers will receive training on income and budgeting policy (MA 3300). Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly, including income calculations Proposed Completion Date: August 31, 2026
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on completing complete and thorough case documentation. Caseworkers will receive additional training on inputting the correct evidence into NCFAST, including inc...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on completing complete and thorough case documentation. Caseworkers will receive additional training on inputting the correct evidence into NCFAST, including income evidence. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 31, 2026
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers will receive additional training on obtaining adequate verifications for income. Caseworkers will receive additional training on completing complete and thorough case documentation. Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 30, 2026
Program(s): Supplemental Nutrition Assistance Program (SNAP), Medical Assistance Program; Foster Care Title IV-E Program 10.561 / 93.778 / 93.658 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing of 1,524 and 1,521 random momen...
Program(s): Supplemental Nutrition Assistance Program (SNAP), Medical Assistance Program; Foster Care Title IV-E Program 10.561 / 93.778 / 93.658 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing of 1,524 and 1,521 random moment study participants reported in quarters one and two, respectively, two individuals were reported on the first quarter time study report that were terminated or resigned prior to the start of the respective quarter. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will continue to monitor its procedures for giving timely notice of an individual’s termination or resignation to other departments, as implemented in July 2025. Additionally, the County will ensure departments are reviewing the information provided to granting agencies. Hennepin County Employee Responsible for the CAP: Samantha Braun Planned Completion Date for CAP: 07/31/2026
Program(s): Supplemental Nutrition Assistance Program (SNAP) 10.561 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following instance of noncompliance in the sample of sixty case files tested: • One MAXIS case ...
Program(s): Supplemental Nutrition Assistance Program (SNAP) 10.561 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following instance of noncompliance in the sample of sixty case files tested: • One MAXIS case file did not have a re-determination of eligibility performed within the 12-month period. • One MAXIS case file did not have documentation of income verification. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered and the information required by the contract is retained in the County’s records. Hennepin County Employee Responsible for the CAP: Jennifer Frey, Human Services Area Manager for SNAP Planned Completion Date for CAP: December 1st, 2026
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