Corrective Action Plans

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PLANNED CORRECTIVE ACTION The Division will contact each unit distributing TEFAP assistance to reinforce the requirement to retain documentation regarding the determination of client eligibility and will review and strengthen existing policies and procedures related to form completion and retention....
PLANNED CORRECTIVE ACTION The Division will contact each unit distributing TEFAP assistance to reinforce the requirement to retain documentation regarding the determination of client eligibility and will review and strengthen existing policies and procedures related to form completion and retention. The Division's Social Services department will implement a quarterly internal review process to provide increased oversight and monitoring across all distributing units. ANTICIPATED COMPLETION DATE 10/1/26 RESPONSIBLE CONTACT PERSON Julie Luft, NW Social Services Director
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended 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...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended 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. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization continues to make improvements to processes and procedures to ensure the accurate documentation and application of sliding fee discounts. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Matt Morrill, CFO, at 970-871-7635.
At the time of the audit, we did not have a policy to require managers sign off on credit card payments in the way that they sign off on check payments. We did not require management approval because receipts were required to be submitted with every credit card purchase and reviewed by the finance t...
At the time of the audit, we did not have a policy to require managers sign off on credit card payments in the way that they sign off on check payments. We did not require management approval because receipts were required to be submitted with every credit card purchase and reviewed by the finance team monthly. The policy to require management approval for credit card payments has since been adopted, however, after the fiscal year under audit.
Almost Home, Inc. has formalized this through our required client file checklist and related policy. The policy was in place and was applied improperly. Staff members who failed to apply the policy were given corrective action at the time. Our quality/compliance control processes did not catch this ...
Almost Home, Inc. has formalized this through our required client file checklist and related policy. The policy was in place and was applied improperly. Staff members who failed to apply the policy were given corrective action at the time. Our quality/compliance control processes did not catch this mistake in time, and our management corrective action plan will include improvements on the quality/compliance control to ensure that all necessary documentation is maintained. Also necessary to note is the fact that Almost Home, Inc. will no longer receive TANF funding as of December 31, 2025.
Name of Responsible Official: Polly Tribble, Executive Director Anticipated Completion Date: September 30, 2026 Disability Rights Mississippi Response Disability Rights Mississippi (DRMS) acknowledges the audit finding and has reviewed the circumstances that resulted in the identified deficiency. Th...
Name of Responsible Official: Polly Tribble, Executive Director Anticipated Completion Date: September 30, 2026 Disability Rights Mississippi Response Disability Rights Mississippi (DRMS) acknowledges the audit finding and has reviewed the circumstances that resulted in the identified deficiency. The finding was attributable to a case being incorrectly assigned to a grant and the absence of required eligibility documentation in the DAD case management system. Although policies and procedures were in place to ensure proper eligibility documentation and grant coding, those procedures were not followed in this instance. Management believes this finding was isolated in nature; however, the corrective actions outlined below are intended to further strengthen controls and prevent similar occurrences in the future. To address this finding, DRMS will implement the following corrective actions: 1. Review and Update Procedures • Existing eligibility verification and grant coding procedures will be reviewed and revised as necessary to clarify documentation requirements and grant assignment responsibilities. • Written guidance will be provided to staff outlining required eligibility documentation for each program and funding source. 2. Staff Training • All legal advocacy, monitoring, and investigations staff will receive refresher training on eligibility determination requirements, documentation standards, and proper grant coding procedures. • Supervisors will reinforce expectations regarding complete and accurate case documentation. 27 ~i■ DISABILITY ~~l~I IRIIGIHITS I MISSISSIPPI 3. Enhanced Supervisory Review • Supervisors will review newly opened cases to verify that required eligibility documentation has been obtained and uploaded into the DAD system prior to final case approval. • Designated funding sources in DAD will be reviewed to ensure cases are charged to the appropriate grant. 4. Quarterly Quality Assurance Reviews • Beginning in FY 2026, management will conduct quarterly reviews of a sample of case files from each program. • Reviews will assess the presence of required eligibility documentation, accuracy of funding source coding in DAD, and compliance with applicable program requirements. • Any deficiencies identified will be corrected promptly, and recurring issues will be addressed through additional training and process improvements. 5. Monitoring and Documentation • Results of quarterly reviews will be documented and maintained for management oversight. • Corrective actions resulting from identified deficiencies will be tracked to ensure timely resolution and ongoing compliance. DRMS is committed to maintaining compliance with applicable grant requirements and to ensuring that case documentation, eligibility determinations, and grant assignments are completed accurately and consistently. The corrective actions described above are designed to enhance monitoring and oversight, reinforce staff accountability, and reduce the likelihood of future documentation or coding deficiencies.
Action taken in response to finding: The Commission is in the process of adopting an updated procurement and conflict of interest policy to comply with compliance requirements.
Action taken in response to finding: The Commission is in the process of adopting an updated procurement and conflict of interest policy to comply with compliance requirements.
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management will review procedures to ensure they have the process in place to ensure timely deposit going forward. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: April 2026
Section 202 HUD-Insured Mortgage– Assistance Listing No. 14.157 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 202 HUD-Insured Mortgage– Assistance Listing No. 14.157 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management will review procedures to ensure they have the process in place to ensure timely deposit going forward. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: October 2025
Finding 1219022 (2025-002)
Material Weakness 2025
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.157 Management is responsible for maintaining required monthly deposits into the Replacement Reserve account in accordance with the form HUD-9250. Recommendation: The Project should establish and follow a consistent monthly review process t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.157 Management is responsible for maintaining required monthly deposits into the Replacement Reserve account in accordance with the form HUD-9250. Recommendation: The Project should establish and follow a consistent monthly review process to ensure all deposits are made on a timely basis. Action taken in response to finding: Management continues to review and establish processes related to review and approval to ensure monthly replacement reserve deposits are made. The missed July payment was made April of 2026. The Project currently does not have the funds to make the deposit and is working with HUD to resolve. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: December 31, 2026
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The security deposit liability needs to be funded by a security deposit asset equal to or greater than the liability. Recommendation: We recommend management ensure they have controls and processes in place to ensure the security deposi...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The security deposit liability needs to be funded by a security deposit asset equal to or greater than the liability. Recommendation: We recommend management ensure they have controls and processes in place to ensure the security deposit liability account is properly funded at all times. Action taken in response to finding: The property sold on November 30, 2025, and the security deposit cash was transferred to the new owners at that point. The $342 shortage in cash was considered in the sale but was not transferred from operating to the security deposit cash before the sale took place. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: November 30, 2025
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management has made all required deposits to the residual receipts account as of May 2025 and the cash account was whole before the sale that took place on November 30, 2025. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: May 31, 2025
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Distributions and payments on surplus cash notes must be within amounts permitted based upon semi-annual surplus cash calculations. Recommendation: Recommend that management account for surplus cash note payments when determining how mu...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Distributions and payments on surplus cash notes must be within amounts permitted based upon semi-annual surplus cash calculations. Recommendation: Recommend that management account for surplus cash note payments when determining how much cash is available for distribution in accordance with the semi-annual surplus cash calculations and review those calculations for accuracy prior to distributions being made. There is no disagreement with the audit finding. Action taken in response to finding: We have surplus cash remaining at December 31, 2025, subsequent to the distributions being made, therefore the finding has corrected itself. Future distributions and payments on surplus cash notes will be monitored closely to ensure they are limited to amounts permitted. Name of the contact person responsible for corrective action: Doug Harrison Planned completion date for corrective action plan: December 31, 2026
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that manage...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that management work with HUD to have the current management agreement approved. There is no disagreement with the audit finding. Action taken in response to finding: We have contacted HUD to obtain an approved management agreement. Name of the contact person responsible for corrective action: Doug Harrison Planned completion date for corrective action plan: December 31, 2026
ALEA performed the monitoring required by 2 CFR 200.332(e) for the subrecipients reviewed and does not believe corrective action is warranted. As part of its ongoing subrecipient monitoring operations, ALEA performs the following activities: 1. ALEA documents a risk assessment for each active subrec...
ALEA performed the monitoring required by 2 CFR 200.332(e) for the subrecipients reviewed and does not believe corrective action is warranted. As part of its ongoing subrecipient monitoring operations, ALEA performs the following activities: 1. ALEA documents a risk assessment for each active subrecipient using a standardized risk assessment tool that produces an individual, supportable risk determination for each subrecipient and updates the assessment when conditions warrant, consistent with 2 CFR 200.332(c). 2. ALEA maintains a centralized monitoring schedule and tracking log that assigns monitoring activities to each subrecipient based on its risk determination and records the status, date, and results of each activity. 3. ALEA performs and documents the monitoring activities required under 2 CFR 200.332(e) and applies the risk-based monitoring tools described in 2 CFR 200.332(1) to subrecipients based on assessed risk, retaining supporting documentation in its grants management system and in each subrecipient file. 4. ALEA verifies that each subrecipient required to obtain a Single Audit under Subpart F of 2 CFR Part 200 is audited as required and reviews the results of each applicable audit, consistent with 2 CFR 200.332(g). 5. ALEA issues written management decisions on any audit findings pertaining to its subawards within six months of acceptance of the applicable audit report and resolves findings specifically related to the subaward, consistent with 2 CFR 200.332(e)(3) and (e)(4) and 2 CFR 200.521. 6. ALEA provides training to staff responsible for subrecipient monitoring and continues that training on an ongoing basis. ALEA continues to monitor its subrecipients and to maintain documentation of the monitoring activities performed under 2 CFR 200.332(e).
The Alabama Law Enforcement Agency will strengthen its review and reporting procedures to ensure Federal Financial Reports (SF-425) are submitted within the required reporting deadlines. Prior to submission, financial report information will be reviewed by multiple employees to verify the accuracy a...
The Alabama Law Enforcement Agency will strengthen its review and reporting procedures to ensure Federal Financial Reports (SF-425) are submitted within the required reporting deadlines. Prior to submission, financial report information will be reviewed by multiple employees to verify the accuracy and completeness of the reported data. In addition, the Agency will implement enhanced monitoring of reporting due dates and establish internal deadlines to ensure sufficient time for review and timely submission. The Grants Section will coordinate with the Programs Office and financial staff to track quarterly reporting requirements and ensure all SF-425 reports are submitted to the federal awarding agency within 30 calendar days following the end of each reporting period. These procedures are intended to improve compliance with federal reporting requirements and ensure timely reporting for effective grant oversight and monitoring.
The Alabama Law Enforcement Agency will strengthen its procedures to ensure expenditures are charged only within the approved period of performance for each federal grant. Grant period dates will be monitored and reviewed by multiple divisions, including the Grants Section, Payroll Section, and Prog...
The Alabama Law Enforcement Agency will strengthen its procedures to ensure expenditures are charged only within the approved period of performance for each federal grant. Grant period dates will be monitored and reviewed by multiple divisions, including the Grants Section, Payroll Section, and Programs Office, to provide additional oversight and verification. Because payroll expenditures are reported and reimbursed on a cash basis and the State payroll expense is in arrears, payroll funding allocations will be reviewed and updated prior to the end of the grant period. Specifically, grant-funded payroll charges will be evaluated at least 30 days before the grant expiration date to ensure that costs incurred after the period of performance are not charged to the grant. These enhanced monitoring and review procedures will help ensure compliance with federal grant requirements and prevent future charges outside the approved grant period.
The Alabama Law Enforcement Agency has corrected the program coding within the State's financial system to ensure that each grant is associated with the appropriate Assistance Listing (CFDA) number. To strengthen internal controls and reduce the risk of similar errors in the future, grant setup and ...
The Alabama Law Enforcement Agency has corrected the program coding within the State's financial system to ensure that each grant is associated with the appropriate Assistance Listing (CFDA) number. To strengthen internal controls and reduce the risk of similar errors in the future, grant setup and coding information will be subject to review by multiple individuals prior to implementation. Additionally, annual reviews will be conducted to verify that grant information recorded in the financial system is consistent with the applicable Notice of Award and other grant documentation. These measures are intended to enhance the accuracy of federal program reporting and ensure expenditures are properly attributed to the correct funding source.
The Alabama Department of Public Health will ensure all expenditures are adequately documented, based on true and accurate invoices, and allowable under the federal award. • The Immunization Division continues to reorganize with the new leadership team. Staff reviews grant guidance semi-annually, or...
The Alabama Department of Public Health will ensure all expenditures are adequately documented, based on true and accurate invoices, and allowable under the federal award. • The Immunization Division continues to reorganize with the new leadership team. Staff reviews grant guidance semi-annually, or when updated, with program grant monitoring staff to ensure compliance. • Invoices and supporting documentation are being reviewed for source documents against grant guidance by program staff and approved by Operations Manager or Division Director to ensure costs to the grant are reasonable, allowable, allocable, and consistently applied before forwarding to Finance. • Grant monitoring staff use the Risk Assessment and Subrecipient monitoring policy to ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and costs are allowable under the federal award. • ADPH Bureau of Financial Services has developed and required the use of a Subrecipient Field Voucher form to include certification statement referencing 2 CFR200 in regard to invoices, along with conducting ffirther reviews of invoices before uploading into STAARS for payment. • All program grant staff have access to attend all available Finance and Grant training courses. • ADPH Bureau of Financial Services has created a Grant Management Centralized Guidance Repository in the ADPH Document Library for access by all ADPH staff • ADPH Bureau of Financial Services is developing an ADPH Grant Manual. • ADPH Bureau of Financial Services will develop policies and procedures related to media usage, college awareness campaigns, and sponsorships to ensure adequate documentation is available to verify the allowability of the expenditures in relation to various programs.
There is no direct guidance detailing steps to update the FMAP rate in STAARS. Changes are made in the STAARS cost allocation test environment and then implemented in the production environment via STAARS Support. Cost allocation runs quarterly. While we initiate the entering of statistics from work...
There is no direct guidance detailing steps to update the FMAP rate in STAARS. Changes are made in the STAARS cost allocation test environment and then implemented in the production environment via STAARS Support. Cost allocation runs quarterly. While we initiate the entering of statistics from work sampling and other sources, we are at the mercy of STAARS Support to actually run cost allocation for DHR.
DHR has added additional steps related to Adult Day Care services entered in FACTS. This will ensure entered services reconcile to the approved invoice prior to approval in FACTS.
DHR has added additional steps related to Adult Day Care services entered in FACTS. This will ensure entered services reconcile to the approved invoice prior to approval in FACTS.
DHR’s Children and Family Services division is working with FACTS to implement a system enhancement for adoption subsidy extensions. However, until that enhancement is in place, the following process has been implemented: 1. A query will be run quarterly producing a report listing any children who a...
DHR’s Children and Family Services division is working with FACTS to implement a system enhancement for adoption subsidy extensions. However, until that enhancement is in place, the following process has been implemented: 1. A query will be run quarterly producing a report listing any children who are turning 18 with a federal subsidy or 19 with a state subsidy within the next 90 days and sent to the adoption unit program manager. Adoptive parents will be sent a letter explaining the extension process and detailing the information required to request a subsidy extension. a. If a request is received and the youth is eligible, an extension will be granted. b. If a request is not received, the subsidy will be end dated on the 18th or 19th birthday, depending on the type of subsidy. 2. Effective June 1, 2026, an actual end date will be entered in FACTS during approval of the subsidy.
However, if this finding is affirmed the corrective action plan will be for the Alabama Military Department to ensure all charges to support federal awards will be charged appropriately in STAARS. Accounting entries in STAARS will be allocable and allowable charges as approved by the Grants Officer.
However, if this finding is affirmed the corrective action plan will be for the Alabama Military Department to ensure all charges to support federal awards will be charged appropriately in STAARS. Accounting entries in STAARS will be allocable and allowable charges as approved by the Grants Officer.
The Alabama Emergency Management Agency (AEMA) will strengthen its subrecipient monitoring procedures to ensure compliance with the audit requirements outlined in 2 CFR 200.501. AEMA will implement formal written procedures requiring the identification of subrecipients subject to Single Audit requir...
The Alabama Emergency Management Agency (AEMA) will strengthen its subrecipient monitoring procedures to ensure compliance with the audit requirements outlined in 2 CFR 200.501. AEMA will implement formal written procedures requiring the identification of subrecipients subject to Single Audit requirements and the timely collection, review, and retention of applicable audit reports. AEMA will establish a centralized tracking system to monitor the receipt of required audit reports and identify subrecipients that have not submitted audits by the required due date. Designated personnel will be responsible for conducting and documenting reviews of all received audit reports to determine whether any findings, questioned costs, or deficiencies impact federally funded programs administered by AEMA. In instances where audit findings are identified, AEMA will follow up with subrecipients to obtain corrective action plans and monitor the implementation of corrective actions to ensure identified deficiencies are adequately addressed. Management will also implement periodic supervisory reviews to verify that audit reports are obtained, reviewed, and documented in accordance with federal requirements.
The Alabama Emergency Management Agency (AEMA) will develop and implement formal written procedures to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. These procedures will include processes for identifying all first-tier subawards subje...
The Alabama Emergency Management Agency (AEMA) will develop and implement formal written procedures to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. These procedures will include processes for identifying all first-tier subawards subject to FFATA reporting, verifying the accuracy and completeness of required subaward data elements, and ensuring timely reporting of applicable subawards and subaward amendments to SAM.gov within the required reporting deadlines. AEMA will establish a tracking mechanism to monitor all subawards of $30,000 or more and will assign responsibility to designated personnel for reviewing and submitting FFATA reports. Additionally, management will implement a supervisory review process to verify that all required reports have been submitted accurately and timely.
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION, PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION, HIGHWAY PLANNING AND CONSTRUCTION 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR ...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION, PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION, HIGHWAY PLANNING AND CONSTRUCTION 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 requires the City of Prior Lake (the City) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the highway planning construction grant. The City did not have sufficient controls in place within its highway planning and construction grant to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The City will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – The City’s Finance Director, Nicole Klekner. Planned Completion Date – December 31, 2026. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – The City’s Finance Director, Nicole Klekner, will ensure appropriate controls are in place to verify that any vendor with which the City contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.
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