Corrective Action Plans

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Return of Title IV Funds Corrective Action Plan: The College Financial Aid Office and Business Office will implement new internal controls and procedures to ensure all student Title IV calculations are calculated correctly, reviewed in a timely manner, and ensure funds are returned promptly. Dea...
Return of Title IV Funds Corrective Action Plan: The College Financial Aid Office and Business Office will implement new internal controls and procedures to ensure all student Title IV calculations are calculated correctly, reviewed in a timely manner, and ensure funds are returned promptly. Deadlines have been created to submit student withdrawals timely to the Financial Aid Department. A monthly reconciliation between the Registrar and Financial Aid Office will ensure withdrawals and correct withdrawal dates are reported to the Financial Aid Office in a timely manner. The Business Office will review the Financial Aid Office's calculation of funds for accuracy to ensure the correct amount is returned to the Department of Education. Anticipated Completion Date: Fiscal year 2025. Name of Contact Person Responsible for the Corrective Action Plan: Rashad Rogers
In Finding 2024-004, it was reported that time and activity report are not maintained for salaried employees. The Organization’s operating processes in place do not require salaried employees to certify time and efforts on a monthly basis. Procedures will be established to maintain time and effort ...
In Finding 2024-004, it was reported that time and activity report are not maintained for salaried employees. The Organization’s operating processes in place do not require salaried employees to certify time and efforts on a monthly basis. Procedures will be established to maintain time and effort certifications by all salaried employees. Procedures will be established to ensure that salaried employees certify time and effort that coincide with the Organization’s payroll cycle (at least on a monthly basis).
Finding Number: 2024-001 Condition: We noted no formal evidence that required inspections were performed prior to contract approval in one instance. We also noted no formal evidence that inspections were performed upon project completion to ensure that work was carried out in accordance with contrac...
Finding Number: 2024-001 Condition: We noted no formal evidence that required inspections were performed prior to contract approval in one instance. We also noted no formal evidence that inspections were performed upon project completion to ensure that work was carried out in accordance with contract specifications in one instance. Planned Corrective Action: After the inspector has done the initial walk through to identify required repairs, a full comprehensive write-up and cost is established for all rehabilitation projects that document additional repairs to be completed that are more preventative in nature. Any additional items discovered during the project or requested by the homeowner will be added to the write-up. For any emergency repairs, a memorandum will be added to the file. To ensure that pre_x0002_rehabilitation and post-rehabilitation inspections are taking place, the Assistant Planning Director will review a list of ongoing rehabilitation projects at a minimum on a monthly basis. Contact person responsible for corrective action: Edwin Manninen Anticipated Completion Date: Immediately
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended March 31, 2024. Finding 2024-001 Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements A/B - Activities Allowed or Unallowed and Allowable Costs/Cost Principles, C – Cash Management, E – Eligibility, L – Reporting, and N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management reported that the failure(s) involved records related to the period managed by the predecessor management company. We will request and keep all required documentation from HUD and establish processes and procedures to ensure compliance with the Regulatory Agreement. Anticipated Completion Date September 30, 2024
Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.
Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.
In Finding 2024-002, it was reported that time and activity reports were not maintained for salaried employees. Although the Organization’s policies require that time records be maintained by salaried employees, current operating procedures are not in place to ensure the time records are completed. ...
In Finding 2024-002, it was reported that time and activity reports were not maintained for salaried employees. Although the Organization’s policies require that time records be maintained by salaried employees, current operating procedures are not in place to ensure the time records are completed. Procedures will be established to require all salaried employees to maintain time and effort certifications that coincide with the Organization’s payroll cycle (at least on a monthly basis) in accordance with the Organization’s policies.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village Manager. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation
Finding 2023-002: Written Uniform Guidance Policies Responsible Individuals: Jeannie Walters, Finance Officer Corrective Action Plan: The Association will develop written Uniform Guidance policies. Anticipated Completion Date: December 31, 2025
Finding 2023-002: Written Uniform Guidance Policies Responsible Individuals: Jeannie Walters, Finance Officer Corrective Action Plan: The Association will develop written Uniform Guidance policies. Anticipated Completion Date: December 31, 2025
The City will design and implement controls to ensure that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles.
The City will design and implement controls to ensure that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the...
Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization discontinued its prior payroll system when staff were laid off and shifted remaining personnel to contractor status. During this period, approval and payment of contractor invoices were processed through Ramp, with documentation maintained but not within a formalized payroll approval workflow. As CSforALL prepares for the 2026 rebuilding phase, management has re-established a structured payroll approval and documentation process aligned with audit recommendations. Corrective Action taken in 2025: Beginning in August 2025, the Organization transitioned to ADP, a trusted payroll service integrated with QuickBooks, in anticipation of restoring full payroll operations in 2026. Since implementation, payroll reporting and documentation have been maintained accurately each month by the Operations Manager and the Accountant, with formal approval granted by the Advisory Consultant. All invoices, payments, and payroll records are shared and stored bi-weekly as payroll is executed, establishing a consistent and documented approval trail. Corrective Action Planned for 2026: Beginning in January 2026, CSforALL will apply standardized supervisory approval procedures within ADP for all payroll transactions. Management will implement periodic monitoring of payroll records, ensure consistent use of the approved timekeeping and approval system, and maintain documentation of all supervisory approvals to ensure compliance with established internal controls throughout the 2026 operating year and beyond.
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or d...
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or debarred prior to entering into the contract. Corrective Action: Effective January 1, 2026, every proposal or contract that goes out will require all vendors to be active in SAMS.gov for all federal grants. This will be a requirement during the biddingprocess. Anticipated date of completion: January 30, 2026.
Finding 1167724 (2023-009)
Material Weakness 2023
As noted above, we are working with consultants and our government partners to determine and define the requirements for each relevant program. We understand the recommendations offered and will review, and possibly revise, our policies and procedures, including supervisory review of documentation t...
As noted above, we are working with consultants and our government partners to determine and define the requirements for each relevant program. We understand the recommendations offered and will review, and possibly revise, our policies and procedures, including supervisory review of documentation to support the allowability of costs charged to federal agreements. We will also review existing policies and procedures for preventing or detecting and correcting unallowable costs charged to federal agreements to ensure consistent application of those policies and procedures for all costs charged to federal agreements.
Views of responsible officials: Before the approval of budget and the contract petition, the legal department will very if the vendors are excluded as a authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the ...
Views of responsible officials: Before the approval of budget and the contract petition, the legal department will very if the vendors are excluded as a authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the excluded list at least once a year. This verification process will ensure compliance with federal regulations and avoid engaging with vendors who may be suspended or debarred. Additionally, this procedure will be recommended to be included in the review process for quotes or bidding requirements, further enhancing the company’s ability to comply with federal regulations and maintain responsible vendor relationships. Names of the contact persons responsible for the corrective action plan: Sra. Carmen Fernandez, Legal Advisory Director Completed date: This corrective action was implemented as of December 31, 2024.
Finding 2023-006: This is for Special Education Condition 1: For 4 of the transactions total question costs $512. The supporting documentations were not provided. Conditional 2: No departmental timecards or timesheets were provided to support compensation. Condition 3. Payroll with timecards, there ...
Finding 2023-006: This is for Special Education Condition 1: For 4 of the transactions total question costs $512. The supporting documentations were not provided. Conditional 2: No departmental timecards or timesheets were provided to support compensation. Condition 3. Payroll with timecards, there were no verification performed at the departments to ensure that what is being paid are correct. Root Cause Analysis a. Condition 1: Ineffective documentation retention at treasury, exacerbated by office relocation. b. Condition 2: Ineffective retention at departmental agencies where timesheets are held. c. Conditions 3(a) and 3(c): Weak internal controls over reconciliation between departmental timesheets and treasury uniform timesheets. Treasury does not regularly obtain departmental timesheets. d. Condition 3(b): Manual timecard errors from daily stamp-based systems. Corrective Actions 1. Strengthen documentation retention controls. 2. Enhance monitoring at the departmental level or implement a uniform timekeeping system to reduce reconciliation issues. 3. Require submission of departmental timekeeping reports to treasury for secondary reconciliation. 4. Ensure explanatory documentation is retained when uniform timesheets differ from departmental records. Responsible Parties For CAP 1. Director of DOTA and Payroll division For CAP 2. Special Education Administrator and his timekeepers For CAP 3. Director of DOTA and Payroll division For CAP 4. Both Department of DOTA and Special Ed Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.
Finding 2023-002: This finding is for Education Department Condition 1. Impact: For 3 or (5%) of 60 non-payroll transactions tested, (a) no financial records were available to substantiate allowability; or (b) the available procurement file documentation was insufficient to substantiate allowability...
Finding 2023-002: This finding is for Education Department Condition 1. Impact: For 3 or (5%) of 60 non-payroll transactions tested, (a) no financial records were available to substantiate allowability; or (b) the available procurement file documentation was insufficient to substantiate allowability, as follows: The noncompliance resulted in a total questioned cost of $604. Condition 2. For 13 or (20%) of 65 payroll transactions tested, no departmental timecards or timesheet documentation was provided to support compensation, taxes, and fringe benefits. Condition 3. Of the 49 payroll transactions tested where departmental timecards or timesheet support was provided, we identified the following: 1) For 1 employee, the uniform timesheet reported 16 hours of sick leave, while the departmental timesheet reported 80 hours of regular work. 2) For 1 employee, the uniform timesheet was not signed by all required authorized signatories. 3) For 1 employee, the uniform timesheet reported 56 regular hours, while the departmental timesheet reflected 43 regular hours; however, the employee was paid for 80 regular hours, resulting in an overpayment of approximately $76 (processed on May 2, 2023). Root Cause Analysis • For Condition 1, ineffective documentation filing and retention controls were exacerbated by the relocation of the State Treasury office during the audit period. • For Condition 2, ineffective documentation filing and retention controls existed at the departmental agency level, where timesheets or other timekeeping records were retained. • For Condition 3(a), insufficient internal controls at the departmental level failed to ensure reconciliation of departmental timesheets with uniform timesheets submitted to the State Treasury. The Treasury does not consistently receive departmental support and therefore relies on agency review and certification. • For Condition 3(b), required signatory authorization controls failed at both the departmental and treasury levels. • For Condition 3(c), existing controls failed to detect and prevent the overpayment. Corrective Actions 1) For Condition 1. Strengthen documentation filing and retention controls. 2) For Condition 2 & 3 a) Enhance monitoring controls at the departmental level or implementing a uniform timekeeping system to reduce reconciliation burdens b) Establish policies requiring submission of department timekeeping report to the State treasury to allow for secondary reconciliation c) Reinforcing the requirement that when changes are made affecting uniform timesheets but not departmental records, appropriate explanatory documentation be retained. Responsible Parties For Condition 1. • Director of DOTA/Payable Section - Strengthen documentation filing and retention controls. For Condition 2 & 3 • Director of Education/Timekeepers - Enhance monitoring controls at the departmental level or implementing a uniform timekeeping system to reduce reconciliation burdens • Director of DOTA and Payroll Section - Establish policies requiring submission of departmental timekeeping reports to the State treasury to allow for secondary reconciliation. • Director of DOTA and Payroll Section - Reinforce the requirement that when changes are made affecting uniform timesheets but not departmental records, appropriate explanatory documentation be retained. Timeline Verification of Effectiveness For condition 1, the State Treasury will perform routine inspections of the filing systems to verify compliance and address individuals who resist necessary changes. For Conditions 2 and 3, payroll will not be disbursed to any department that fails to adhere to the new action plan
Views of Responsible Officials: In the first quarter of 2023, management deployed a standardized platform across LCMC Health to enhance automated approval workflows. Automated enhancements included: • Automated approval routing based on predefined authorization hierarchies. • System-enforced approva...
Views of Responsible Officials: In the first quarter of 2023, management deployed a standardized platform across LCMC Health to enhance automated approval workflows. Automated enhancements included: • Automated approval routing based on predefined authorization hierarchies. • System-enforced approval checkpoints prior to payment processing. • Audit trail functionality that logs all approval actions and user activities. In addition, management conducts routine staff training and periodic reviews of authorization hierarchies to ensure on-going effectiveness and compliance with financial controls. These enhancements reflect LCMC Health’s proactive commitment to maintaining strong internal control processes
The Organization will be working with staff on retaining and obtaining all applicable, required forms in each client files for the 2024 calendar year end.
The Organization will be working with staff on retaining and obtaining all applicable, required forms in each client files for the 2024 calendar year end.
Action Item Title 2023-002 – Federal Award Findings Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining whether the activities allowed or unallowed and the allowability of costs as described in subpart E, Cost Principles of 2 CFR Part 200. Ide...
Action Item Title 2023-002 – Federal Award Findings Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining whether the activities allowed or unallowed and the allowability of costs as described in subpart E, Cost Principles of 2 CFR Part 200. Identified root cause In 2022, the Corporation became subject to Single Audit compliance requirements for the first time. However, it underestimated the complexity of navigating the intricate laws, regulations, and financial management requirements associated with federal funds. The lack of prior experience in implementing adequate internal controls, coupled with the absence of established written policies, contributed to challenges in ensuring compliance with federal cost principles and financial reporting obligations. Grantee resolution plan Written Policies The Corporation received federal funds for the first time in 2022. For the purposes of purchases or acquisitions, the Corporation is governed by Law of the General Service Administration for the Centralization of Government Purchases in Puerto Rico, Law No. 73 of 2019, which establishes the uniform purchasing process for acquisitions by the Commonwealth. The Corporation will adopt regulations for the use and disbursement of federal funds and comply with the federal regulations. Completion date By December 31, 2025. Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov
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