Corrective Action Plans

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Finding 2025-056 WIOA Cluster, ALN 17.258, 17.259, and 17.278 Management Views LEO agrees with the finding. LEO management recognizes the importance of timely and accurate FFATA reporting and acknowledges that internal processes can be strengthened to better support reporting consistency, particular...
Finding 2025-056 WIOA Cluster, ALN 17.258, 17.259, and 17.278 Management Views LEO agrees with the finding. LEO management recognizes the importance of timely and accurate FFATA reporting and acknowledges that internal processes can be strengthened to better support reporting consistency, particularly during high-volume periods such as quarter-end. LEO remains committed to compliance and continuous improvement. Planned Corrective Action LEO will improve existing FFATA reporting processes by reinforcing internal timelines, clarifying staff responsibilities, and implementing an additional review step prior to submission to help ensure subaward information is reported timely and accurately. Management will train appropriate staff responsible for FFATA reporting to strengthen understanding of reporting requirements, deadlines, and review expectations. These improvements are intended to enhance process consistency, improve communication, and reduce the likelihood of future timing or minor reporting discrepancies. LEO will enhance documented procedures that outline specific FFATA reporting processes related to the Workforce Innovation and Opportunity Act (WIOA). Anticipated Completion Date September 30, 2026 Responsible Individual(s) Arica Johnson, LEO
Finding 2025-012 SNAP Cluster, ALN 10.551 and 10.561 and Summer Electronic Benefits Transfer Program for Children, ALN 10.646 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is currently evaluating the two System and Organization Con...
Finding 2025-012 SNAP Cluster, ALN 10.551 and 10.561 and Summer Electronic Benefits Transfer Program for Children, ALN 10.646 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is currently evaluating the two System and Organization Controls (SOC) reports and will document the evaluation and determination of whether a review is required. Based on these evaluations, if MDHHS determines reviews are required, MDHHS will document the SOC report reviews by June 30, 2026. Also, MDHHS will assess the current SOC review process and implement any needed improvements to ensure subservice organizations are properly evaluated, formally documented, and that SOC report reviews are submitted within 60 days of receiving each report, by September 30, 2026. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Tony Weber, MDHHS Veronica Maxson, MDHHS Dani Wager, MDHHS Tim Kubu, MDHHS
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
CORRECTIVE ACTION PLAN Concerning Finding 2025-001 - Procurement Contact Person Responsible for Corrective Action: Darcy K. Labbe, Superintendent Corrective Action: The Eagle Lake Sewer District will take the following actions to address finding 2025-001. A procurement policy was drawn up and implem...
CORRECTIVE ACTION PLAN Concerning Finding 2025-001 - Procurement Contact Person Responsible for Corrective Action: Darcy K. Labbe, Superintendent Corrective Action: The Eagle Lake Sewer District will take the following actions to address finding 2025-001. A procurement policy was drawn up and implemented on February 23, 2026. Anticipated Completion Date: A procurement policy was signed by the Board of Trustees and implemented on February 23, 2026.
Corrective Action Plan Finding No.: 2025 - 005 Condition: ECHO did not maintain a listing of capital equipment acquired with Federal funds. During testing of equipment purchased under the Education Stabilization Program, we noted that management was unable to provide a complete inventory identifying...
Corrective Action Plan Finding No.: 2025 - 005 Condition: ECHO did not maintain a listing of capital equipment acquired with Federal funds. During testing of equipment purchased under the Education Stabilization Program, we noted that management was unable to provide a complete inventory identifying equipment purchased with Federal awards or documenting the information required by the Uniform Guidance. As a result, ECHO could not demonstrate that equipment acquired with Federal funds was properly tracked and monitored. Plan: ECHO will establish procedures to record and maintain an inventory of capital equipment acquired with Federal and non-federal grant funds. The inventory lists will be maintained by the Director of Finance and Operations. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Dr. Rena Whitten, Superintendent
Corrective Action Plan Finding No.: 2025 - 004 Condition: During testing of expenditures claimed under the Education Stabilization Fund program we identified $41,157 of expenditures that were included in a reimbursement request were not supported by allowable program expenditures. Subsequent to the ...
Corrective Action Plan Finding No.: 2025 - 004 Condition: During testing of expenditures claimed under the Education Stabilization Fund program we identified $41,157 of expenditures that were included in a reimbursement request were not supported by allowable program expenditures. Subsequent to the reimbursement request and receipt of grant funds, the checks issued as payment to vendors were voided as the vendors did not provide goods or services. These expenditures were determined to be unsupported and resulted in questioned costs. Plan: Administration will not create and hold checks for goods and services not yet rendered under a grant award, as this can lead to unsupported expenditures, should the goods or services not be provided or the checks are voided and not timely reported. The encumbrance process will be used appropriately, and payments will be made once the goods or services have been rendered. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Dr. Rena Whitten, Superintendent
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.
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