Corrective Action Plans

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Finding 2022-005 Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As o...
Finding 2022-005 Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2022, the Hospital should have USDA debt reserves at least equal to $320,669. Responsible Individuals: Douglas B. Lewis, CFO Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.
Finding 2022-004 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Compliance Requirement: Allowable Costs and Activities Finding Summary: The Hospital opte...
Finding 2022-004 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Compliance Requirement: Allowable Costs and Activities Finding Summary: The Hospital opted for a budget to actual comparison for the calculation of lost revenue as an alternate reasonable methodology, however the actual amounts used did not consider adjustments during the fiscal year. Responsible Individuals: Douglas B. Lewis, CFO Corrective Action Plan: Period 4 reporting was completed prior to the financial statement audit for fiscal year 2022. Management will evaluate the process for the calculation of lost revenues to incorporate any financial statement adjustments.
Finding 2022-003 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Compliance Requirement: Reporting Finding Summary: The Hospital opted for a budget to act...
Finding 2022-003 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Compliance Requirement: Reporting Finding Summary: The Hospital opted for a budget to actual comparison for the calculation of lost revenue as an alternate reasonable methodology, however the actual amounts used did not consider adjustments during the fiscal year. Responsible Individuals: Douglas B. Lewis, CFO Corrective Action Plan: Period 4 reporting was completed prior to the financial statement audit for fiscal year 2022. Management will evaluate the process for reporting to consider any financial statement adjustments.
The District does recognize this is difficult with a limited number of employees.  We will continue to review our procedures to best meet the needs of the district as well as have internal controls in place.  We will work on dividing out duties and responsibilities so no one person is handling all c...
The District does recognize this is difficult with a limited number of employees.  We will continue to review our procedures to best meet the needs of the district as well as have internal controls in place.  We will work on dividing out duties and responsibilities so no one person is handling all cash, receipts, and financial transactions without checks and balances in place.
Finding 2022-002, ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds Following the comprehensive audit conducted on the CWWAPP 1.0 disbursement Year Ended June 30, 2022, the following exceptions have been identified that require immediate attention. Below is a summary of the exceptions obs...
Finding 2022-002, ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds Following the comprehensive audit conducted on the CWWAPP 1.0 disbursement Year Ended June 30, 2022, the following exceptions have been identified that require immediate attention. Below is a summary of the exceptions observed: Summary of Exceptions: 1.Credits applied for electric and secondary water disbursements exceeded the prescribed 60-day timeframe. 2.Recalculation of eligible credits for three out of sixty samples resulted in awarded amounts surpassing the calculated eligibility, leading to questioned costs (i.e., over award). Corrective Action Plan: 1.In order to ensure adherence to the stipulated 60-day window for credit applications, for the upcoming CWWAPP arrearage funding we have initiated immediate testing of bill notices upon receipt of the CWWAPP 2.0 disbursement check. Simultaneously, a secondary query has been implemented to validate consistency between the initial query and the present data. Should any discrepancies or technical issues arise, we will promptly seek extension from the State Water Resources Control Board (SWRCB) to facilitate timely funding. 2.To mitigate the risk of over awarding eligible customers, a final query will be conducted prior to disbursement to confirm the accuracy of awarded amounts for each eligible account. We are committed to implementing these corrective measures swiftly and effectively to uphold compliance standards and improve efficiency within the framework of the SWRCB and CWWAPP. Responsible Official: Jeff Sparks Assistant Customer Service Manager Corrective Action Plan Implementation Date: May 17th, 2024
View Audit 305456 Questioned Costs: $1
New HR Director, Brooke Olson hired 8/13/2022 now reviews all checks with invoices after Board has approved expenses. In addition, she reviews all bank statements along with copies of checks provided in bank statement. She does not have check writing capabilities. • Deposit Specialist from NSB B...
New HR Director, Brooke Olson hired 8/13/2022 now reviews all checks with invoices after Board has approved expenses. In addition, she reviews all bank statements along with copies of checks provided in bank statement. She does not have check writing capabilities. • Deposit Specialist from NSB Bank does check reconciliation report each month • District is going with cashless gate system through Varsity Bound • Board is currently approving a Budget Review Committee Policy
The District will continue to review procedures to obtain the maximum internal control possible utilizing current personnel.
The District will continue to review procedures to obtain the maximum internal control possible utilizing current personnel.
Program: Continuum of Care Federal Financial Assistance Listing No.:14.267 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward Award Year: 2022 Compliance Requirement: Special Tests and Provisions – Reasonable Rental Rates Grant Award Number: CA095...
Program: Continuum of Care Federal Financial Assistance Listing No.:14.267 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward Award Year: 2022 Compliance Requirement: Special Tests and Provisions – Reasonable Rental Rates Grant Award Number: CA0955L9T032007, CA0955L9T032108, CA0143L9T032013, CA0143L9T032114, CA1303L9T032006, CA1303L9T032107 Finding Summary: As a result of our procedures performed, we noted for 56 out of 60 rental payment transactions tested, the Organization did not have policies and procedures in place to ensure the reasonableness of contract rents being paid for individual housing units in relation to rents being charged for comparable units. This should have included an analysis of rents in the immediate area of the participants housing. However, we noted the rental payments made using grant funds did not exceed the HUD-determined fair market rents and ranged from 1% to 39% below the 2022 HUD-determined fair market rents. Management’s Response: We concur. Views of Responsible Officials and Corrective Action: • Develop policies and procedures for staff working on grants to ensure that all contract rents being paid for individual housing units are reasonable in relation to rents being charged for comparable units. Additionally, the policies and procedures will ensure that grant funds being used to pay rent will not exceed HUD-determined fair market rents. • Train grant staff on new policies and procedures. Name of Responsible Person: Bryan Wagner, CFO Projected Implementation Date: December 31, 2024
Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management to assign a person that verifies all the documents are in place before processing the determination of eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audi...
Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management to assign a person that verifies all the documents are in place before processing the determination of eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A checklist will be created that staff will use to check off all relevant data that has come in. This list will be reviewed by the Intake team before files are sent to Public Housing. Name(s) of the contact person(s) responsible for corrective action: Myvy Ngo Planned completion date for corrective action plan: Immediately
Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management to assign a person that verifies all relevant documents are gathered and added to the tenant file before processing new move ins. Explanation of disagreement with audit finding: There is no disagreement...
Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management to assign a person that verifies all relevant documents are gathered and added to the tenant file before processing new move ins. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A checklist will be created that staff will use to check off all relevant data that has come in. This list will be reviewed by the Intake team before files are sent to Public Housing and public housing will review again before moving a prospective tenant into housing. Name(s) of the contact person(s) responsible for corrective action: Myvy Ngo Planned completion date for corrective action plan: Immediately
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are issued...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS housing inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The supervisor for the Owner Services Department, Ilya Prozorov, is responsible for ensuring that all inspections are completed timely and that no HAP is issued for units that do not pass HQS. Name(s) of the contact person(s) responsible for corrective action: Ilya Prozorov, supervisor Planned completion date for corrective action plan: Immediately
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the housing authority designate an individual to reschedule all inconclusive QC inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Explanation o...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the housing authority designate an individual to reschedule all inconclusive QC inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Explanation of disagreement with audit finding: We contract with NanMcKay Associates, Inc to complete all inspections. The QC inspections are completed by their management team which are located outside the jurisdiction and are flown in at regular intervals to complete the QC inspections. In order to avoid the costs of bringing in the team a second time to follow up with inspections where the inspector cannot gain access to the unit, they schedule more inspections than are necessary to meet the quantity of QC that are required. Inspections are deemed “inconclusive” if the inspector cannot gain access or if the inspection is cancelled as the number of inspections have been met. Action taken in response to finding: The supervisor for the Owner Services Department is responsible for ensuring that QC inspections are scheduled and conducted in numbers sufficient to meet requirements. Name(s) of the contact person(s) responsible for corrective action: Ilya Prozorov, Supervisor for the Owner Services Unit Planned completion date for corrective action plan: Immediately
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC, assure the fatal errors and warnings are correctly in a reasonable time to avoid variances. Explanation of disagreement with audit finding: There is no di...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC, assure the fatal errors and warnings are correctly in a reasonable time to avoid variances. 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 taken in response to finding: Ken Olson, Senior Program Analyst, is responsible for submitting the 50058s to PIC. He will regularly review and correct errors and resubmit as needed. Name(s) of the contact person(s) responsible for corrective action: Ken Olson, Senior Program Analyst Planned completion date for corrective action plan: immediately
Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files Were prepared in accordance w...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files Were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. 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 taken in response to finding: Melanie Olson, Program Manager for the Operations Unit, is working with her management team to regularly review a sample of completed recertification from each of the staff in this unit. File reviews are important, not only for quality control purposes but also to review staff performance and to provide additional training/clarification as needed. Name(s) of the contact person(s) responsible for corrective action: Melanie Olson Planned completion date for corrective action plan: immediately
Information on the Federal Program: Assistance Listing Number 93.600 – Head Start Cluster, United States Department of Health & Human Services. Pass-Through Entity: N/A. Award Number: 10CH011432. Compliance Requirements: Reporting. Type of Finding: Material Noncompliance. Criteria: The entity should...
Information on the Federal Program: Assistance Listing Number 93.600 – Head Start Cluster, United States Department of Health & Human Services. Pass-Through Entity: N/A. Award Number: 10CH011432. Compliance Requirements: Reporting. Type of Finding: Material Noncompliance. Criteria: The entity should have a system of internal controls in place to ensure submission of applicable reports on a timely basis. Condition: During our compliance testing, we noted the SF-429 report was not submitted as required. Cause: We believe accounting staff turnover and inexperienced replacements during the year under audit were led to the lack of and/or failure in internal controls. Effect: The required report was not submitted to the agency. Identification of Repeat Finding: This is not a repeat finding. Recommendation: Staff turnover appears to have stabilized with the new finance director and the changes she implemented related to procedures and staffing. CSC may consider obtaining part-time or temporary assistance to help with fiscal year clean-up/close out to avoid similar problems with the accounting records in the current fiscal year due to a lack of time for current staff to prepare the accounting records while also performing their normal duties. Action Taken: We concur with the recommendation and have begun adding staff and restructuring the Finance Department. We have brought in 3 contract employees to assist with audits, have added an operations supervisor to assist with internal control implementations, and are actively recruiting a temporary accounting tech and a permanent accounting analyst to round out our team. We have also restricted the area of supervision of the grants supervisor to grants only rather than all financial operations. Given the large number of grants processed through CSC, we believe that having an individual dedicated to ensuring compliance on our grants will ensure that this type of significant deficiency will not continue. Names(s) and Title(s) of Responsible Person(s): Katie Henry, Finance Director
Management Response and Corrective Action Plan City's Response: The City concurs with the finding. The staff responsible for this control during FY 2022 are no longer employed by the City. Corrective Action Plan: Current City Finance staff in conjunction with a third-party organization, Michael Bake...
Management Response and Corrective Action Plan City's Response: The City concurs with the finding. The staff responsible for this control during FY 2022 are no longer employed by the City. Corrective Action Plan: Current City Finance staff in conjunction with a third-party organization, Michael Baker, to ensure timely filing. Planned Implementation Date: started in Q4 FY 2023 and has continued into FY 2024
We will continue to monitor and refine procedures and segregate duties as much as possible.
We will continue to monitor and refine procedures and segregate duties as much as possible.
Finding 394926 (2022-004)
Significant Deficiency 2022
Finding 2022-004 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure costs requested for reim...
Finding 2022-004 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure costs requested for reimbursement were eligible under program requirements. Time incurred on a different program was included in error when summarizing payroll costs. Responsible Individuals: Nancy Burke, CEO Corrective Action Plan: We will implement controls and processes to review reimbursement requests to ensure allowable costs are being reimbursed through the grant. Anticipated Completion Date: December 31, 2023
Finding 2022-003 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure matching expenses were a...
Finding 2022-003 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure matching expenses were appropriately tracked to meet award requirements. In addition, it was identified that all expenses did not have adequate documentation supporting the review and approval of the amounts meeting the matching requirements. Additionally, select payroll allocations did not have supporting documentation for the amounts allocated to the program. Responsible Individuals: Nancy Burke, CEO Corrective Action Plan: We will implement controls and processes to appropriately track and monitor matching requirements in each period for all awards. In addition, we will implement approval processes to ensure proper qualification for the match requirements and allocations. Anticipated Completion Date: December 31, 2023
Finding Number: 2022-008 Finding Title: LCTS Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Ann Ozan – Fiscal Supervisor II. Corrective Action Planned: Document the review of the public health, corrections, and school district quarterly...
Finding Number: 2022-008 Finding Title: LCTS Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Ann Ozan – Fiscal Supervisor II. Corrective Action Planned: Document the review of the public health, corrections, and school district quarterly reports. Review is being done when the state report is prepared, but not currently documented. Anticipated Completion Date: December 31, 2023.
U.S. Department of Education COVID-19 Governor’s Emergency Education Relief CFDA #84.425C Finding Summary: One out of 15 payroll expenditures tested allocated more time to the program than what was actually spent. Seven out of 15 payroll expenditures tested were improperly applied to the grant. Re...
U.S. Department of Education COVID-19 Governor’s Emergency Education Relief CFDA #84.425C Finding Summary: One out of 15 payroll expenditures tested allocated more time to the program than what was actually spent. Seven out of 15 payroll expenditures tested were improperly applied to the grant. Responsible Individuals: Lona Teague, Jessi Black Corrective Action Plan: The finance department will ensure retention of all personnel activity reports to support hours applied to the grant. Anticipated Completion Date: 06/30/2024
View Audit 304557 Questioned Costs: $1
U.S. Department of Education COVID-19 Governor’s Emergency Education Relief CFDA #84.425C Finding Summary: One out of 15 payroll expenditures tested lacked the required support to show that hours billed by program employees were allocated in accordance with actual time spent rather than predetermin...
U.S. Department of Education COVID-19 Governor’s Emergency Education Relief CFDA #84.425C Finding Summary: One out of 15 payroll expenditures tested lacked the required support to show that hours billed by program employees were allocated in accordance with actual time spent rather than predetermined budgeted amounts. Responsible Individuals: Lona Teague, Jessi Black Corrective Action Plan: The finance department will ensure retention of all personnel activity reports to support hours billed by program employees. Anticipated Completion Date: 06/30/2024
View Audit 304557 Questioned Costs: $1
U.S. Department of Education Education Innovation and Research CFDA #84.411C Finding Summary: A complete system of internal controls requires all expenditures to be properly approved and supported by appropriate documentation. In addition, all expenditures charged to the federal programs are requir...
U.S. Department of Education Education Innovation and Research CFDA #84.411C Finding Summary: A complete system of internal controls requires all expenditures to be properly approved and supported by appropriate documentation. In addition, all expenditures charged to the federal programs are required to be allowable costs under the program and allocated in accordance with CFA’s cost allocation plan. Responsible Individuals: Lona Teague, Jessi Black, All Staff Corrective Action Plan: Staff will ensure that all expenditures are supported by appropriate documentation and allowable under the program it is allocated to. The finance department will ensure all expenditures are properly approved before payment. Anticipated Completion Date: 06/30/2024
The audit firm used by the Foundation for 30+ years notified the Foundation in summer of 2022 that it would no longer be able to provide local audit staff. After many conversations with the firm it was agreed that they would perform the annual audit and single source audit remotely with staff from ...
The audit firm used by the Foundation for 30+ years notified the Foundation in summer of 2022 that it would no longer be able to provide local audit staff. After many conversations with the firm it was agreed that they would perform the annual audit and single source audit remotely with staff from first Madison and then Chicago. All of the audit materials and trial balance were uploaded from the Foundation to the audit firm in October 2022. The final audit was not completed until August 2023. In order to improve the timeliness for the annual audit, the Foundation has engaged a local audit firm for subsequent audits.
The Village board of trustees will continue to provide additional oversight by making the budget committee a permanent standing committee that will meet quarterly to go over finances presented to them by the clerk and treasurer. Additionally, the budget committee will continue to go over line items ...
The Village board of trustees will continue to provide additional oversight by making the budget committee a permanent standing committee that will meet quarterly to go over finances presented to them by the clerk and treasurer. Additionally, the budget committee will continue to go over line items of the budget comparison looking for incorrect entries.
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