Corrective Action Plans

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Finding 2023.002 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken The proficiency of all billing staff respon...
Finding 2023.002 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken The proficiency of all billing staff responsible for applying sliding fee discounts and ensuring proper calculations based on family size and income will be evaluated. The organization implemented an Onboarding and Enrollment department in June 2023 to review clinic schedules prior to the patient’s appointment. The onboarding and enrollment staff meet with each new patient to review and verify insurance information, check Medicaid eligibility, ensure fully completed registrations and complete application for any slide fee discounts applicable based on income and family size. Billing staff reviews this information and applies the appropriate discount to the patient charges. This crosschecking process will improve internal controls related to the sliding fee discount process.
Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend that the Seminary review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...
Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend that the Seminary review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The seminary will update our current WISP to comply with additional requirements and newer standards. Name(s) of the contact person(s) responsible for corrective action: Raymond Ingram, Director of Finance Planned completion date for corrective action plan: February 1,2024
Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend the Seminary reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to ensure timely reporting as well as put a process in place to ensure the enrollment effective date reported to NSLDS...
Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend the Seminary reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to ensure timely reporting as well as put a process in place to ensure the enrollment effective date reported to NSLDS is aligning with the Seminary's last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Seminary will continue to use the import / export function to report to NSLDS. Financial Aid Services will reiew the report, prior to submission, for any errors, duplications, etc. Name(s) of the contact person(s) responsible for corrective action: Maryjo Lewis, Registar Planned completion date for corrective action plan: January 1,2024
Management Response - The District Superintendent and Business Manager review and approve the financial statements. Upon completion of the full audit, the school board reviews, comments on, and approves the audited financial statements.
Management Response - The District Superintendent and Business Manager review and approve the financial statements. Upon completion of the full audit, the school board reviews, comments on, and approves the audited financial statements.
Management Response – Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition, and we realize that the concentration of duties and responsibilities in a limited number of indiv...
Management Response – Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition, and we realize that the concentration of duties and responsibilities in a limited number of individuals in not desirable for an effective system of internal control. To mitigate the issue of lack of segregation of duties, we have cross trained virtually each of the business office employees. While we do have a dedicated payroll person, another individual will perform cross checks & verifications independently. The same goes for issuing checks, accounts receivable, accounts payable, and activity funds. These functions are overseen by the business manager.
Christopher Natelborg (Director of Financial Aid) and Dawn Sallee-Justesen (Director of Enrollment Services) will implement the following procedures and internal controls to ensure accurate dates are reported to NSLDS that agree with District records: • For NSLDS Enrollment Reporting purposes, 34 CF...
Christopher Natelborg (Director of Financial Aid) and Dawn Sallee-Justesen (Director of Enrollment Services) will implement the following procedures and internal controls to ensure accurate dates are reported to NSLDS that agree with District records: • For NSLDS Enrollment Reporting purposes, 34 CFR 685.305(c) requires schools to report the same withdrawal date that the school used for the return of Title IV funds (R2T4) purposes under 668.22(b) or (c). That is, the effective date for the withdrawn (‘W’) status is the withdrawal date used by the school in the R2T4 calculation. To ensure reporting is accurate, the Office of Financial Aid will communicate to the Registrar the specific student files and the dates of withdrawal used for any unofficial withdrawal R2T4 calculations after each term and the Registrar will update the student’s date of withdrawal on file with NSLDS within the required enrollment reporting deadlines. • The Director of Financial Aid and Director of Enrollment Services will also explore Information Technology automating the unofficial withdrawal date reporting to NSLDS. These corrective actions will be implemented by February 2024, including updating the dates in NSLDS for the 2023 summer and fall term unofficial withdrawals.
Rogers Behavioral Health System, Inc. and Subsidiaries CORRECTIVE ACTION PLAN YEAR ENDED July 31, 2023 Identifying Number: 2023-001 Finding: In the internal tracking of eligible COVID-19 related expenses applied to the Period 4 PRF receipts for Rogers Behavioral Health System, Inc. and Subsidiari...
Rogers Behavioral Health System, Inc. and Subsidiaries CORRECTIVE ACTION PLAN YEAR ENDED July 31, 2023 Identifying Number: 2023-001 Finding: In the internal tracking of eligible COVID-19 related expenses applied to the Period 4 PRF receipts for Rogers Behavioral Health System, Inc. and Subsidiaries (the Health System), the Health System calculated invoice amounts related to legal services incurred as part of the Health System’s response to COVID-19 in a manner that increased legal expenses applied to PRF funds by the percent discount given by legal counsel rather than decreasing legal expenses applies to PRF funds. Calculating the identified eligible legal expenses in this manner occurred for legal expenses incurred and applied to PRF funds from August 2021 to February 2022. Additionally, for one month, the Health System included the eligible expenses twice in the internal tracking of eligible COVID-19 related expenses. Corrective Actions Taken or Planned: Rogers ensured there were enough valid qualifying expense to support the funds received. Future assignments of costs will be reviewed for reasonableness and appropriateness to ensure only proper allowable costs are submitted to support funds received. This will be achieved by the utilization of work tag assignments on allowable costs. Due to a recent financial system implementation, Rogers will be able to use enhanced tools to track costs more accurately. Person Responsible: Emily Russart, Controller Anticipated Completion Date: March 31, 2024
View Audit 14135 Questioned Costs: $1
Recommendation: YWCA of Western Massachusetts Inc.’s internal control procedures should be revised to ensure an adequate review process is in place to ensure expenditures incurred are allowable under the terms of the grant. ...
Recommendation: YWCA of Western Massachusetts Inc.’s internal control procedures should be revised to ensure an adequate review process is in place to ensure expenditures incurred are allowable under the terms of the grant. Views of Responsible Officials: Despite DPH's mandate to remove all personally identifiable information from these funding requests, the YWCA reconstructed every ERAP request using identifying vendor numbers. The YWCA ultimately identified how and where the three former employees illegally used ERAP funds to pay their bills as well as some of their family members or friends. They stole ERAP funds to illegally pay such bills as electricity, water and sewer bills, rent, car insurance payments, and credit card payments. As soon as the YWCA discovered these thefts, the YWCA immediately notified the appropriate authorities (such as the YWCA's Board of Directors, the police, and DPH) and kept them updated. Additionally, the employment ended for the three YWCA employees responsible for this fraud and theft. As of this audit issue date, all three former employees have been indicted for multiple felonies such as credit card fraud over $1300, larceny over $1200, and false entry in corporate books. Their criminal cases are pending in Hampden County Superior Court. The YWCA maintains an expectation that justice will be served. Finally, to prevent future theft and misuse of any grant funding, the YWCA has implemented some new policies and procedures. One, the YWCA will not hire close relatives. Two, a thorough review of all financial policies and procedures is in process to ensure that the appropriate checks and balances are in place. Three, any supervisor, who has access to YWCA funds, will be required to participate in a background check to ensure that do not have any personal or financial problems.
View Audit 14119 Questioned Costs: $1
2023-005: Gramm-Leach-Bliley Act Compliance Recommendation: We recommend the District review and finalize its information security policy and ensure it contains all seven elements required for compliance with Gramm-Leach-Bliley. Action taken in response to finding: Fill the newly created Interim Dir...
2023-005: Gramm-Leach-Bliley Act Compliance Recommendation: We recommend the District review and finalize its information security policy and ensure it contains all seven elements required for compliance with Gramm-Leach-Bliley. Action taken in response to finding: Fill the newly created Interim Director of Information Security and Special Projects position with an Interim placement effective February 1, 2024, to provide leadership in developing, implementing, and maintaining the District’s Information Security Policy including the seven elements required by the Gramm-Leach-Bliley Act. Names of the contact person responsible for corrective action: James “Kimo” Calilan, Director – Information Systems Planned completion date for corrective action plan: April 30, 2024
2023-004: 240 Days Outstanding Check Recommendation: We recommend the District re-evaluate their procedures for processing and documenting outstanding Title IV funds to the Department of Education. Action taken in response to finding: This issue is the result of a conflict between the procedures use...
2023-004: 240 Days Outstanding Check Recommendation: We recommend the District re-evaluate their procedures for processing and documenting outstanding Title IV funds to the Department of Education. Action taken in response to finding: This issue is the result of a conflict between the procedures used by the awarding team (Financial Aid) and the disbursement team (Fiscal Services). The Financial Aid team was operating with a set of pre-pandemic instructions that had them contact students to fix their address information (the typical reason that disbursements timeout) and send a list of students with verified addresses to Fiscal Services for reissuing. Nothing in their procedures mentioned the need to rescind aid—only the need to verify addresses to allow funds to reach students. The Fiscal Services team’s procedures, on the other hand, assumed the Financial Aid team was rescinding aid as necessary and thus would reissue repeatedly as long as the funds remained awarded in the school’s information system, even in cases where the initial disbursement had been made more than 240 days prior. The combination of these two procedures led to the findings in this year’s audit and last year’s audit, as well. The Financial Aid team’s procedures were updated and presented to the team on October 4, 2023. These new procedures included:  Directions on how to rescind funds  A policy statement requiring recission when the time since first disbursement has exceeded 90 days (an institutional policy that is stricter than the 240 days allowable under federal regulations)  A clear set of instructions on how to make the determination to rescind funds. Name of the contact person responsible for corrective action: Patrick Scott, Dean – Financial Aid Planned completion date for corrective action plan: October 2023 for procedure correction. February 2024 for completed review of affected students in audit list.
2023-003: NSLDS Enrollment Reporting Recommendation: We recommend that the District review its enrollment reporting procedures to ensure information is accurately reported to NSLDS as required by regulations. Action taken in response to finding: The District will review its enrollment reporting proc...
2023-003: NSLDS Enrollment Reporting Recommendation: We recommend that the District review its enrollment reporting procedures to ensure information is accurately reported to NSLDS as required by regulations. Action taken in response to finding: The District will review its enrollment reporting procedures to ensure information is accurately reported to NSLDS as required by regulations. Name of the contact person responsible for corrective action: Patrick Scott, Dean – Financial Aid Planned completion date for corrective action plan: Spring 2024
Recommendation: We recommend that the District improve the existing procedures and controls to ensure compliance with the aforementioned criteria. Action taken in response to finding: This issue was discovered during the audit process and the staff member associated with this error was made aware of...
Recommendation: We recommend that the District improve the existing procedures and controls to ensure compliance with the aforementioned criteria. Action taken in response to finding: This issue was discovered during the audit process and the staff member associated with this error was made aware of it in July 2023. Refresher training occurred during August 2023 and we have added members to the R2T4 calculation team in December 2023 in hopes of spreading workload and allowing more time to complete calculations and returns before the relevant deadlines. Names of the contact persons responsible for corrective action: Patrick Scott, Dean – Financial Aid, and Kate Larot, Financial Aid Specialist Planned completion date for corrective action plan: January 2024
Finding 10418 (2023-003)
Significant Deficiency 2023
Contact Person – Kristine Wehrkamp Herman, Superintendent; Corrective Action Plan – The District will follow their cash disbursement procedures.; Completion Date – January 31, 2024
Contact Person – Kristine Wehrkamp Herman, Superintendent; Corrective Action Plan – The District will follow their cash disbursement procedures.; Completion Date – January 31, 2024
U.S. Department of Education College of DuPage, Community College District Number 502 (the College), respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: CliftonLarsonAllen LLP, Oak Brook, Illinois Audi...
U.S. Department of Education College of DuPage, Community College District Number 502 (the College), respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: CliftonLarsonAllen LLP, Oak Brook, Illinois Audit period: July 1, 2022 – June 30, 2023 The findings from the schedule of findings, responses, and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings – Financial Statement Audit: None Findings – Federal Award Programs Audits: Department of Education 2023‐001 – Enrollment Status Reporting Recommendation: We recommend that the College review its procedures to ensure enrollment status changes are reported to NSLDS accurately, as required by regulations. Planned Corrective Action: The College of DuPage has reviewed and agrees with the enrollment reporting finding. The College has already taken multiple steps to resolve all issues ensuring complete, accurate and timely reporting. However, all those steps have not fully resolved the issue with enrollment reporting. As such, we will be working on a long‐term system improvement with the goal of limiting issues and future audit findings. The Financial Aid Office and the Registrar’s Office will work closely with the Information Technology department to automate a process of capturing unofficial withdrawal information, using the NSLDS template and then uploading that report directly to NSLDS on a weekly basis. The College will continue to send records to the National Student Clearinghouse and use this new report to supplement reporting and resolve the issues with reporting unofficial withdrawals. The goal is to implement this new report by June 30, 2024. Contacts Responsible for Corrective Action: Dr. Diana Del Rosario, Assistant Provost, Student Affairs Jill Pierson, Registrar Scott Brady, CFO & Treasurer Anticipated Completion Date: June 30, 2024 If the U.S. Department of Education has questions regarding this plan, please do not hesitate to call me at (630) 942‐2219.
Finding 10392 (2023-003)
Material Weakness 2023
Management will seek approval from the funding Agency for the questioned costs and return funds if costs are not approved.
Management will seek approval from the funding Agency for the questioned costs and return funds if costs are not approved.
View Audit 14054 Questioned Costs: $1
Finding 10391 (2023-002)
Material Weakness 2023
Management will seek approval from the funding Agency for the questioned costs and return funds if costs are not approved.
Management will seek approval from the funding Agency for the questioned costs and return funds if costs are not approved.
View Audit 14054 Questioned Costs: $1
Name of Contact Person: Jason Hayes, Superintendent. Recommendation: We recommend the District check the Excluded Parties List System or collect certifications from the entity for any vendor in which the District expects to spend more than $25,000 of federal grant funds for the year. Corrective ...
Name of Contact Person: Jason Hayes, Superintendent. Recommendation: We recommend the District check the Excluded Parties List System or collect certifications from the entity for any vendor in which the District expects to spend more than $25,000 of federal grant funds for the year. Corrective Action: The District will ensure they comply going forward.
Condition: Additional detail, documentation and approval/oversight is needed on some of time sheets for allocation to projects. Plan: To ensure proper allocations to projects, job duties will be documented for each position and sufficient detail will be provided on timesheets to reflect duties pe...
Condition: Additional detail, documentation and approval/oversight is needed on some of time sheets for allocation to projects. Plan: To ensure proper allocations to projects, job duties will be documented for each position and sufficient detail will be provided on timesheets to reflect duties performed. Anticipated Completion Date: Dec 31, 2023 Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer
Condition: The certifier for HUD forms should be a current employee with oversight in the area the form pertains to. HUD forms must be certified by an authorized user. Plan: A procedure will be implemented to ensure that changes in certifiers on forms at Projects are made in a timely fashion. Ant...
Condition: The certifier for HUD forms should be a current employee with oversight in the area the form pertains to. HUD forms must be certified by an authorized user. Plan: A procedure will be implemented to ensure that changes in certifiers on forms at Projects are made in a timely fashion. Anticipated Completion Date: Completed June 30, 2023 Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer
CORRECTIVE ACTION PLAN September 14, 2023 UNITED STATES DEPARTMENT OF EDUCATION UNITED STATES DEPARTMENT OF AGRICULTURE Southwest R-V School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Contact information for the individual responsible fo...
CORRECTIVE ACTION PLAN September 14, 2023 UNITED STATES DEPARTMENT OF EDUCATION UNITED STATES DEPARTMENT OF AGRICULTURE Southwest R-V School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Contact information for the individual responsible for the corrective action: Tosha Tilford, Superintendent Southwest R-V School District 300 N Myrtle Street Washburn, MO 65772 (417) 826-5410 Independent Public Accounting Firm: The CPA Group, PC, 217 4th Street, Monett, MO 65708 Audit Period: Year ended June 30, 2023 The findings from the June 30, 2023, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT Material Weakness – Internal Control over Financial Reporting - Segregation of duties Finding 2023-001 Recommendation: We realize Because of limited resources and personnel, management may not be able to achieve a proper segregation of duties; however, our professional standards require that we bring this lack of segregation of duties to your attention in this report. Action Taken: The limited number of available personnel prohibits segregation of incompatible duties and the District does not have the resources to hire additional accounting personnel. Completion Date: Not applicable Sincerely, Tosha Tilford, Superintendent Southwest R-V School District
The College meets or exceeds the system and data security requirements as stipulated in the GLBA and best industry practice and standards for IT system security. There are no identified weaknesses or concerns for the security of College data. Formal documentation of procedures and process are in pl...
The College meets or exceeds the system and data security requirements as stipulated in the GLBA and best industry practice and standards for IT system security. There are no identified weaknesses or concerns for the security of College data. Formal documentation of procedures and process are in place and being formalized by the Institution and the College will be in compliance with the requirement for formal written standards going forward.
Finding 10259 (2023-010)
Significant Deficiency 2023
2023-010 – Special Tests and Provisions – Federal Perkins Loan Liquidation – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University reconcile the information to the most recent filed FISAP to ensure the entire portfolio of Perkins loans wa...
2023-010 – Special Tests and Provisions – Federal Perkins Loan Liquidation – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University reconcile the information to the most recent filed FISAP to ensure the entire portfolio of Perkins loans was properly liquidated. Planned corrective actions: To ensure the Perkins loan portfolio was correctly liquidated, the University will reconcile the data with the most current FISAP filed. Name of Responsible Party: 1. Financial Aid Director 2. Alysia Stevens, Controller 3. VP of Administration/CFO 4. Dr. Andrew Sund, President Anticipated completion date: 6/30/2024
Finding 10253 (2023-009)
Significant Deficiency 2023
2023-009 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University review their policies and procedures to ensure that all withdrawals have the appropriate documentation to su...
2023-009 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University review their policies and procedures to ensure that all withdrawals have the appropriate documentation to support the withdrawal date used in the calculation. Planned corrective actions: In order to make sure that all withdrawals have the proper evidence to support the withdrawal date used in the computation, the University will evaluate its rules and procedures. Name of Responsible Party: 1. Mary Neal, Registrar 2. Financial Aid Director 3. Melissa Hill, Provost 4. VP of Administration/CFO 5. Dr. Andrew Sund, President Anticipated completion date: 6/30/2024
View Audit 13897 Questioned Costs: $1
Finding 10248 (2023-007)
Significant Deficiency 2023
2023-007 – Special Tests and Provisions - Enrollment Reporting – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University follow and enhance existing policies to ensure all student changes in status are identified timely and submitted accu...
2023-007 – Special Tests and Provisions - Enrollment Reporting – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University follow and enhance existing policies to ensure all student changes in status are identified timely and submitted accurately within the required time frame. The auditors also recommend the University establish a formal internal monitoring control whereby a designated individual with NSLDS access, on a sample basis, spot checks the status updates on NSLDS so to internally audit the National Student Clearinghouse submissions. Planned corrective actions: The University will adhere to current regulations and improve them if necessary to guarantee that all student status changes are recognized promptly and filed correctly within the allotted period. In order to internally audit the National Student Clearinghouse submissions, the University established a formal internal monitoring system wherein a designated individual with NSLDS access, on a sample basis, spot-checks the status updates on NSLDS. Name of Responsible Party: 1. Mary Neal, Registrar 2. Financial Aid Director 3. Melissa Hill, Provost 4. VP of Administration/CFO 5. Dr. Andrew Sund, President Anticipated completion date: 6/30/2024
2023-004 – Reporting – Material Weakness in Internal Controls over Compliance and Material Noncompliance Recommendation: The auditors recommend the University update previously posted reports to accurately reflect the actual expenditures during the time period covered by the report. The auditors ...
2023-004 – Reporting – Material Weakness in Internal Controls over Compliance and Material Noncompliance Recommendation: The auditors recommend the University update previously posted reports to accurately reflect the actual expenditures during the time period covered by the report. The auditors recommend each report be posted to the University’s website on separate documents by quarter and should not be cumulative. The auditors also recommend the University implement a process to ensure the submission dates and publication dates are maintained to ensure compliance with the reporting due dates and that the data submitted in the reports is properly supported by institutional records. Lastly, the auditors recommend each report be properly reviewed by someone other than the preparer and that the review be documented with a signature and date. Planned corrective actions: Heritage University will update the previously posted reports to accurately reflect the actual expenditures during FY21, FY22 & FY23 on the University’s website by quarter. Going further it will be the Grant accountant’s practice that the submission dates and publication dates are maintained and documented with reporting due dates. All documents will be reviewed and approved by the VP of Administration/CFO with dated signatures. Name of Responsible Party: 1. Yolanda Maltos, Grant Accountant 2. Alysia Stevens, Controller 3. VP of Administration/CFO 4. Dr. Andrew Sund, President Anticipated completion date: 6/30/2024
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