Corrective Action Plans

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Anticipated Contact Finding: 2022-004 Agency: Children & Youth Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title: Lack of Documentation of Common Program Requirements Corrective Action: Our fiscal department will begin putting language in our contracts beginning...
Anticipated Contact Finding: 2022-004 Agency: Children & Youth Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title: Lack of Documentation of Common Program Requirements Corrective Action: Our fiscal department will begin putting language in our contracts beginning in the FY25-26. For those contracts already signed, an addendum will be sent to providers to add this language. Completion Date: August 2025
• 2021 fiscal audit submitted. • Independent auditors contracted for 2023 and 2024 single audits, with completion projected for December 2025 and February 2026, respectively. • Ongoing integration and evaluation of corrective practices into daily operations. STATUS: In Progress
• 2021 fiscal audit submitted. • Independent auditors contracted for 2023 and 2024 single audits, with completion projected for December 2025 and February 2026, respectively. • Ongoing integration and evaluation of corrective practices into daily operations. STATUS: In Progress
• Shared calendar with grant-specific deadlines and automated reminders. • Joint oversight by Finance and Operations Managers. • Monthly and Quarterly compliance updates to the Finance Committee and Board. STATUS: Implemented
• Shared calendar with grant-specific deadlines and automated reminders. • Joint oversight by Finance and Operations Managers. • Monthly and Quarterly compliance updates to the Finance Committee and Board. STATUS: Implemented
Finding 2022-1 & 2022-2 Control Activities, Information and Communication, Monitoring • Monthly reconciliation of all financial reports within the accounting system. • Dual review by Operations Manager and Board Treasurer at monthly finance committee meetings. • Use of accounting software tools and ...
Finding 2022-1 & 2022-2 Control Activities, Information and Communication, Monitoring • Monthly reconciliation of all financial reports within the accounting system. • Dual review by Operations Manager and Board Treasurer at monthly finance committee meetings. • Use of accounting software tools and training for accurate grant-based reporting. • Accounting software issues related to transition to cloud-based software have been problem solved as possible. • Due to unresolved system limitations, TLCHB will transition to QuickBooks in January 2026, per the recommendation of the independent auditor. STATUS: Implemented bullet 1-4, bullet 5 target January 2025 • Policy to ensure funds are expended within 30 days, with exceptions approved by senior leadership. STATUS: Implemented • Monthly bank reconciliations prepared by Finance Manager and reviewed by leadership, Finance committee. • Additional staff resources allocated to support reconciliation. STATUS: Reconciliations completed; ongoing compliance in place.
Finding 2022-1 & 2022-2 Control Activities, Information and Communication, Monitoring • Monthly reconciliation of all financial reports within the accounting system. • Dual review by Operations Manager and Board Treasurer at monthly finance committee meetings. • Use of accounting software tools and ...
Finding 2022-1 & 2022-2 Control Activities, Information and Communication, Monitoring • Monthly reconciliation of all financial reports within the accounting system. • Dual review by Operations Manager and Board Treasurer at monthly finance committee meetings. • Use of accounting software tools and training for accurate grant-based reporting. • Accounting software issues related to transition to cloud-based software have been problem solved as possible. • Due to unresolved system limitations, TLCHB will transition to QuickBooks in January 2026, per the recommendation of the independent auditor. STATUS: Implemented bullet 1-4, bullet 5 target January 2025 • Policy to ensure funds are expended within 30 days, with exceptions approved by senior leadership. STATUS: Implemented • Monthly bank reconciliations prepared by Finance Manager and reviewed by leadership, Finance committee. • Additional staff resources allocated to support reconciliation. STATUS: Reconciliations completed; ongoing compliance in place.
1. Policy Adoption: A formal disbursement approval policy was adopted in 2024. The policy defines required documentation, establishes tiered approval thresholds, and assigns authorization responsibility based on role.
1. Policy Adoption: A formal disbursement approval policy was adopted in 2024. The policy defines required documentation, establishes tiered approval thresholds, and assigns authorization responsibility based on role.
2. System Controls: SCMRC’s accounting system was configured to require digital documentation of disbursement approvals. All disbursements are now traceable to authorized personnel.
2. System Controls: SCMRC’s accounting system was configured to require digital documentation of disbursement approvals. All disbursements are now traceable to authorized personnel.
3. Routine Oversight: The CEO and contract accountant conduct quarterly sampling of disbursement activity to verify proper documentation and authorization.
3. Routine Oversight: The CEO and contract accountant conduct quarterly sampling of disbursement activity to verify proper documentation and authorization.
4. Board Involvement: SCMRC’s Finance Committee reviews disbursement policies and internal controls annually as part of the broader fiscal oversight process.
4. Board Involvement: SCMRC’s Finance Committee reviews disbursement policies and internal controls annually as part of the broader fiscal oversight process.
5. Staff Training: Finance and administrative staff received updated training in 2024 on disbursement procedures and documentation protocols.
5. Staff Training: Finance and administrative staff received updated training in 2024 on disbursement procedures and documentation protocols.
1. SCMRC will conduct internal audits twice per year to verify continued compliance with disbursement approval and documentation requirements.
1. SCMRC will conduct internal audits twice per year to verify continued compliance with disbursement approval and documentation requirements.
2. A dashboard tracking disbursement approval timeliness and compliance will be developed in FY26 to support real-time monitoring.
2. A dashboard tracking disbursement approval timeliness and compliance will be developed in FY26 to support real-time monitoring.
3. The Controller will maintain a master log of all disbursement approvals and provide quarterly updates to the CEO.
3. The Controller will maintain a master log of all disbursement approvals and provide quarterly updates to the CEO.
4. SCMRC’s Disbursement Approval Policy will be reviewed and updated annually, with proposed revisions presented to the Finance Committee.
4. SCMRC’s Disbursement Approval Policy will be reviewed and updated annually, with proposed revisions presented to the Finance Committee.
5. Refresher training on approval protocols will be incorporated into the annual finance team training calendar beginning Q1 FY26.
5. Refresher training on approval protocols will be incorporated into the annual finance team training calendar beginning Q1 FY26.
1. All CMS-838 Credit Balance Reports for the audit period and subsequent quarters were submitted in September 2024 and accepted by CMS.
1. All CMS-838 Credit Balance Reports for the audit period and subsequent quarters were submitted in September 2024 and accepted by CMS.
2. SCMRC updated its Medicare compliance protocols in 2025 and established centralized tracking of required federal reports in the CEO’s compliance calendar.
2. SCMRC updated its Medicare compliance protocols in 2025 and established centralized tracking of required federal reports in the CEO’s compliance calendar.
3. Ongoing Medicare reporting oversight has been assigned to the Controller, with CEO review and incorporation into Board-level financial and compliance workplans.
3. Ongoing Medicare reporting oversight has been assigned to the Controller, with CEO review and incorporation into Board-level financial and compliance workplans.
1. Maintain documentation of CMS guidance confirming discontinuation of the CMS-838 reporting requirement.
1. Maintain documentation of CMS guidance confirming discontinuation of the CMS-838 reporting requirement.
2. Continue centralized tracking of Medicare-related reporting requirements through the CEO’s compliance calendar.
2. Continue centralized tracking of Medicare-related reporting requirements through the CEO’s compliance calendar.
3. Ensure that changes in federal reporting requirements are verified, documented, and reviewed by the Controller and CEO.
3. Ensure that changes in federal reporting requirements are verified, documented, and reviewed by the Controller and CEO.
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