Corrective Action Plans

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Management agrees with the auditor's findings. The Director of Litigation (Lisa Hollingsworth) will have the Regional Leaders remind their staff about the necessity of obtaining retainer agreements from clients in extended service cases.
Management agrees with the auditor's findings. The Director of Litigation (Lisa Hollingsworth) will have the Regional Leaders remind their staff about the necessity of obtaining retainer agreements from clients in extended service cases.
Management agrees with the auditor's findings and will take immediate action to revise the attorney fees allocation. The Director of Finance (Vannam Khen) will review and work directly with the Finance staff to ensure attorney fees are allocated properly.
Management agrees with the auditor's findings and will take immediate action to revise the attorney fees allocation. The Director of Finance (Vannam Khen) will review and work directly with the Finance staff to ensure attorney fees are allocated properly.
2024-001 Head Start – Assistance Listing No. 93.600 Significant Deficiency in Internal Control Over Compliance and Noncompliance – Inadequate Payroll Review and Documentation B. Allowable Costs/Cost Principles Recommendation: The auditor recommended that management establish detective controls to ...
2024-001 Head Start – Assistance Listing No. 93.600 Significant Deficiency in Internal Control Over Compliance and Noncompliance – Inadequate Payroll Review and Documentation B. Allowable Costs/Cost Principles Recommendation: The auditor recommended that management establish detective controls to ensure payroll expenses are being charged consistent with established policies and approved allocations. Action Taken: We agree with the recommendation and portions of the plan were implemented in February 2024, while the remainder was implemented in July 2025. In January 2024, the ELI team reviewed team members and their respective salary allocations, specifically for the Early Head Start program. Allocations were documented and updated in Axiom, ELI’s payroll system of record. Those allocations were then updated in early February 2024 and regular meetings to review, document and update allocations as needed, have since been held on a consistent basis. The secondary piece, corrected in July 2025, was a system correction for allocation of PTO and Holiday pay, those were not being allocated to EHS consistent with the agreed upon allocations and not going to EHS as they should have been. This has been corrected in Axiom and the ELI accounting team will now perform regular reviews to confirm allocation in agreement with the agreed upon amounts. In addition, correcting entries for 2024 and 2025 will be made by August 31, 2025.
View Audit 365042 Questioned Costs: $1
Management will continue to reinforce utilization of the time tracking system that was implemented in 2024. In addition, management will ensure that the timecards submitted by staff are reviewed and approved timely.
Management will continue to reinforce utilization of the time tracking system that was implemented in 2024. In addition, management will ensure that the timecards submitted by staff are reviewed and approved timely.
View Audit 364980 Questioned Costs: $1
2024-002 – Written Policies and Procedures Required by the Uniform Guidance Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): o City ...
2024-002 – Written Policies and Procedures Required by the Uniform Guidance Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): o City Council o City Manager o City Finance Director Anticipated Completion Date: June 18, 2025
Finding 574638 (2024-005)
Material Weakness 2024
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will ha...
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor start signing off on all reports to verify the dates are correct for the reporting period. Anticipated Completion Date: August 30, 2025
Finding 574636 (2024-003)
Material Weakness 2024
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Depa...
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Department head will review and document their review for all Federal Grant disbursements for applicable grant requirements and Federal regulations. Anticipated Completion Date: August 30, 2025
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur wi...
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will collect dual signatures on all submissions for reporting requirements. The Auditor’s Office will also have additional employees verify submissions to ledgers for accuracy. Anticipated Completion Date: Completion is anticipated for all reports due after 12-31-2025.
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Su...
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Supportive Services for Veterans Families: CFDA 64.033 b. Criteria: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as tracking administrative expenses charged to the program outside of the general ledger and in other matters noted in licensing reviews. c. Condition: The Organization has failed to comply with grant requirements due to lack of proper tracking of administrative expenses, limited compliance policies including approval over supplemental pay wages, and lack of proper training over verification and documentation processes. d. Response: The organization has been successfully running the SSVF program for 11+ years and tracking/calculating administrative costs utilizing offline Excel spreadsheets since inception which provided a low cost and flexible solution for our accounting team. However, as an outcome of our last SSVF audit and due to the size and scope of our SSVF operations, the VA is requiring Adjoin to cease maintaining offline spreadsheets and ensure that all SSVF grant costs are logged in the general ledger. We're partnering with JMT Consulting (our Sage Intacct solution provider) for their assistance in implementing a new Dynamic Allocation Module to our Sage platform allowing click thru capabilities to all of the administrative costs that hit the grant (not to exceed 10%). We're committed to rolling out this functionality and are excited about the efficiencies it will bring to the team along with ensuring compliance with VA requirements. 2. Prior Year Finding 2023-001 None noted. Contact person responsible for corrective action: Pat Phelan, CFO Completion date: August 31, 2025 If you have any questions regarding this plan, please contact Pat Phelan, CFO, 858- 292-2030, pat.phelan@adjoin.org. Sincerely, Pat Phelan CFO Adjoin
View Audit 364796 Questioned Costs: $1
Effect: The Organization may be paying subcontractors that are suspended or debarred, which would be unallowable costs. However, none of the 4 subcontractors were suspended or debarred as of the date audit procedures were performed. Recommendation: The auditor recommends that the Organization implem...
Effect: The Organization may be paying subcontractors that are suspended or debarred, which would be unallowable costs. However, none of the 4 subcontractors were suspended or debarred as of the date audit procedures were performed. Recommendation: The auditor recommends that the Organization implement policies and procedures to ensure that all subcontractors and subrecipients of covered transactions are properly verified before entering into transactions, and that this be documented as a control each time it is performed. 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit findings. 2. Action Planned in Response to Finding: The Organization has implemented procedures to verify that subcontractors with goods or services transactions expected to exceed $25,000 are verified before entering into transactions, which will be documented each time. 3. Official Responsible for Ensuring CAP: Kari Jo Lawrence, Chief Executive Officer and Jernon Kelly, Chief Financial Officer are responsible for ensuring corrective action of this deficiency. 4. Planned Completion Date for CAP: December 31, 2025.
Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees...
Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees to the program who were transferred internally. A correction was made to the April 2025 claim to adjust for the amount overclaimed. Indiana University Health strengthened claim review controls to ensure such changes go through additional review before claim submission. Contact Person(s) Responsible for Corrective Action: Christine Smith Completion Date: July 31, 2025
Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allow...
Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.
Program: Summer Food Service Program CFDA: 10.559 Finding Type: Noncompliance / Significant Deficiency Issue: Two closed enrolled sites lacked documentation to support eligibility based on child enrollment. Management's Response: Response: Management recognizes the critical role of eligibility docum...
Program: Summer Food Service Program CFDA: 10.559 Finding Type: Noncompliance / Significant Deficiency Issue: Two closed enrolled sites lacked documentation to support eligibility based on child enrollment. Management's Response: Response: Management recognizes the critical role of eligibility documentation in maintaining compliance with SFSP regulations and ensuring program integrity. Corrective Action Taken: • The YMCA has implemented a formal monitoring protocol for all SFSP operating sites, including a pre-operational review checklist to verify eligibility documentation. • Site agreements now explicitly require submission of enrollment records and eligibility documentation prior to participation. Ongoing site monitoring includes periodic reviews to ensure continued compliance with eligibility requirements. Staff have been trained on 7 CER 225.6(c) and 2 CFR 200.303 to reinforce sponsor responsibilities. Responsible Individuals: Jeff Reynolds and Rachel Dumas Completion Date: Plan has been implemented as of the date of audit submission.
Gateway Domestic Violence Services, in 2024, was utilizing paper timesheets that included the funder allocation for each staff person. The funder allocations were then entered into QuickBooks spreadsheets. In February of 2025, we engaged with Paychex Payroll Services which utilizes simple online so...
Gateway Domestic Violence Services, in 2024, was utilizing paper timesheets that included the funder allocation for each staff person. The funder allocations were then entered into QuickBooks spreadsheets. In February of 2025, we engaged with Paychex Payroll Services which utilizes simple online software built to streamline payroll and automate taxes. It does include a job costing process that allows for identifying payroll costs to be distributed appropriately to funders. This electronic payroll system decreases the chances of human error. Also in August of 2025, there is a change in personnel to Finance & Operations Director rather than Finance and Operations Manager. The new position comes with increased responsibilities and increased skills. This position will be responsible for reconciling payroll allocations from Paychex to Payroll allocations in QuickBooks to government funding reports to ensure accuracy. These changes along with the systems that we have had in place should help prevent this issue from being repeated.
Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025
Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025
2024-001. Allowable Costs/Cost Principles United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Passed Through Vibrant Emotional Health: Substance Abuse and Mental Health Services Administration - 988 National Suicide Prevention Lifeline ALN...
2024-001. Allowable Costs/Cost Principles United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Passed Through Vibrant Emotional Health: Substance Abuse and Mental Health Services Administration - 988 National Suicide Prevention Lifeline ALN: 93.243 Substance Abuse and Mental Health Services Administration - Disaster Distress Helpline ALN: 93.243 Passed Through New York State Office of Mental Health: Substance Abuse and Mental Health Services Administration - 988 S11MY1 ALN: 93.243 Condition: Time records prepared by employees reflect the total hours worked for the day, but do not reflect the actual time spent on programs funded by each federal award, rather they are based on budgeted hours. Recommendation: The Organization’s use of Personnel Activity Report (PAR) equivalent documentation should allow each employee to accurately reflect the time work is performed for each federal award. Corrective Action: The Organization will complete the implementation of procedures for its time keeping records, which will provide information for PAR equivalent documentation. Actual time worked performing duties funded by each federal award will be reflected. Responsible Contact Person(s): Meryl Cassidy, Executive Director Response of Suffolk County, Inc., - P.O. Box 300 - Stony Brook, New York 11790 Anticipated Completion Date: December 31, 2025.
The Town of Ramah is in the process of creating a Procurement Policy.
The Town of Ramah is in the process of creating a Procurement Policy.
Finding Number: 2024-001 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal & Support Services Supervisor Corrective Action Planned: Due to ...
Finding Number: 2024-001 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal & Support Services Supervisor Corrective Action Planned: Due to overlap of when we found the errors from 2023 and the corrections of those in 2024, this triggered other areas we knew would have to change in 2024. This included more movement in personnel expenses for programs not considered under federal financial participation. These programs were all removed from the Family Services budget by January 1, 2025. The corrections to our internal systems were corrected in 2025. Chippewa County staff will connect with DHS to review the corrections made in our system as it pertains to the quarterly reports and will adjust as they instruct. For the Administrative split being used each year, we will use the A87 Report to determine the rate. It will be shared with the Payroll department, the County Auditor/Treasurer’s department and Family Services accounting staff prior to the start of the year or prior to any mid-year change. More oversight will be given to placement of “Other” charges that are paid in County systems and to make sure placement of those are correct in the quarterly reports. Anticipated Completion Date: December 2025
• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review firs...
• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review first three months of FY26 by 12/31/25
Finding 574051 (2024-001)
Significant Deficiency 2024
The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Direct...
The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Director and approved by the Finance Director prior to submission to the auditing firm. In addition to federal grants adopted as part of the City's annual operating budget, after adoption of the annual operating budget any federal grant approved by City Council for acceptance and expenditure will be maintained in the City's electronic archival system. The SEFA will be compard to the list of budgeted grants and the grants accepted after adoption of the annual operating budget to ensure grants are appropriately reported on SEFA.
Finding 574028 (2024-003)
Significant Deficiency 2024
During our testing, we noted there was no documentation of review or approval on the calculation for the draw of funding for the program. In addition, draws are not performed in a timely manner after the expenditures are incurred. Recommendation: We recommend The Food Trust implement a clear approv...
During our testing, we noted there was no documentation of review or approval on the calculation for the draw of funding for the program. In addition, draws are not performed in a timely manner after the expenditures are incurred. Recommendation: We recommend The Food Trust implement a clear approval process for the drawing of federal funding. In addition, it is important to establish a clear process and timeline for performing draws. This may involve regular monitoring of expenditures, timely submission of draw requests, and efficient processing of those requests. By implementing an approval and a timely draw process, the organization can enhance internal controls, reduce the risk of fraud, and ensure the accuracy and integrity of the fund draw process, and can better manage its cash flow, meet its financial obligations, and maintain the smooth operation of the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement an electronic approval system, and draws will be completed within 30 days of month end. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: the planned corrective action will be completed by August 2025.
Finding 574021 (2024-002)
Significant Deficiency 2024
During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort ...
During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement processes and tools to ensure that all employee time and effort charged to federal grants is appropriately documented. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by October 2025.
The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.
The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.
Finding 573909 (2024-003)
Significant Deficiency 2024
Management Response: We have had significant turnover in HR and Payroll and documentation was not maintained properly. We have a new HR Director and new Payroll Manager who will work closely together and are aware of record keeping and maintaining files for compliance. A checklist has been created t...
Management Response: We have had significant turnover in HR and Payroll and documentation was not maintained properly. We have a new HR Director and new Payroll Manager who will work closely together and are aware of record keeping and maintaining files for compliance. A checklist has been created to ensure all required documents are on file. Anticipated Completion Date: We are conducting a file review and will ensure all documents are in order by September 30, 2025. Responsible Party: HR Director, Payroll Manager, Benefits Coordinator and Business Manager will have oversight.
Starting in May 2024, the Alliance adapted its monthly Time and Effort Report that is reviewed by Kim Atkins, Executive Director, to be used for allocation of expenses other than payroll. This ensures a consistent, reviewed and authorized report is being used for expense allocation. This report is s...
Starting in May 2024, the Alliance adapted its monthly Time and Effort Report that is reviewed by Kim Atkins, Executive Director, to be used for allocation of expenses other than payroll. This ensures a consistent, reviewed and authorized report is being used for expense allocation. This report is shared monthly with the Alliance’s funding agencies along with the submission of monthly vouchers for processing. During the year ended June 30, 2025, the Alliance has ensured that allocations were signed off on by Kim and has significantly reduced the amount of finance staff time required to process the allocation of administrative costs. As of July 1, 2025, the approved staff allocations are being uploaded into ADP in the anticipation of a direct link between ADP and the NetSuite general ledger so that personnel costs will be allocated automatically going forward. As of July 1, 2025 the Alliance is modifying all of its grants to adopt the 15% de minimis cost rate for all expenses other than personnel, direct program, and space costs.
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