Corrective Action Plans

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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
#2025-006 FINDING: Reporting Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will reconcile individual program expenditure activity to the completed SF425 report and establish deadlines for filing submissions within the grant agreement timelines. The...
#2025-006 FINDING: Reporting Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will reconcile individual program expenditure activity to the completed SF425 report and establish deadlines for filing submissions within the grant agreement timelines. The Business Manager will follow the recommendation of the auditor. Anticipated Completion Date: Ongoing
#2025-005 FINDING: Payroll Testing Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will continue to review payroll prior to payroll being paid. The Payroll/Accountant will double check all timesheets before entering and double check payrate against c...
#2025-005 FINDING: Payroll Testing Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will continue to review payroll prior to payroll being paid. The Payroll/Accountant will double check all timesheets before entering and double check payrate against contract amount. Anticipated Completion Date: Ongoing
#2025-004 FINDING: Documentation of Internal Controls Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager and their staff will maintain and retain records of special pay and reconcile year-end balances to subsidiary listings. The Business Manager does re...
#2025-004 FINDING: Documentation of Internal Controls Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager and their staff will maintain and retain records of special pay and reconcile year-end balances to subsidiary listings. The Business Manager does review journal entries, bank statements, and bank reconciliations. The Business Manager will document their review of journal entries prior to posting, bank statement reconciliations upon completion, and bank collateralization for all accounts. Anticipated Completion Date: Ongoing
#2025-003 FINDING: Grant Tracking Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will follow the recommendation of the auditors. This expenditure of the Curriculum Subscription was paid for the first year to get started with the material, we did not...
#2025-003 FINDING: Grant Tracking Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will follow the recommendation of the auditors. This expenditure of the Curriculum Subscription was paid for the first year to get started with the material, we did not expense it in the second and third year. A discount was given to pay the three years up front. The prepaid upfront expense was approved by the grantor. The Business Manager will continue to agree that actual expenditures incurred to the general ledger before requesting reimbursement. Anticipated Completion Date: Ongoing
#2025-002 FINDING: Financial Statement and Schedule of Expenditure of Federal Awards (SEFA) Preparation and Audit Adjustments Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: Management of the School has reviewed the financial statements and schedule of expenditures of fe...
#2025-002 FINDING: Financial Statement and Schedule of Expenditure of Federal Awards (SEFA) Preparation and Audit Adjustments Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: Management of the School has reviewed the financial statements and schedule of expenditures of federal awards prepared by Ketel Thorstenson, LLP. The financial statements and SEFA have been compared and reconciled to the internal records maintained by the School. Management and the Board has been given adequate opportunity to ask questions regarding the financials statements and note disclosures and have received sufficient responses from the auditors prior to final publication of the audited financial statements and SEFA. Management is satisfied that appropriate actions have been taken to allow them to take responsibility for the financial statements. Crazy Horse School Business Office staff will follow auditor’s recommendation. Anticipated Completion Date: Ongoing
Segregation of Duties
Segregation of Duties
Name of Contact Person: Chelsey Traeger, City Clerk
Name of Contact Person: Chelsey Traeger, City Clerk
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Auditor Prepared Financial Statements
Auditor Prepared Financial Statements
Name of Contact Person: Chelsey Traeger, City Clerk
Name of Contact Person: Chelsey Traeger, City Clerk
Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.
Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
2025-002 – Home Investments Partnerships Program, Assistance Listing #14.239 Recommendation: The auditors recommend the Division establish procedures to ensure all required documentation is retained in participant files and monitored throughout the year. Corrective Action: The Division will strength...
2025-002 – Home Investments Partnerships Program, Assistance Listing #14.239 Recommendation: The auditors recommend the Division establish procedures to ensure all required documentation is retained in participant files and monitored throughout the year. Corrective Action: The Division will strengthen controls to ensure complete eligibility documentation is obtained, verified, and retained for all program participants. At intake, case managers will verify income and HUD homelessness eligibility by completing required forms, collecting two months of income source documentation, calculating and validating income against applicable AMI limits, and obtaining appropriate homelessness verification with preference for third-party documentation. All required documentation will be maintained in participant files using standardized checklists to ensure completeness. In addition, all new client files will undergo supervisory review for eligibility compliance, and ongoing spot monitoring will be conducted throughout the program period. Responsibility for these reviews has been reassigned to designated staff to ensure consistent oversight and timely correction of any identified deficiencies. Name of Contact Person Responsible: Lee Ann Girard – Divisional Controller Proposed Completion Date: June 30, 2026
CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Depar...
CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the Agency perform case file reviews on a more representative sample of the total clients served and that adequate documentation be retained of those reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Waylon Welvaert, Finance Manager Planned completion date for corrective action plan: December 31, 2026
ELIGIBILITY DETERMINATION Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minneso...
ELIGIBILITY DETERMINATION Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the Agency implement procedures to ensure the citizenship, asset, and income verification documentation in the casefiles be retained and that it matches the METS eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and show staff proper documentation and entry into METS and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Waylon Welvaert, Finance Manager Planned completion date for corrective action plan: December 31, 2026
Project Legal Name: Booth Residence, Inc., A Georgia Corporation HUD Project No.: 061-11293 Audit Firm: CohnReznick LLP Period covered by the audit: 10/01/24-9/03/25 (day before sale) Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory ...
Project Legal Name: Booth Residence, Inc., A Georgia Corporation HUD Project No.: 061-11293 Audit Firm: CohnReznick LLP Period covered by the audit: 10/01/24-9/03/25 (day before sale) Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and notes that the property was sold on September 4, 2025 to an unrelated party, therefore we consider this finding closed and no further action required.
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.
5. Finding 2025-005 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...
5. Finding 2025-005 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. 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 was able to implement procedures to submit the 2025 audit within the 9-month period.
4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to continue to follow up with HUD to complete activation of their EIV system access. Once access is established, management should implement procedur...
4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to continue to follow up with HUD to complete activation of their EIV system access. Once access is established, management should implement procedures to ensure all required EIV reports are generated, retained, and reviewed in accordance with HUD guidelines. b. Action(s) Taken or Planned on the Finding Management acknowledged the challenges experienced in obtaining EIV access from HUD and stated that follow-up efforts are ongoing. Once access is granted by HUD as already approved, management will generate and maintain all required EIV reports and strengthen controls to ensure compliance with HUD requirements.
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 implement procedures to ensure all replacement reserve withdrawals are supported with a HUD-signed Form HUD-9250 prior to releasing funds, the rec...
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 implement procedures to ensure all replacement reserve withdrawals are supported with a HUD-signed Form HUD-9250 prior to releasing funds, the recommendation to repay the $3,970 withdrawal, and the recommendation to obtain HUD approval for the 2024 unauthorized withdrawals of $39,282 or pay the amounts back to the reserve. b. Action(s) Taken or Planned on the Finding Management stated that a correction was processed to return the $3,970 to the replacement reserve account, with the repayment clearing in October 2025. The prior year unauthorized withdrawal remains unresolved, as management does not have the funds to repay the $39,282. Management will also strengthen internal controls to ensure all future withdrawals are fully supported with HUD-signed Form HUD-9250 approvals.
Project Legal Name: Evangeline Booth Residence, Inc., A Florida Corporation HUD Project No.: 063-EE011-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Fina...
Project Legal Name: Evangeline Booth Residence, Inc., A Florida Corporation HUD Project No.: 063-EE011-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to review the project budget to determine if nonessential costs can be cut (or request a loan from the owner) to ensure that the replacement reserve is funded in accordance with the terms of the regulatory agreement and the recommendation to obtain from HUD a waiver for the missing replacement reserve deposits if possible, or fund the missing deposits. b. Action(s) Taken or Planned on the Finding Due to significant delays in receipt of PRAC funds for over a year, management suspended making the deposits to the reserve until PRAC funding was replenished. Management also borrowed funds from the replacement reserve in 2024 which funds were repaid during the year ended September 30, 2024 once past-due PRAC funds were received. Due to ongoing issues with PRAC funding, management continues to be behind on making the monthly deposits during the year ended September 30, 2025.
4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to establish additional procedures and monitor any modifications or material changes to revenues that may impact the management fee calculation. And ...
4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to establish additional procedures and monitor any modifications or material changes to revenues that may impact the management fee calculation. And the recommendation to pay back the overpaid management fee. b. Action(s) Taken or Planned on the Finding Management agrees with the finding. We are reviewing our procedures to ensure we do not overpay management fees in the future. We believe it happened as a result of transition to new software, and was not intentional.
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 establish internal controls and procedures to ensure that residual receipts reserve deposits are made both timely and in the correct amount based ...
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 establish internal controls and procedures to ensure that residual receipts reserve deposits are made both timely and in the correct amount based on final audited financial statements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and will deposit the shortage of $21,305 during fiscal year end September 30, 2026.
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