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CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Pullman January 1, 2023 through December 31, 2023 This schedule presents the corrective action the City is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (C...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Pullman January 1, 2023 through December 31, 2023 This schedule presents the corrective action the City is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The City did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of District contact person: Jeff Elbracht, Director of Finance 190 SE Crestview Street, Pullman, WA 99163 (509) 338-3212 Corrective action the auditee plans to take in response to the finding: Controls and training will be put in place to ensure staff complies with federal suspension and debarment requirements including completion for the process on all subsequent agreements with each contractor. Anticipated date to complete the corrective action: Immediately
For employees who are paid in full or in part with federal and other funds, management will increase the frequency of the time and effort reporting to quarterly intervals. Specifically, employees will document their time and effort based on funding sources for each payroll period; and at the end eac...
For employees who are paid in full or in part with federal and other funds, management will increase the frequency of the time and effort reporting to quarterly intervals. Specifically, employees will document their time and effort based on funding sources for each payroll period; and at the end each quarter, management will review and compare the actual time and effort percentages with the current ADP Labor Distribution Report for reasonableness. The Management review report will be used as a basis to effect changes to the labor distribution report using the employee status change forms. The time and effort documentation will be available for audit. The implementation of the Corrective Action Plan did not commence until fiscal year 2025 given the timing of the fiscal year 2021 and 2022 audits and receipt of this finding.
Finding 554151 (2023-019)
Significant Deficiency 2023
The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control...
The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control process to monitor and review additional invoice samples from Branches after they have been processed and reviewed by Branch Program Technicians and Branch Auditors. Additionally, the DDSD Central Support Services Branch implemented a secondary audit process and created a new Auditor role to routinely sample additional Medical Evidence of Record (MER) and Consultative Examination (CE) contracts. Findings are provided to branches to reinforce accuracy and assure compliance. The DDSD, also transitioned from MIDAS to DCPS, which provides more sophisticated fiscal controls. To remediate any inaccuracies, DDSD’s centralized auditor will assess findings and develop an action plan to prevent erroneous invoices. The CDSS ensures that all necessary controls are in place to verify the accuracy and proper documentation of invoices. The CDSS concludes that the sample size of 15 MER cases does not provide sufficient audit evidence that controls are not operating effectively resulting in a calculated $54,398 in potential costs. However, CDSS agrees with the finding and is committed to the control and mitigation of risk related to the audit recommendation. Estimated Implementation Date: Implemented Contact: Bernice Stanfield, Fiscal and Procurement Section Chief Central Support Services Branch Disability Determination Service Division California Department of Social Services
View Audit 352774 Questioned Costs: $1
CDPH is addressing the findings of the audit through a combination of outreach and training for internal stakeholders, updated internal policies, and data verification to ensure proper review and approval of the Form CMS-1539. Estimated Implementation Date: April 2025 Contact: Nate Gilmore, Branch ...
CDPH is addressing the findings of the audit through a combination of outreach and training for internal stakeholders, updated internal policies, and data verification to ensure proper review and approval of the Form CMS-1539. Estimated Implementation Date: April 2025 Contact: Nate Gilmore, Branch Chief Center for Health Care Quality California Department of Public Health
The CDSS will complete its development and implementation of a monitoring process over license-exempt health and safety standards in collaboration with the federal Administration of Children and Families and the State Legislature. Estimated Implementation Date: July 1, 2027 Contact: Jeff Fowler, St...
The CDSS will complete its development and implementation of a monitoring process over license-exempt health and safety standards in collaboration with the federal Administration of Children and Families and the State Legislature. Estimated Implementation Date: July 1, 2027 Contact: Jeff Fowler, Staff Services Manager III Child Care and Development Program California Department of Social Services
The CDSS disagrees with the finding. California’s subsidized child care system is locally operated. The CDSS relies on hundreds of local county offices and nonprofit agencies to administer child care and development programs at the local level, rather than having the State pay subsidized providers d...
The CDSS disagrees with the finding. California’s subsidized child care system is locally operated. The CDSS relies on hundreds of local county offices and nonprofit agencies to administer child care and development programs at the local level, rather than having the State pay subsidized providers directly. As a result, CDSS required Alternative Payment Programs, direct-service contractors that administer Family Child Care Home Education Networks, and fiscal partners to track survey completion as a prerequisite for awarding American Rescue Plan Act (ARPA) subgrants. This local infrastructure and the size of California’s subsidized child care and development system separates California from other states. As a result, CDSS worked very closely with the federal grantor, the Administration for Children and Families, to ensure that the ARPA survey methodology met federal monitoring requirements and tracked data elements required by the federal government. For this reason, CDSS believes it has fulfilled its responsibility and does not need to further establish a monitoring program. Estimated Implementation Date: Will not implement Contact: Jeff Fowler, Staff Services Manager III Child Care and Development Program California Department of Social Services
View Audit 352774 Questioned Costs: $1
The CDSS agrees with the finding and recognizes the importance of effective report tracking and the timely submission of fiscal and compliance reports, with clearly defined responsibilities and workflows to ensure accuracy. When the grants were transferred from CDE to CDSS, no formal guidance was pr...
The CDSS agrees with the finding and recognizes the importance of effective report tracking and the timely submission of fiscal and compliance reports, with clearly defined responsibilities and workflows to ensure accuracy. When the grants were transferred from CDE to CDSS, no formal guidance was provided during the transition. The delay in submission was due to multiple factors including training new staff, understanding the different pieces of the various grants, and the most impactful factor was the information to produce the Federal Funding Accountability and Transparency Act (FFATA) report. To produce the FFATA report, the Federal Reporting Section (FRS) had to reach out to every contractor, vendor, county, etc. and ask for their assistance to fill out the FFATA report information. This was a labor- and time-consuming process due to the size of the grant. As a result, it took some time for the FRS to gather the necessary information and become fully familiar with the procedures required to prepare the FFATA report. To minimize the risk of late report submission, FRS has ensured that all staff understand the final deadline and all key milestones along the way. The FRS has broken down the report into smaller, manageable tasks within individual deadlines which helps to avoid last-minute rushes and ensure steady progress. The FRS utilizes Microsoft Teams as a project management tool to track deadlines, monitor progress, and send reminders to keep everyone on track. The FRS conducts regular check-ins to discuss progress, address any challenges early, and adjust the plan as needed to prevent delays. Additionally, FRS has created a standardized template to save time and allow the team to work efficiently. Staff are now completing their individual reports ahead of time which gives ample room for review and revisions to ensure the FFATA report is prepared accurately and timely. Estimated Implementation Date: Implemented Contact: Daniel During, Federal Reporting Section Chief Accounting and Fiscal Systems Branch Finance and Accounting Division California Department of Social Services
Finding 554135 (2023-018)
Significant Deficiency 2023
DHCS recently implemented and instructed all staff on an improved leave management and timesheet submission process, effective November 20, 2024, beginning with the December 2024 pay period. The change addresses the recommendations from CSA by streamlining the submission, review, and storage of empl...
DHCS recently implemented and instructed all staff on an improved leave management and timesheet submission process, effective November 20, 2024, beginning with the December 2024 pay period. The change addresses the recommendations from CSA by streamlining the submission, review, and storage of employee timesheets, ensuring efficient and transparent management of time-related data across DHCS. Furthermore, the new process ensures a manager or supervisor reviews and approves all timesheets before submission. Estimated Implementation Date: November 20, 2024 Contact: California Department of Health Care Services • Primary – Erika Cristo Assistant Deputy Director, Behavioral Health • Secondary – Wendy Rasmussen, Chief, Office of Compliance - Internal Audits
Finding 554133 (2023-017)
Significant Deficiency 2023
Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certi...
Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certified enrollment workers across California are consistently adhering to eligibility and documentation requirements. However, due to staffing challenges caused by the redirection of staff during the state of emergency declared for the COVID-19 pandemic, ADAP faced significant workforce shortages from March 2020 through much of 2023. This caused a backlog in SR processing, which delayed tasks, including the review of this client’s application. The client’s eligibility lapsed after 130 days, before SR could be conducted. The Eligibility Operations Section (EOS) of ADAP which conducts SR, is now fully staffed and has successfully addressed the backlog. As of early 2024, SR processing has returned to normal operations and is current. Estimated Implementation Date: Already implemented as of April 2024 Contact: Joseph Lagrama, ADAP Branch Chief California Department of Public Health
DHCS implemented a process to impose payment withholds for significantly late cost reports, which addresses CSA’s recommendations. As of January 1, 2025, DHCS has issued 26 Notices of Delinquency to contracted counties of Short-Doyle funding (two notices for FY 2015-16, four notices for FY 2016-17, ...
DHCS implemented a process to impose payment withholds for significantly late cost reports, which addresses CSA’s recommendations. As of January 1, 2025, DHCS has issued 26 Notices of Delinquency to contracted counties of Short-Doyle funding (two notices for FY 2015-16, four notices for FY 2016-17, one notice for FY 2018-19, three notices for FY 2019-20, six notices for FY 2020-21, and ten notices for FY 2021-22). DHCS has received positive responses from some of the delinquent counties, stating the cost reports should be submitted shortly. If the counties do not submit their cost reports within 30 calendar days of the delinquency notice, DHCS will send a Notice of Intent to Impose Temporary Withhold of Funds with an option to meet and confer. If a county still has not submitted its cost report within 30 calendar days after Notice of Intent to Impose Temporary Withhold of Funds, the county will be put on Final Notice of Intent to Impose Temporary Withhold of Funds with an effective date of 30 days, at which time a withhold of funds will be processed. Estimated Implementation Date: January 1, 2025 Contact: California Department of Health Care Services • Primary – Ryan Whalen, Behavioral Health Interim Settlement, Section Chief, Audit & Investigations (A&I) Financial Review Outpatient and Behavioral Health Division (FROBHD) • Secondary – Lisa Alder, Behavioral Health Financial Review, Branch Chief, A&I FROBHD • Tertiary – Charles Anders, Behavioral Health Financing Branch, Chief, Local Governmental Financing Division (LGFD)
Public Health agrees with the recommendation. Public Health will develop a process for conducting risk assessments of subrecipient funding, develop and implement procedures for obtaining single audit reports from subrecipients, as well as a system to monitor and track compliance with the single audi...
Public Health agrees with the recommendation. Public Health will develop a process for conducting risk assessments of subrecipient funding, develop and implement procedures for obtaining single audit reports from subrecipients, as well as a system to monitor and track compliance with the single audit mandate among subrecipients. Public Health will ensure each subaward includes all requirements imposed on the subrecipient so that the federal award is used in accordance with Federal Statutes, regulations, and terms of conditions of the federal award. Estimated Implementation Date: May 2025 Contact: Melissa Relles, Assistant Deputy Director Division of Operations, Center for Preparedness and Response California Department of Public Health
California Department of Transportation (Caltrans) has determined that federal award information is not always disseminated to the project managers. Caltrans will review current policies and procedures of each division and revise, if necessary, so that best practices are followed. Caltrans Internal ...
California Department of Transportation (Caltrans) has determined that federal award information is not always disseminated to the project managers. Caltrans will review current policies and procedures of each division and revise, if necessary, so that best practices are followed. Caltrans Internal Audits Office will be working with Local Assistance’s single audit report monitoring process and take on the responsibility to monitor for all Caltrans divisions. Estimated Implementation Date: June 2025 Contact: Ben Shelton, Chief – Caltrans Internal Audits Office Division of Risk and Strategic Management
Finding 554122 (2023-005)
Significant Deficiency 2023
As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency ...
As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency fraud task force that reviews fraud data and fraud reports on a continual basis and recommends adjustments to filters and tools as necessary. EDD has successfully halted two large fraud scheme attempts over the previous two years and continues to work towards immediate detection and prevention of fraud attempts. EDD will continue to analyze and assess our processes to stay ahead of the ever-evolving fraud landscape. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating PUA claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. Estimated Implementation Date: Completed September 2024 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 352774 Questioned Costs: $1
As reported in the prior year’s response, given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For exam...
As reported in the prior year’s response, given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. EDD began automatically cross-matching EDD wage records and Franchise Tax Board records in November 2020 to assist in verifying the income of PUA claimants who could not be automatically verified through these procedures. Such claimants were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California WBA of $167, and the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), based on the U.S. Department of Labor’s (DOL) guidance in Unemployment Insurance Program Letter 05 24, EDD notified DOL on February 6, 2024, that California Unemployment Insurance Code (CUIC) section 1376 bars EDD from resolving the wage verification and self-employment verification items. Section 1376 provides that EDD cannot establish overpayments more than one year after the close of the benefit year in which the overpayment was made unless the overpayment is found to be a result of fraud, misrepresentation, or willful nondisclosure. Given that there is no fraud in creating these overpayments on the part of the individuals identified in these populations, EDD is no longer able to establish overpayments for these populations. On May 31, 2024, DOL notified EDD that the February 6, 2024, submission regarding how California’s finality laws affect the actions required to correct the wage verification and self-employment findings is sufficient to close these findings. Estimated Implementation Date: Completed May 2024 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 352774 Questioned Costs: $1
Finding 554120 (2023-003)
Significant Deficiency 2023
Reference No. 2023-003: The EDD resumed adjudicating all potential eligibility issues as of January 2021 and completed the retroactive determination workload on April 30, 2023. Estimated Implementation Date: Completed April 2024 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch ...
Reference No. 2023-003: The EDD resumed adjudicating all potential eligibility issues as of January 2021 and completed the retroactive determination workload on April 30, 2023. Estimated Implementation Date: Completed April 2024 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department
View Audit 352774 Questioned Costs: $1
Finding 554028 (2023-001)
Significant Deficiency 2023
The deficiency occurred due to such documentation not received or forwarded from former personnel, and perhaps inadequate training by former personnel on compliance requirements. Mana Maoli plans to facilitate increased training for all personnel using debit cards to increase competency and complian...
The deficiency occurred due to such documentation not received or forwarded from former personnel, and perhaps inadequate training by former personnel on compliance requirements. Mana Maoli plans to facilitate increased training for all personnel using debit cards to increase competency and compliance under 2 CFR § 200.302(b)(3) and 2 CFR § 200.403(g). Prior to and during the course of the FY2023 audit, Mana Maoli has already taken steps to train our personnel before issuing debit cards to better ensure staff understand the importance of receipt retention. Staff training focuses on how to implement and comply with federal documentation retention policies. As our new training protocols continue to be implemented, we will monitor for more comprehensive receipt retention and approvals. Mana Maoli’s management will evaluate and monitor the training’s effectiveness in producing more timely receipt retention. The responsible persons for training staff are Ruth Faioso Leau, Finance Manager, and Erik Yoshimoto, Office Manager. We will assess, monitor, and verify ongoing compliance for the second half of FY2025 and will have the new training protocol fully implemented by the first half of FY2026. Each quarter, the Finance Director will review a sample of federal disbursements that supporting documentation is maintained. The results will be reported to senior management. In conclusion, we will be taking steps immediately to address the findings in the audit. If additional information is needed, please contact Ruth Faioso Leau, Finance Director at faioso@manamaoli.org or 808-753-8746.
Finding Number: 2023-009 Planned Corrective Action: The Treasurer will monitor future grants for this requirement. At the writing of this response ARP ESSER grants for the district have been completely expended. Anticipated Completion Date: March 1, 2025 Responsible Contact Person: Ashley Miller
Finding Number: 2023-009 Planned Corrective Action: The Treasurer will monitor future grants for this requirement. At the writing of this response ARP ESSER grants for the district have been completely expended. Anticipated Completion Date: March 1, 2025 Responsible Contact Person: Ashley Miller
View Audit 352599 Questioned Costs: $1
Finding Number: 2023-006 Planned Corrective Action: The corrective action in 2023-005 will assist in providing accurate financial information when completing the Schedule of Expenditures of Federal Awards. Anticipated Completion Date: March 1, 2025 Responsible Contact Person: Ashley Miller
Finding Number: 2023-006 Planned Corrective Action: The corrective action in 2023-005 will assist in providing accurate financial information when completing the Schedule of Expenditures of Federal Awards. Anticipated Completion Date: March 1, 2025 Responsible Contact Person: Ashley Miller
Finding 553879 (2023-006)
Material Weakness 2023
Consortium’s Fiscal Agent Executive Director and Chief Fiscal Officer shall review and approve each invoice/payment in order to determine that expenditures are in accordance with grant requirements and Federal laws and such approval should be documented on each invoice/payment.
Consortium’s Fiscal Agent Executive Director and Chief Fiscal Officer shall review and approve each invoice/payment in order to determine that expenditures are in accordance with grant requirements and Federal laws and such approval should be documented on each invoice/payment.
Finding 553823 (2023-004)
Significant Deficiency 2023
FINDING #2023-004: Written Uniform Guidance Policies Responsible Individuals: Jessicca McKeown, Finance Officer Corrective Action Plan: The City is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
FINDING #2023-004: Written Uniform Guidance Policies Responsible Individuals: Jessicca McKeown, Finance Officer Corrective Action Plan: The City is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
Suspension and Debarment Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization retain support of suspension and debarment checks for each vendor to support the written policy is implemented and the Uniform Grant Requirements are being...
Suspension and Debarment Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization retain support of suspension and debarment checks for each vendor to support the written policy is implemented and the Uniform Grant Requirements are being followed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization will retain support of suspension and debarment checks for each vendor to support the written policy is implemented and the Uniform Grant Requirements are being followed. Name of the contact person responsible for corrective action: Megan Mattimoe, Executive Director Planned completion date for corrective action plan: June 1, 2025
Allowable Costs Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure the draw down requests and related support are formally reviewed and approved by the Executive Director for allowability before submitting...
Allowable Costs Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure the draw down requests and related support are formally reviewed and approved by the Executive Director for allowability before submitting the request to the awarding agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization will put a formal layer of review after preparation of the draw down request and support and before submission to the awarding agency and make sure the approved support is kept on file. Name of the contact person responsible for corrective action: Megan Mattimoe, Executive Director Planned completion date for corrective action plan: June 1, 2025
The Sheriff’s Department separated from the individual that handled the grant funding as of the first of 2025. We have worked diligently to get these reports correct as of December 31, 2024.
The Sheriff’s Department separated from the individual that handled the grant funding as of the first of 2025. We have worked diligently to get these reports correct as of December 31, 2024.
Condition: The Organization did not have appropriate segregation of duties surrounding the preparation and review of the monthly NIST schedules which accumulate the information necessary to calculate allowable costs and matching for drawdown requests. Further, while the Organization had written proc...
Condition: The Organization did not have appropriate segregation of duties surrounding the preparation and review of the monthly NIST schedules which accumulate the information necessary to calculate allowable costs and matching for drawdown requests. Further, while the Organization had written procedures over cash management, they were outdated and did not reflect the current staffing model. Planned Corrective Action: Subsequent to year end, the reorganized finance team put new controls and procedures in place. Moving forward the Accounting Supervisor will calculate the NIST MEP monthly program income which is used to determine the monthly award drawdown of cash from the available grant award funds. This is reviewed by the Controller and this report is used to create SF-425. Contact person responsible for corrective action: Alan Kowalewski, Controller Anticipated Completion Date: 07/01/24
2022-004: Telecommunication Costs Name of contact person: Stacey Holbrook, Executive Director Corrective Action: Executive Director and Fiscal Officer will review all items of cost for the federal award against 2 CFR Part 200, Subpart E annually for their allowability. Proposed completion dat...
2022-004: Telecommunication Costs Name of contact person: Stacey Holbrook, Executive Director Corrective Action: Executive Director and Fiscal Officer will review all items of cost for the federal award against 2 CFR Part 200, Subpart E annually for their allowability. Proposed completion date: The Board will implement the above procedure immediately.
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