Corrective Action Plans

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Corrective Action: NTU will enforce policies and procedures for cash drawdowns to ensure all drawdowns are properly supported. Additionally, an electronic filing system will be developed to maintain all drawdowns and the related backup documentation, enhancing the processing and record-keeping of dr...
Corrective Action: NTU will enforce policies and procedures for cash drawdowns to ensure all drawdowns are properly supported. Additionally, an electronic filing system will be developed to maintain all drawdowns and the related backup documentation, enhancing the processing and record-keeping of drawdown documents. Person Responsible: Beverly Miller, Accounting Manager and Harshwal & Company, LLC Estimated Completion Date: July 31, 2024
Corrective Action: NTU has established a monthly cash management schedule to track and identify all grant funds, detailing the total cash received in advance from grantors and amounts due to NTU. To increase cash balances, NTU will focus on the timely collection of outstanding grants receivable. Add...
Corrective Action: NTU has established a monthly cash management schedule to track and identify all grant funds, detailing the total cash received in advance from grantors and amounts due to NTU. To increase cash balances, NTU will focus on the timely collection of outstanding grants receivable. Additionally, NTU will analyze cash requirements and may liquidate investments held in the Capital Reserve fund to ensure adequate cash is available for grants received in advance. Person Responsible: Beverly Miller, Accounting Manager Estimated Completion Date: July 31, 2024
Finding 406008 (2023-004)
Significant Deficiency 2023
Finding 2023– 004 CONDITION During the current audit period, the Cook County Department of Public Health (DPH) did not adequately comply with its cash management requirements in accordance with federal regulations. CORRECTIVE ACTION: The CCDPH will work with program staff to develop and implement a ...
Finding 2023– 004 CONDITION During the current audit period, the Cook County Department of Public Health (DPH) did not adequately comply with its cash management requirements in accordance with federal regulations. CORRECTIVE ACTION: The CCDPH will work with program staff to develop and implement a vendor receipt tracker, contingency plan to continue the workflow in the event a vacancy occurs; monitor to ensure the Grant AP and Procurement process follow established process for timely award ofsubrecipient contracts; provide subrecipients with documented processes for submitting invoices for reimbursement; create an internal AP document to track lead time in processing invoices. Anticipated completion of the corrective action is estimated to be December 31, 2024. The corrective action will be coordinated by the Director of Grants Accounting.
2023-03: Approval for expenditures Name of contact person: Stephen Bontekoe, Program Coordinator Corrective Action: A member of management of the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed...
2023-03: Approval for expenditures Name of contact person: Stephen Bontekoe, Program Coordinator Corrective Action: A member of management of the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Proposed completion date: The Board will implement the above procedure immediately.
2023-01: Segregation of Duties Name of contact person: Stephen Bontekoe, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to ...
2023-01: Segregation of Duties Name of contact person: Stephen Bontekoe, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregated certain duties are not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.
Healthy Start has implemented a double check by the Director and the Administrator to verify that all monitor visits are done in a timely manner. An audit is done each quarter to ensure that all monitor visits are completed within the six month time frame. In fiscal year 2024 as of December 31, 2023...
Healthy Start has implemented a double check by the Director and the Administrator to verify that all monitor visits are done in a timely manner. An audit is done each quarter to ensure that all monitor visits are completed within the six month time frame. In fiscal year 2024 as of December 31, 2023 all monitor visits have been performed within the six month time frame.
Additional preventive internal control procedures will be implemented, including an additional level of review of the reimbursement requests prior to submission. These procedures and internal controls have been implemented as of the date of this report.
Additional preventive internal control procedures will be implemented, including an additional level of review of the reimbursement requests prior to submission. These procedures and internal controls have been implemented as of the date of this report.
View Audit 311441 Questioned Costs: $1
Finding 2023-003 – Cash Collateralization Criteria: Uniform Guidance 2 CFR, Part §200.305(b)(7) requires advance payments of Federal funds to be deposited and maintained in insured accounts whenever possible. Condition: During our review of the Coalition’s cash, it was noted that as of September 30,...
Finding 2023-003 – Cash Collateralization Criteria: Uniform Guidance 2 CFR, Part §200.305(b)(7) requires advance payments of Federal funds to be deposited and maintained in insured accounts whenever possible. Condition: During our review of the Coalition’s cash, it was noted that as of September 30, 2023, they have. not collateralized cash balances in excess of the amounts insured by the Federal Despot Insurance Corporation. Cash balances of $10,608,222 were uninsured at September 30, 2023. Unearned revenue was reported at approximately $5,389,532 which includes advance payments of Federal funds. Questioned Costs: None Cause: The Coalition has not entered into a cash collateralization agreement with their financial institution. Effect: The Coalition is not in compliance with Uniform Guidance 2 CFR, Part §200.305(b)(7) as not all cash balances received in advance from the funding agency were adequately insured or collateralized and were exposed to custodial credit risk in the event of a bank failure. Recommendation: We recommend the Coalition enter into a cash collateralization agreement with their financial institution to ensure that all amounts related to grant agreements and awards received in advance are not exposed to custodial credit risk in the event of a bank failure. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs. Responsible Officials; Dr. Donna L. Polk CEO, Carlett Gregory CFO, Anne Steinhoff Board Treasurer. Corrective Action: In response to the finding regarding the lack of collateralization for cash balances in excess of the amounts insured by the Federal Deposit Insurance Corporation (FDIC). NUIHC will get clarification from I.H.S. and our financial institution to address the best way to resolve this issue. Possible options are using the CDARS program or finding a local DIF member institution. The Coalition will take the following corrective actions: 1. Establish Cash Collateralization Agreement: o The Coalition will promptly enter into a cash collateralization agreement with our financial institution. This agreement will ensure that all cash balances, including those received in advance from federal funding agencies, are adequately insured or collateralized. 2. Review of Cash Management Policies: o We will review and update our cash management policies to ensure compliance with Uniform Guidance 2 CFR, Part §200.305(b)(7). This review will include assessing our current banking arrangements and making necessary adjustments to mitigate custodial credit risk. 3. Monitoring and Compliance: o The Coalition will implement a monitoring system to regularly review cash balances and ensure that they do not exceed insured limits without proper collateralization. This system will involve periodic checks and coordination with our financial institution to maintain compliance. 4. Training and Education: o We will provide training to our financial and accounting staff on the importance of cash collateralization and the requirements of Uniform Guidance 2 CFR, Part §200.305(b)(7). This training will ensure that all relevant personnel are aware of the new procedures and the need to maintain insured or collateralized cash balances. Timeline for Implementation: The corrective actions outlined above will be implemented within the next 30 days. The cash collateralization agreement will be established immediately, and updates to cash management policies will be completed within this period. Training sessions for relevant staff will be conducted promptly following the implementation of these changes.
Finding 405786 (2023-001)
Significant Deficiency 2023
The Area Coordinators will be retrained to double check their meal counting on their menus at least once before they submit their meal counts and one time after they submit their meal counts.
The Area Coordinators will be retrained to double check their meal counting on their menus at least once before they submit their meal counts and one time after they submit their meal counts.
Finding: 2023-003 - Oversight over cash management compliance requirement. Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action pla...
Finding: 2023-003 - Oversight over cash management compliance requirement. Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned: In September 2023, CLR has addressed the finding that its policies and procedures over reimbursement requests for federal funds lacked proper documentation of approvals according to the Uniform Guidance for federal grants. We have added a step in the online submission process with the Substance Abuse and Mental Health Services Agency (SAMHSA) to capture a screenshot of the reimbursement form to be approved before submission. Due to the timing of the FY 2022 Single Audit completion and the ending of the CCBHC contract, we were limited in the execution of this new procedure, however it is now part of our Single Audit accounting Policies and Procedures Manual. Anticipated completion date: Completed September 2023.
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-004 Reporting Material Weakness in Internal Control Over Compliance an...
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-004 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The Department of Housing and Urban Development (HUD) requires a quarterly reporting of financial and statistical data. Amounts reported under “All Non‐Operating Revenue” and “Other Changes in Fund Balance” in the Organization’s third quarter report submitted to HUD were not reconciled to and did not agree with the underlying financial data. The internal financial statements do not present all of the information that is required in the HUD quarterly reports and the differing information was all put to one line on the HUD quarterly report when the differences should have been evaluated and documented. Responsible Individuals: Charles Roeder, Vice President Finance/CFO Corrective Action Plan: To ensure the accuracy of the report, the Organization approved the policy Review of Reports Filed with Federal Agencies which details that the preparer of the report will submit it to the CFO or delegated staff member different from the preparer to review and formally approve before the report is filed with the federal agency. A different staff member will document and date the review and when formal approval was received and maintain a file on the process. Anticipated Completion Date: September 30, 2024
Association will develop more detailed policies for subrecipient monitoring, including responses to and consequences for subrecipient noncompliance, as well as procedures for reconciling monthly expenditure reports and drawdown requests to supporting documentation. Policies will be reviewed and appr...
Association will develop more detailed policies for subrecipient monitoring, including responses to and consequences for subrecipient noncompliance, as well as procedures for reconciling monthly expenditure reports and drawdown requests to supporting documentation. Policies will be reviewed and approved by the finance committee.
Finding 404842 (2023-003)
Significant Deficiency 2023
Guild
MN
Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifyin...
Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifying their payment support to show any payer-initiated adjustments. Responsible Individuals: Keith Rachey, Chief Financial Officer Anticipated Completion Date: Completed and staff trained by September 2024
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under ...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (the program) was not reviewed and approved by a separate individual outside of the preparer. Additionally, the Hospital claimed mortgage reimbursements as expenditures under the program. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. Anticipated Completion Date: June 30, 2024
View Audit 311195 Questioned Costs: $1
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a sep...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a separate individual. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Hospital personnel will compile the initial requests for reimbursement with the help of Management to provide proof of invoices and payments. The final request for reimbursement will then be verified by Management prior to requesting reimbursement to the Communities Facilities Grant Coordinator. Anticipated Completion Date: June 30, 2024
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a separate bookkeep...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a separate bookkeeping account or as a separate bank account. The Hospital had excess cash available to cover the required reserve amount. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Management will establish a separate bookkeeping account in the general ledger to establish the correct reserve amount of cash within its general operating bank account. The reserve account will be part of total cash in the bank to maximize interest earned on the reserve balance. Anticipated Completion Date: June 30, 2024
2023-001 GRANT REPORTING Recommendation: The City should review and revise, as needed, its current control structure over grant reporting to ensure that all required reports are independently reviewed prior to being submitted to the grantor. This should include review of reports prepared by any th...
2023-001 GRANT REPORTING Recommendation: The City should review and revise, as needed, its current control structure over grant reporting to ensure that all required reports are independently reviewed prior to being submitted to the grantor. This should include review of reports prepared by any third party consultants. Management’s Response: The City will update its control process to incorporate procedures to ensure that reviews of reports prepared by third party consultants are subject to independent review by City personnel prior to the reports being remitted to the grantor and that such reviews will be documented. Responsible Parties: Natalia Eckroth, CFO and Christine Aiken, Assistance Finance Director Anticipated Completion Date: December 31, 2024
Valle del Sol, Inc. is in the process of ensuring the proper reimbursement rates for the Mercy Care program will be utilized to invoice accurately. Val del Sol, Inc. will discuss with Mercy Care obtaining the most current formal fee schedule instead of a listing of allowable CPT codes. We will als...
Valle del Sol, Inc. is in the process of ensuring the proper reimbursement rates for the Mercy Care program will be utilized to invoice accurately. Val del Sol, Inc. will discuss with Mercy Care obtaining the most current formal fee schedule instead of a listing of allowable CPT codes. We will also implement a training for all front and back office staff to include a better understanding of the Mercy Care City program. Scripts for frequently asked questions from patients, and worksheets for staff to complete to ensure all required documents are received, will be available to staff to ensure proper application of eligibility of the Mercy Care program.
Upon discovering issues related to eligibility requirements, Valle del Sol, Inc. addressed and fixed the issues to ensure all patients who are eligible to be covered under the Mercy Care City of Phoenix ARPA award are appropriately charged for services. We implemented a training for all front offic...
Upon discovering issues related to eligibility requirements, Valle del Sol, Inc. addressed and fixed the issues to ensure all patients who are eligible to be covered under the Mercy Care City of Phoenix ARPA award are appropriately charged for services. We implemented a training for all front office staff to include a better understanding of the Mercy Care City of Phoenix ARPA program, scripts for frequently asked questions from patients, and worksheets for staff to complete to ensure all required documents are received, to ensure proper application of eligibility of the Mercy Care City of Phoenix ARPA program. Our staff were fully retrained on the Mercy Care City of Phoenix ARPA program. We feel confident that the re-training to the front office staff and managers will ensure the the accurate application of the policy and accurate discounts are given to our patients. Valle del Sol, Inc. will track and monitor compliance through our QA/QI Committee on a regular basis.
Finding 404724 (2023-005)
Significant Deficiency 2023
Finding number: 2023-005 Federal agency: U.S. Department of Education Programs: Federal Pell Grants Assistance listing #: 84.063 Award year: 2023 Corrective Action Plan: As found, the College has policies and procedures in place to report the disbursement records to the Department of Educat...
Finding number: 2023-005 Federal agency: U.S. Department of Education Programs: Federal Pell Grants Assistance listing #: 84.063 Award year: 2023 Corrective Action Plan: As found, the College has policies and procedures in place to report the disbursement records to the Department of Education through the COD system within the required fifteen calendar days. This singular Pell update was caught by the College while performing the year end Pell closeout. The record was corrected prior to the audit, but past the required timeframe. The College's corrective plan for this is to perform monthly Pell reconciliation at the same time as the required monthly Direct Loan reconciliation. By doing monthly reconciliation, we will catch potential corrections within the required timeframe. We enacted this practice in advance of the FY24 year. Timeline for Implementation of Corrective Action Plan: This was corrected in advance of the start of FY24. We will continue to review as noted. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO
Finding number: 2023-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2023 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2...
Finding number: 2023-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2023 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the role was previously filled by a single temporary employee). Part of the Bursar’s scope of work is to work with Financial Aid to ensure that ledgers are correct. Reconciliation reports are also reviewed monthly to ensure accuracy and resolve discrepancies timely. Timeline for Implementation of Corrective Action Plan: Ongoing. Fully implemented by the end of FY24. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO
The Housing Authority understands that our prior procedure was incorrect and inadequate for capital fund drawdowns. The Finance Director has been instructed on the proper procedure of capital fund drawdowns to first reconcile LOCCS requests to vendor billing to properly request and expend funds with...
The Housing Authority understands that our prior procedure was incorrect and inadequate for capital fund drawdowns. The Finance Director has been instructed on the proper procedure of capital fund drawdowns to first reconcile LOCCS requests to vendor billing to properly request and expend funds with the three-day period
Management has established and implemented written procedures to ensure future compliance. Management will increase the detail of the review process over the tracking of meals, including both the financial function and those with direct knowledge and supervision of the services being performed. Mana...
Management has established and implemented written procedures to ensure future compliance. Management will increase the detail of the review process over the tracking of meals, including both the financial function and those with direct knowledge and supervision of the services being performed. Management will also offer additional training for program staff.
Response and Corrective Action Plan: The District (Kevin Baccam) will implement a process to review and retain meal claim reporting documentation as outlined by the Iowa Department of Education and Office of Management and Budget.
Response and Corrective Action Plan: The District (Kevin Baccam) will implement a process to review and retain meal claim reporting documentation as outlined by the Iowa Department of Education and Office of Management and Budget.
Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completene...
Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completeness of transactions. Proposed Completion Date: Management will complete the corrective action plan by October 2024.
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