Corrective Action Plans

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At the onset of the pandemic, certain employees were sent to work remotely. During this period of time, the Organization experienced larger than usual turnover, including the CFO position, which remained unfilled for a significant period of time. Due to these factors, many employees were forced to h...
At the onset of the pandemic, certain employees were sent to work remotely. During this period of time, the Organization experienced larger than usual turnover, including the CFO position, which remained unfilled for a significant period of time. Due to these factors, many employees were forced to handle new responsibilities for the first time in a new remote setting, as the Organization worked diligently to continue operations. Since many of the shows were being cancelled or modified from their traditional format, smaller projects related to design buildout, maintenance, and advertising were taken on. Many of these projects involved smaller retail purchases for which documentation was not properly retained. The Organization acknowledges the findings and has since hired a new CFO and instituted policies and procedures surrounding documentation of all cash disbursements and expenditures of federal awards.
The Organization had not previously been subjected to the Uniform Guidance standards. The internal controls over time and effort reporting did not operate as designed resulting in instances of noncompliance with the reconciliation of actual time worked versus vouchered reimbursement requests. The Or...
The Organization had not previously been subjected to the Uniform Guidance standards. The internal controls over time and effort reporting did not operate as designed resulting in instances of noncompliance with the reconciliation of actual time worked versus vouchered reimbursement requests. The Organization plans to enhance its controls over time and effort reporting and ensure that payroll costs are reported and vouchered based on actual rather than budgeted allocations.
Finding: 2022-005: Significant Deficiency in Internal Controls over Compliance – Allowability– Payroll Transactions Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: • All payroll journal entries will be reviewed and ...
Finding: 2022-005: Significant Deficiency in Internal Controls over Compliance – Allowability– Payroll Transactions Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: • All payroll journal entries will be reviewed and approved by program staff and the Controller since the Staff Accountant prepares the journal entries. • CCS will implement a process for Controller to review payroll entries after they are imported for accuracy between Paycor and the accounting system. • CCS will be looking into whether program staff should start direct charging their time. CCS will set up an after- payroll review to be done by program and finance/HR to review for any possible errors missed prior to running payroll. If errors are found, corrective entries will be made immediately. Also, we will be looking into whether an indirect rate would simply our very complicated allocation system we currently use. Additionally, program staff will review all new or adjusted allocations in Paycor. • Program staff will review all new or changed payroll allocations for employees they supervise. • Detailed allocation reports will be sent to program staff for review. • Program staff are to review preliminary and final reports monthly to check for any discrepancies. • The finance staff currently looks at reports monthly for discrepancies. Proposed Completion Date: 2/28/23
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023
March 27, 2024 2022-004: Significant Deficiency in Internal Control / Immaterial Noncompliance – Activities Allowed/Allowable Cost (repeat Finding) Condition: Allocations of non-direct charged wage time (i.e., paid time off, bereavement, jury duty, holiday, medical paid time off, medical waivers) ar...
March 27, 2024 2022-004: Significant Deficiency in Internal Control / Immaterial Noncompliance – Activities Allowed/Allowable Cost (repeat Finding) Condition: Allocations of non-direct charged wage time (i.e., paid time off, bereavement, jury duty, holiday, medical paid time off, medical waivers) are managed through a labor allocation whereby amounts of non-direct charged wage time are charged to various programs incorrectly. Corrective Action: We agree with the finding. We have addressed this issue with management within the consortium to properly allocate non-direct wage time. This includes the current (March of 2024) procurement of a sufficient payroll and time keeping software to assist in the remediation of this finding. Contact Person: Shamar Herron: Sherron@mwse.org Completion Date: August 2025, procurement will be completed and system implemented. Respectfully, Shamar Herron
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reviewed and updated existing controls. Comm...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reviewed and updated existing controls. Communicate with leadership on controls and proper approval process. Cash disbursement request will be reviewed and approved by supervisor prior to submissions. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 9/30/2022
Recommendations: The Board should strive to submit the Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end. Views of Responsible Officials and Planned Corrective Actions: The Board will strive to submit its Single Audit Reporting Pac...
Recommendations: The Board should strive to submit the Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end. Views of Responsible Officials and Planned Corrective Actions: The Board will strive to submit its Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end for all future funds received from the federal government.
Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.
Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.
View Audit 301535 Questioned Costs: $1
Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1,...
Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1, 2024.
View Audit 301078 Questioned Costs: $1
Finding 390130 (2022-004)
Significant Deficiency 2022
1. The Center will retain evidence of competitive bidding, unless an emergency or other situation precluding the delay of competitive bidding has arisen (in which case, the Center will retain the evidence and rationale justifying the sole source contract). The Center will retain verification of susp...
1. The Center will retain evidence of competitive bidding, unless an emergency or other situation precluding the delay of competitive bidding has arisen (in which case, the Center will retain the evidence and rationale justifying the sole source contract). The Center will retain verification of suspension and debarment for all potential contract service providers. The Center notes that one of the contracts selected for testing arose during an emergency situation (flooding). 2. CFO will ensure that all invoices and supporting documentation are retained. ED and/or Director of Legal Services (depending on amount of expenditure, both may be required) will approve electronic payments in Bill.com. Approval of expenses paid with paper checks will be indicated by signature of checks after reviewing accompanying support.
View Audit 301014 Questioned Costs: $1
Finding 390129 (2022-003)
Significant Deficiency 2022
Personnel costs will be charged to the program based on actual time recorded in the organization’s case management software. Hours will be audited quarterly to ensure accuracy and completeness. The Center notes that the grantor, the State Bar of California, never requested the Center to charge payro...
Personnel costs will be charged to the program based on actual time recorded in the organization’s case management software. Hours will be audited quarterly to ensure accuracy and completeness. The Center notes that the grantor, the State Bar of California, never requested the Center to charge payroll expenses to the program based on actual time documents, nor had they ever noted this discrepancy during their periodic audits of the program.
View Audit 301014 Questioned Costs: $1
Recommendation: We recommend the Agency draft and adopt written procedures in accordance with Uniform Guidance requirements. Action Taken: Management agrees with the finding and adopted the appropriate policies and procedures in December 2023.
Recommendation: We recommend the Agency draft and adopt written procedures in accordance with Uniform Guidance requirements. Action Taken: Management agrees with the finding and adopted the appropriate policies and procedures in December 2023.
Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...
Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.
View Audit 300148 Questioned Costs: $1
Finding 387785 (2022-001)
Material Weakness 2022
Hayim Prero, as lead person for the SFSP program for Machne Naarim, will ensure that all expenditures show proper approval before purchases are made. This recommendation was made in the fall of 2022 and went into effect in the summer of 2023. As this was the procedure until now, however, there was n...
Hayim Prero, as lead person for the SFSP program for Machne Naarim, will ensure that all expenditures show proper approval before purchases are made. This recommendation was made in the fall of 2022 and went into effect in the summer of 2023. As this was the procedure until now, however, there was no signature to verify the approval, and this took minimal time to correct. As part of yearly training, the director of each site will be directed to ensure that there is a signature indicating proper approval for all expenditures before purchases are made. This will also be verified for all the sites by the Machne Naarim bookkeeping staff when the invoices are submitted to Machne Naarim for verification of the integrity of their programs.
County had additional funds available in Other Allowable Costs to offset the premuim pay to exempt workers. County will not offer premium pay to employees classified as exempt.
County had additional funds available in Other Allowable Costs to offset the premuim pay to exempt workers. County will not offer premium pay to employees classified as exempt.
The School System concurs with the auditor’s findings and recommendations. The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions ...
The School System concurs with the auditor’s findings and recommendations. The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines.
The School System concurs with the auditor’s findings and recommendations. As an on-going effort, the process for creating pay elements for specialized compensation will be monitored for accuracy during the creation stages. Electronic alerts generated in the oracle system will be re-employed to no...
The School System concurs with the auditor’s findings and recommendations. As an on-going effort, the process for creating pay elements for specialized compensation will be monitored for accuracy during the creation stages. Electronic alerts generated in the oracle system will be re-employed to notify appropriate finance personnel when new elements are created by the Payroll Department to ensure the distribution accuracy of salary expenses along with applicable fringes to the appropriate grant accounts. This will prevent manual journal entry realignment postings of large data sets of salary and fringes to the primary assignment costing versus accounts created specifically for specialized pay that is approved in the respective grant application as an allowable cost.
2022-008 Allocation of Grant Expenses U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that all expenses are for actual expenses incurred, and that timely reconciliations are performed to ...
2022-008 Allocation of Grant Expenses U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that all expenses are for actual expenses incurred, and that timely reconciliations are performed to ensure the expenses are properly charged to the correct assistance listing number and grant. Action Taken: The Board has developed a process to correctly allocate expenditures to the correct funding stream. At each month’s end, all employees complete an allocation spreadsheet. When all spreadsheets are completed, approved, and turned in, the Board determines the allocation of payroll and expenditures. Expenditures that occurred in March will be allocated using the allocation chart for February. Also, this procedure is backup for each cash request that is submitted for funding. Also, this is reviewed for the reconciliation between the cash request and the Board’s accounting software.
2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who...
2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who is knowledgeable of the period of performance is reviewing and approving all transactions prior to payment. Action Taken: For each accounting procedure, internal controls have been put in place. The Board’s payroll processing goes through three levels of approval before it is processed. The expenditures process goes through three levels of approval before the bill is paid. The Board is verifying that each report or process is approved by at least three levels of approval and within a timely manner. Expenditure checks are issued every two weeks. The approval of these checks is also approved by an officer of the Board of Directors. Any out of the ordinary practices have both the approval of the Executive Director and an officer of the Board of Directors. With the past issues of this Board, the Board added an internal control for the sake of period of performance, for reports that are submitted to Workforce WV. In addition, these reports will be reviewed and approved by one of the managers of the Board within the time the report is due.
View Audit 299381 Questioned Costs: $1
2022-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment, and that a...
2022-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment, and that adequate supporting documentation for all federal program charges is maintained. Action Taken: The Board is taking adequate action to review and approve all charges to the federal programs. The Board’s steps have been reviewed with Workforce WV and has been approved our procedures. Supporting documentation is kept both in physical and electronic forms. Each check the Board distributes has an approved purchase order attached, (if applicable), invoice, or if it is a monthly recurring charge, statement or bill attached and once the bill is entered into our system and the bill is paid, the check has the Executive Director’s initials and date showing it is approved in our accounting system. Also, if the expenditures are questionable, we will receive approval before submission of the bill from our liaison in the Workforce WV office.
View Audit 299381 Questioned Costs: $1
The Council agrees with this finding. The Council has hired a new Finance Director with the appropriate skills, knowledge, and experience to oversee the Finance Department. The Finance Director has identified and corrected internal control issues.
The Council agrees with this finding. The Council has hired a new Finance Director with the appropriate skills, knowledge, and experience to oversee the Finance Department. The Finance Director has identified and corrected internal control issues.
Corrective Action Plan: The nursing home payroll staff compiled a list of staff beginning in March 2020, where there was a workforce-related actual expense to prevent, prepare for or respond to coronavirus during the reporting period. To complete the Provider Relief Fund expenses for Payroll/General...
Corrective Action Plan: The nursing home payroll staff compiled a list of staff beginning in March 2020, where there was a workforce-related actual expense to prevent, prepare for or respond to coronavirus during the reporting period. To complete the Provider Relief Fund expenses for Payroll/General and Administrative Expenses, this extensive payroll expense list needed to be sorted & tabulated to meet the PRF report. In the process, a portion of 5 weeks of covid expense were included twice causing double expense, an additional $41,046.24. This was a clerical error by the Director of Finance. To correct this issue moving forward, a secondary reviewer needs to inspect the compilation of payroll expenses and formulas in the spreadsheet before submitting. Due to the excessive amount of lost revenues in all reporting periods, the reporting of expenses was not needed, but reported for historical information. The Director of Finance called the HRSA helpdesk on 2/5/2024 as soon as this error was noted. HRSA replied that unless CCNH receives a letter, they will not reopen this reporting period and they will not reopen a reporting period for an outside auditor finding. Name of Responsible Person: Carrie Klebe Anticipated Implementation Date of Corrective Action: The above actions will take effect immediately.
View Audit 298844 Questioned Costs: $1
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