Corrective Action Plans

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Public and Indian Housing AL #14.850 Material Weakness Internal Control Over Compliance Eligibility Checklists 2023-003 Condition: The Commission uses internal control checklists to demonstrate compliance with the various eligibility requirements. During audit fieldwork, we identified two instances...
Public and Indian Housing AL #14.850 Material Weakness Internal Control Over Compliance Eligibility Checklists 2023-003 Condition: The Commission uses internal control checklists to demonstrate compliance with the various eligibility requirements. During audit fieldwork, we identified two instances in which the checklists were used, but steps related to background checks were not complete. In addition, there was no documentation maintained to prove these checks were performed. Criteria: All eligibility requirements must be verified prior to determining tenant eligibility. Repeat of Prior Year Finding: No Auditor’s Recommendation: We recommend the Commission provide further training for program staff and implement periodic reviews of tenant files to ensure internal control processes are followed and eligibility documentation is maintained. Management’s Response: The Commission has provided training for program staff and performs periodic reviews of tenant files to ensure internal control processes are followed and eligibility documentation is maintained. Anticipated Completion Date: Periodic reviews began January 2023. Staff training and periodic reviews are ongoing.
In Finding 2023-001, it was noted that the Organization had found 1 of the 15 patients tested were not in the proper slide category based on the income backup received for the patient. We also found 1 of the 15 patients tested did not have backup for income on file for the sliding fee scale but was ...
In Finding 2023-001, it was noted that the Organization had found 1 of the 15 patients tested were not in the proper slide category based on the income backup received for the patient. We also found 1 of the 15 patients tested did not have backup for income on file for the sliding fee scale but was on the scale and had visits that were applied to the scale. Management recognizes the importance of complying with grant guidelines. In response to Finding 2023-001, Management has taken the necessary steps to ensure full compliance with the provisions of the program, identified specifically as Sliding Fee Discount Program (SFDP) within our organization. These steps include: a.       Implementing a new process for adding the sliding fee discount to patient accounts. Each patient that applies for the slide will be scheduled under “eligibility” with an appointment. After the patient has completed the application, the information will be entered into Athena, and then the plan will be calculated. The paperwork will then be uploaded as an attachment to the Sliding Fee Discount Policy. Each week, a report will be generated in Athena and sent to the Clinical Services Manager. This report will list all patients that had an appointment with eligibility for the prior week. The Clinical Services Manager will then use that report and verify that all information is uploaded and entered correctly. b.       Training on the new process will occur. All support staff responsible for entering and uploading the Sliding Fee Discount will go through thorough training of the new process. Additionally, the Clinical Services Manager will complete peer-to-peer training on the verification process.
Action Plan for Enrollment Reporting Audit Finding 2023-001 Issue - It was discovered that there was a Colleague system update that occurred that caused the Standard Reporting Flag to change from Yes to No, which resulted in inaccurate reporting to NSC. For all terms that a student can attend, the...
Action Plan for Enrollment Reporting Audit Finding 2023-001 Issue - It was discovered that there was a Colleague system update that occurred that caused the Standard Reporting Flag to change from Yes to No, which resulted in inaccurate reporting to NSC. For all terms that a student can attend, the flag must be set to Yes for the reporting to be accurate. The following action plans will be put into place, to ensure that reporting is accurate: Action Plan 1 - A self-audit will be completed monthly when National Student Clearinghouse enrollment reporting is completed. This self-audit is to verify the students' enrollment status is accurate. To verify the accuracy, a sample of students will be pulled from the self-audit who have withdrawn, graduated, or had enrollment changes. Action Plan 2 - Admissions and Records and Financial Aid will work closely with the IT department any time there is a Colleague system update to fully comprehend the implications of the system update and how that could impact reporting and documented procedures.
Identifying Number: 2023-005 Finding: The College did not apply the appropriate clock to credit hour conversion formula for certain applicable financial aid eligible programs. The College also did not have sufficient evidence of controls being in place to ensure compliance with this requirement. ...
Identifying Number: 2023-005 Finding: The College did not apply the appropriate clock to credit hour conversion formula for certain applicable financial aid eligible programs. The College also did not have sufficient evidence of controls being in place to ensure compliance with this requirement. Corrective Action Planned: Moraine Valley Community College will evaluate all certificates that are standalone programs. Financial Aid will receive a list of these programs and work with IT to identify students enrolled in those programs. Financial Aid will also update our policies and procedures to ensure that all clock to credit hour conversion formulas are being applied and documented per Uniform Grant Guidance (34 CFR 688.8). Anticipated Completion Date: June 30, 2024 Responsible Person: Tasha Campbell, Director of Financial Aid campbellt68@morainevalley.edu
The accounting department, under direction of the CFO, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionist to minimize errors. Receptionists have been mandated, along with assistance from internal billing s...
The accounting department, under direction of the CFO, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionist to minimize errors. Receptionists have been mandated, along with assistance from internal billing staff, to review all patients' accounts (including income verification) at least annually.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for July 31, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for July 31, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Finding 2023-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies a...
Finding 2023-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.
Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A review is being completed by the Registrar’s Office to determine if something is in the student record that may prevent a student from being reported correctly. If a common factor can be determined, then ...
Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A review is being completed by the Registrar’s Office to determine if something is in the student record that may prevent a student from being reported correctly. If a common factor can be determined, then it will be corrected. Until then, Enrollment reporting to NSC will be reviewed twice. Follow up will be done regarding last date of attendance reporting for those students who do fail to complete the semester. Person Responsible for Corrective Action Plan: Karen LaQuey, Director, Student Financial Aid Director; Wendy McNeeley, previous Registrar; Kristina Penland, Registrar Anticipated Date of Completion: 12/12/2023
Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi...
Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi, Vice President and CFO Completion Date: March 31, 2022
The Director has added to her monthly checklist to review quality control logs and follow up on any QC reviews that are not being conducted in a timely fashion.
The Director has added to her monthly checklist to review quality control logs and follow up on any QC reviews that are not being conducted in a timely fashion.
Finding 361 (2023-003)
Significant Deficiency 2023
Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed
Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed
Condition - The institution had the following changes that were required to be updated on their ECAR: • The V.P. of Finance (equivalent to a chief financial officer) was no longer active at the institution as of April 2022. • A Board Member was no longer serving the institution as of May 2021. •...
Condition - The institution had the following changes that were required to be updated on their ECAR: • The V.P. of Finance (equivalent to a chief financial officer) was no longer active at the institution as of April 2022. • A Board Member was no longer serving the institution as of May 2021. • A Board Member was added to the Board in October 2021. These changes to the institution’s ECAR information were not submitted until June 2023, subsequent to inquiry by auditors. Corrective Action Plan - The College will review current procedures and adjust accordingly to ensure timely ECAR updates. Contact Person, Title and Phone Number - Chris Scott, President, (815)-772-7218, Ext. 212 Anticipated Completion Date - August 1, 2023
Management agrees with the finding and will begin an independent review of each tenant file to include examination of proof of disability paperwork to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the in...
Management agrees with the finding and will begin an independent review of each tenant file to include examination of proof of disability paperwork to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including eligibility requirements and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases. Management has requested proof of disability from the tenant that satisfies HUD guidelines and will not renew lease if it is not received. The training and file review will be completed by November 30, 2023. If the tenant does not produce proof of disability their lease will not be renewed on May 11, 2024.
View Audit 460 Questioned Costs: $1
Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight boar...
Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board has reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.
Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financia...
Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financial aid grant to the student's oustanding account balance as a condition of receipt of or eligibility for an emergency financial aid grant funding. The recipient also acknowledges that adding preconditions to receiving a financial aid grant that thwart this requirement may be subjected to oversight and corrective action. In consideration for this award, Recipients agree that they hold these grant funds in trust for students and act in the nature of a fiduciary for students. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. Now that the FY23 audit is finalized, any such compliance issues with students will be taken care of during actual registration process. In the future, any such forms that will need student authorization will be handled during the registration process. Responsbile Person(s): Robin Jefferson, Director of Student Accounts rljefferson@vuu.edu 804 342-3976. Robert Merino, Executive Director of Financial Aid jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.
Finding 119 (2023-002)
Significant Deficiency 2023
The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining ...
The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.
Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, se...
Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, services or “assistance”. The child must be less than 18 years old, or, if a full-time student in a secondary school (or the equivalent level of vocational or technical training), less than 19 years old. Freestore Foodbank Inc. and Affiliates require all individuals receiving food to complete an eligibility form prior to receiving food. Condition: We noted one instance (in a sample of 40 clients) in which an eligibility form was not obtained prior to client receiving food. Planned Corrective Action: Management will perform periodic audits of eligibility forms starting 10/15/2023 to ensure compliance. Management will retrain staff to ensure completeness of the intake process. Furthermore, by 9/30/2023, management will work with the developers of the database to see if controls can be implemented in the software, so food cannot be distributed before the signing of the required form.
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.
Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9...
Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9 forms will be remediated where permissible. Management will retain evidence of completion and conduct periodic compliance reviews to ensure ongoing adherence. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by January 31, 2023.
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the executive Director left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director, onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the Executive Director, left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
Finding: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients i...
Finding: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients included under this program are eligible. During the compliance testing of 44 sample items, there was two instances where the Organization applied a sliding fee discount to a patient who had not submitted any documents regarding their income level or family size and we could not determine whether the patient should have been included as a sliding fee patient, and one instance where the patient had properly submitted their forms, but the Organization applied the incorrect sliding fee rate. Currently, there is no known monetary impact, improper expenditure of funds or questioned costs identified. However, if the Organization does not strengthen the internal controls in regard to the eligibility determination process, there is a possible effect on the ability of the Organization to obtain additional funding under this program if ineligible patients are being treated with grant funding. Views of responsible officials and planned corrective actions: Management agrees with the recommendation to review policies, procedures and practices in place over the controls related to obtaining, retaining and reviewing proof of income support for patients. • Train relevant staff on the Sliding Fee eligibility process and supporting documentation requirements. Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO
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