Corrective Action Plans

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Recommendation: We recommend that the School implement procedures and controls to ensure the required reports are accurate and completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Explanation of disagreement with audit finding: There is n...
Recommendation: We recommend that the School implement procedures and controls to ensure the required reports are accurate and completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has contracted with an outside firm to assist with developing the required Internal Controls and Processes with an estimated completion date of December 31, 2026. Name(s) of the contact person(s) responsible for corrective action: Mary Hunt, CFO. Planned completion date for corrective action plan: December of 2026.
Recommendation: The school should strengthen its documentation retention and record management procedures to ensure that all transactions included in audit populations—regardless of fiscal year—are readily available and adequately supported. Management should also implement controls to verify that s...
Recommendation: The school should strengthen its documentation retention and record management procedures to ensure that all transactions included in audit populations—regardless of fiscal year—are readily available and adequately supported. Management should also implement controls to verify that supporting documentation is complete and accessible prior to submission for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has contracted with an outside firm to assist with developing the required Internal Controls and Processes with an estimated completion date of December 31, 2026. Name(s) of the contact person(s) responsible for corrective action: Mary Hunt, CFO. Planned completion date for corrective action plan: December of 2026.
Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that financial statement line items are properly stated and clas...
Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that financial statement line items are properly stated and classified. Internally prepared financial statements should also be thoroughly reviewed by members of the board and management outside the finance department on a periodic (monthly or quarterly). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has contracted with an outside firm to assist with developing the required Internal Controls and Processes with an estimated completion date of December 31, 2026. Name(s) of the contact person(s) responsible for corrective action: Mary Hunt, CFO. Planned completion date for corrective action plan: December of 2026.
Management concurs with Finding 2025 - 4 and acknowledges that controls over the review and approval of timecards for federally funded staff were not consistently applied. In response, we will reinforce timekeeping expectations, clarify roles, and ensure that policies and procedures are aligned with...
Management concurs with Finding 2025 - 4 and acknowledges that controls over the review and approval of timecards for federally funded staff were not consistently applied. In response, we will reinforce timekeeping expectations, clarify roles, and ensure that policies and procedures are aligned with 2 CFR § 200.430. We will conduct targeted training for supervisors to reinforce expectations. Central office monitoring will now include quarterly internal audit reviews and follow-up, creating a continuous feedback loop that supports compliance. These enhancements reflect management’s commitment to ensuring that payroll charges to federal programs are accurate, well supported, and reliably documented going forward.
US Department of Health and Human Services
US Department of Health and Human Services
Passed-through State of Hawaii Department of Health
Passed-through State of Hawaii Department of Health
Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2025 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745...
Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2025 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745 Fort Street, Suite 2100, Honolulu HI 96813
FEDERAL AWARD FINDINGS AND QUESTIONED COSTS
FEDERAL AWARD FINDINGS AND QUESTIONED COSTS
Activities Allowed or Unallowed / Allowable Costs / Cost Principles
Activities Allowed or Unallowed / Allowable Costs / Cost Principles
U.S. Department of Health and Human Services
U.S. Department of Health and Human Services
Federal Assistance Listing Number 93.917
Federal Assistance Listing Number 93.917
During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted one instance where HHHRC ...
During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted one instance where HHHRC determined that the client met the eligibility requirements and incurred certain costs which were charged to the RWB program. However, we found that the client exceeded the income threshold to be considered low-income, as defined by the state. Accordingly, this client was not eligible to participate in the RWB program and any costs charged to the RWB program were unallowable.
Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification ...
Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements. To be eligible, clients must have a medical diagnosis of HIV/AIDS and be (a) a low-income individual, (b) a resident of the state, and (c) uninsured or underinsured, as defined by the state. Eligibility determination is required before participation in the RWB program during the in-take process. Re-assessments are performed at least once every 12 months thereafter.
Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client...
Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client attesting to no income or very low income.
Additionally, costs associated with clients determined to be ineligible to receive assistance under the RWB program are unallowable.
Additionally, costs associated with clients determined to be ineligible to receive assistance under the RWB program are unallowable.
HHHRC did not adhere to established policies and procedures requiring that the client meet all eligibility requirements during the in-take and re-assessment process before costs are charged to the RWB program.
HHHRC did not adhere to established policies and procedures requiring that the client meet all eligibility requirements during the in-take and re-assessment process before costs are charged to the RWB program.
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