Corrective Action Plans

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Recommendation: We recommend that the District implement procedures and controls to ensure that only eligible students are included on the MARSS listing. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The ...
Recommendation: We recommend that the District implement procedures and controls to ensure that only eligible students are included on the MARSS listing. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure that only eligible students are included on the MARSS listing. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
Recommendation: We recommend that the District implement procedures and controls to ensure the journal entries are accurate before posting. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will ...
Recommendation: We recommend that the District implement procedures and controls to ensure the journal entries are accurate before posting. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on implementing procedures and controls to ensure all journal entries are reviewed and accurate before posting. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
Recommendation: We recommend that the District implement procedures and controls to ensure that all paper applications are being reviewed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will c...
Recommendation: We recommend that the District implement procedures and controls to ensure that all paper applications are being reviewed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure that all paper applications are being reviewed. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
We agree with the auditor's comments, and the following actions will be taken to ensure official written documentation is obtained for a student enrolled in another school or in an educational program before removing the student from the graduation cohort: 1. Annual training to school office staff a...
We agree with the auditor's comments, and the following actions will be taken to ensure official written documentation is obtained for a student enrolled in another school or in an educational program before removing the student from the graduation cohort: 1. Annual training to school office staff at the August enrollment and attendance meeting provided by the Attendance Accounting Analyst. 2. Additional reminder training was provided to all school office staff on December 4, 2025 and December 5, 2025. 3. The policies and procedures related to the training are on a shared drive to be accessed at any time. Please reach out to us with any questions.
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Center's reserve account is fully funded per the requirements of the loan resoluti...
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Center's reserve account is fully funded per the requirements of the loan resolution security agreement. However, there is no documented secondary monitoring of the reserve balance as compared to the required minimum reserve balance. Responsible Individuals: Crystal Richter, Interim CFO Corrective Action Plan: Hired an Accountant July 2025. Management will ensure there are multiple people involved and overseeing the reserve balance and documentation will be retained review and approval over the reserve balance. Anticipated Completion Date: December 2025
Management's Response/Planned Corrective Action: The Organization's Director overseeing these programs will provide training to staff on policies. The Organization has recently implemented internal chart audits to aid in verifying compliance with funder regulations and identifying any deficiency in ...
Management's Response/Planned Corrective Action: The Organization's Director overseeing these programs will provide training to staff on policies. The Organization has recently implemented internal chart audits to aid in verifying compliance with funder regulations and identifying any deficiency in supporting document retention and will continue this practice going forward.
2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurr...
2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurred before the Federal award was made that were authorized by the Federal awarding agency or pass-through entity. All financial obligations incurred under the Federal award must be liquidated within the required time period. Costs incurred outside the approved period of performance are unallowable and constitute questioned costs. Client’s Response: During the grant cycle, the Organization submitted for an extension but did not receive confirmation of said extension. During the current fiscal year, the Organization has implemented additional controls to ensure that all grant funding is expended within the timeframe allotted. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444
Contact Person – Superintendent, Dr. Erich Heise Corrective Action Plan – Will establish policy to ensure payrolls are submitted a week after the week of work is performed. Completion Date – Ongoing
Contact Person – Superintendent, Dr. Erich Heise Corrective Action Plan – Will establish policy to ensure payrolls are submitted a week after the week of work is performed. Completion Date – Ongoing
HHC has reviewed our process for reporting appropriate charges for each CPT code on bills to all third-party payors and found that in isolated cases, the EPIC system was reporting the Sliding Fee Discount Fee on the bill and not the charge from our Fee Schedule for selected CPT codes. HC will collab...
HHC has reviewed our process for reporting appropriate charges for each CPT code on bills to all third-party payors and found that in isolated cases, the EPIC system was reporting the Sliding Fee Discount Fee on the bill and not the charge from our Fee Schedule for selected CPT codes. HC will collaborate with our EPIC partner- UPMC- to identify why the bills are not appropriately reflecting the CPT code fees from our Fee Schedule instead of the Sliding Fee Discount Fee. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements. HHC has reviewed our Sliding Fee Discount Policy and determined that there are areas that require revision. There should not be any patients that are given a sliding fee discount based on their self-declaration of income and then continue to receive care without the provision of income verification. HHC is in the process of a total review of our Sliding Fee Discount Policy/Process/Application and will make appropriate adjustments to ensure compliance with the HRSA Sliding Fee Discount Requirements. HHC will replace our One-Time Sliding Fee process with a more compliant approach that will involve: Self-Declaration of Income, whereby the patient will provide us with the income and family size without the required supporting documentation and the appropriate sliding fee will be applied for that visit only, and all future visits will be considered a full fee patient until the patient provides the appropriate support for income and family size; All patients will be requested to provide their income and family size. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements. HHC has reviewed the claim in question and has no explanation as to why the income reported for a patient was different than the supporting income documents provided by the patient. HHC recognizes that this occurred in only one of forty patient samples. HHC will ensure that all employees that are involved with the Sliding Fee Discount program are re-trained on the importance of accurately reporting the patient’s income based on the supporting documentation provided by the patient. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements.
HHC recognizes their responsibility to ensure that all required Federal Reports, including FFRs, are filed on a timely basis. HHC recognizes that during the fiscal year ended 3/31/2025, we were deficient in meeting the timely filing requirement for FFR reports. HHC established a new process in Augus...
HHC recognizes their responsibility to ensure that all required Federal Reports, including FFRs, are filed on a timely basis. HHC recognizes that during the fiscal year ended 3/31/2025, we were deficient in meeting the timely filing requirement for FFR reports. HHC established a new process in August 2025, whereby the Controller will review the Payment Management System on a bi-weekly basis, but not less frequently than monthly, to identify the deadline for all required Federal Grant reports, including but not limited to FFR reports. The Controller will notify all appropriate individuals of any reports that require attention to meet the reporting deadlines and will be responsible for the timely completion of all such required reporting.
CONTACT PERSON: Dana Hudgins, Executive Director Upstate Workforce Board 864-596-2028 dana@upstatewb.org CORRECTIVE ACTION: The County will follow its internal control policies and procedures. Effective immediately, all agreements between the County and its consultant for the WIOA program will be up...
CONTACT PERSON: Dana Hudgins, Executive Director Upstate Workforce Board 864-596-2028 dana@upstatewb.org CORRECTIVE ACTION: The County will follow its internal control policies and procedures. Effective immediately, all agreements between the County and its consultant for the WIOA program will be updated and signed. PROPOSED COMPLETION DATE: June 30, 2026
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Condition: The Intermediate School District (ISD) did not have internal controls in place to ensure that all the expenditures included in the quarterly claims for reimbursement were allowable. Planned Corrective Action: The ISD will review the process used by the local districts to report quarterly ...
Condition: The Intermediate School District (ISD) did not have internal controls in place to ensure that all the expenditures included in the quarterly claims for reimbursement were allowable. Planned Corrective Action: The ISD will review the process used by the local districts to report quarterly expenditures for the Administrative Outreach program. We will then create a process that ensures that the local districts provide supporting documentation that allows us to monitor the quarterly submission amounts for accuracy. Contact person responsible for corrective action: Chris Frank, Asst. Superintendent for Business Anticipated Completion Date: 1/31/2026
RE: Finding Reference Number: 2025-001 Corrective Action: Sea Mar will implement a compliance worksheet that will be used by staff to ensure they have collected all necessary documentation for each tenant. This tool will assist in tracking income verification documents and move-in/move-out dates and...
RE: Finding Reference Number: 2025-001 Corrective Action: Sea Mar will implement a compliance worksheet that will be used by staff to ensure they have collected all necessary documentation for each tenant. This tool will assist in tracking income verification documents and move-in/move-out dates and will be included as a cover sheet for each tenant file. Sea Mar will also provide staff with additional training on eligibility determination for qualifying applicants in alignment with applicable program guidelines. This will be completed by 3/31/2026. Name of Contact Person Responsible for Implementation: John Clerkin, Housing Director Sincerely, John Clerkin Housing Director P: (206) 788-3399 E: johnclerkin@seamarchc.org Proudly serving the community since 1978
Enforce the organization's R2T4 refund calculation proceedures
Enforce the organization's R2T4 refund calculation proceedures
2025-003 – UNALLOWABLE COSTS Corrective Action Plan: We have implemented a new policy that requires the Superintendent to review and sign-off on all outgoing EFT and ACH payments. We have implemented a new policy that requires the Superintendent to review and sign-off on all bank statements. Respons...
2025-003 – UNALLOWABLE COSTS Corrective Action Plan: We have implemented a new policy that requires the Superintendent to review and sign-off on all outgoing EFT and ACH payments. We have implemented a new policy that requires the Superintendent to review and sign-off on all bank statements. Responsible Party(ies): • Superintendent and Board of Education Anticipated Completion Date: June 30, 2026
Adjusting Journal Entries and Required Disclosures to the Financial Statements. Year ended June 30, 2025. Auditor's Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under new pronouncement, the District should continue to review and accept both p...
Adjusting Journal Entries and Required Disclosures to the Financial Statements. Year ended June 30, 2025. Auditor's Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under new pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. School District's Response: The District has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the School Business Administrator believes she has a thorough understanding of these financial statements and the ability to make informed judgements based on these financial statements.
Condition During our testing over direct loan disbursement notifications, we found that for twenty out of twenty students tested, City Colleges could not provide evidence that notifications were sent within the required timeframe informing the student, or parent, that a credit will be made to the st...
Condition During our testing over direct loan disbursement notifications, we found that for twenty out of twenty students tested, City Colleges could not provide evidence that notifications were sent within the required timeframe informing the student, or parent, that a credit will be made to the student’s account for a direct loan disbursement. While City Colleges demonstrated that its system was configured to automatically send notification letters and confirmed that notifications were issued, City Colleges could not provide documentation showing the specific date each notification was sent in relation to the loan disbursement. Cause City Colleges’ system is designed to record the date notifications are sent to students; however, it does not retain a copy of the actual notification content that was transmitted. Corrective Action Taken or Planned City Colleges’ IT team, in collaboration with a consultant, will configure the system to bring all Direct Loan communication letters into the Financial Aid (FA) Status pages. Integrating these letters directly into the FA Status page will ensure they are easily accessible for FA staff. As part of this enhancement, City Colleges will be able to view a timestamp indicating when each communication was sent to the student, as well as view the information required to be communicated by 34 CFR 668.165. Contact Person: Leticia Garcia, District Director of Student Financial Aid Anticipated Completion Date: December 13, 2025
Condition For one out of forty students tested, City Colleges properly recalculated a return of Title IV funds for a student but did not subsequently adjust the student's account to perform the return or notify the student of the adjusted award amount. Cause The lack of return of Title IV funds was ...
Condition For one out of forty students tested, City Colleges properly recalculated a return of Title IV funds for a student but did not subsequently adjust the student's account to perform the return or notify the student of the adjusted award amount. Cause The lack of return of Title IV funds was an oversight due to human error. Corrective Action Taken or Planned To strengthen internal controls, the District Office assigned an analyst to conduct a review of a random selection of files across all seven colleges scheduled for audit to help identify any discrepancies early and ensure compliance. All R2T4 specialists will receive yearly refresher trainings on R2T4 procedures and controls. Contact Person: Leticia Garcia, District Director of Student Financial Aid Anticipated Completion Date: December 13, 2025
Responsible party: Bethany Johnson, Interim Executive Director and Commercial Lending Manager and Tyler Ward, Interim Finance Director and Commercial Lender Implementation date: December 31, 2025 Corrective Action Plan Both Bethany Johnson, Interim Executive Director and Commercial Lending Manager, ...
Responsible party: Bethany Johnson, Interim Executive Director and Commercial Lending Manager and Tyler Ward, Interim Finance Director and Commercial Lender Implementation date: December 31, 2025 Corrective Action Plan Both Bethany Johnson, Interim Executive Director and Commercial Lending Manager, and Tyler Ward, Interim Finance Director and Commercial Lender, will continue to monitor the budget vs actuals both on a monthly and quarterly basis. Tyler Ward will provide an initial review and Bethany Johnson will provide a secondary review of the financial statements. If any variances are more than 5% over within a category, this category and the overall variances of each line item will be monitored closely to determine if any cumulative changes would cause a 10% or more increase or decrease overall in addition to a particular category. If a budget revision is determined to be required, Tyler Ward will prepare this document and Bethany Johnson will review and sign before submitting it to SBA. A reminder will be added to both Bethany Johnson and Tyler Ward’s SCKEDD calendars along with the existing reporting reminders. This will serve as a secondary reminder to monitor the budget at 90, 60 and 30 days before the end of the grant year. This will ensure that any changes in the 4th quarter can be addressed before the budget revision cutoff date to SBA. Calendar reminders will be added on 12/15/2025, and financials statement variances towards the Microloan grant will be reviewed with more scrutiny moving forward beginning with December 31, 2025 financial statements.
Corrective Action: The organization has established a compliance calendar with automated reminders to ensure all reporting deadlines are met. Additionally, the Executive Vice President has been authorized as an alternate signer for this report to prevent delays caused by signature requirements. Resp...
Corrective Action: The organization has established a compliance calendar with automated reminders to ensure all reporting deadlines are met. Additionally, the Executive Vice President has been authorized as an alternate signer for this report to prevent delays caused by signature requirements. Responsible Party: Jeremy Ashbaugh, Director of Finance Anticipated Completion Date: Corrected.
Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit...
Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2025. Any findings through the audit process will be reported to the COO. At least five patient charts will be audited monthly. o In addition, the Revenue Cycle Manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper analysis and implementation of sliding fee discounts. o COO and Revenue Cycle Manager will review, implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and Revenue Cycle Manager.
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Contact Person: Elise Lopez – Vice President, Organizational Operations Anticipated Completion Date: January 31, 2026 Planned Corrective Action: The TANF C...
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Contact Person: Elise Lopez – Vice President, Organizational Operations Anticipated Completion Date: January 31, 2026 Planned Corrective Action: The TANF Cash Assistance eligibility for each client served is one of the dozens of data points that Emerge tracks as part of our requirements for the Arizona Department of Economic Security (ADES) funding. The categorization of whether clients are eligible for TANF Cash Assistance, while a reporting requirement, is not tied to our contract billing. In other words, the accuracy of this categorization does not affect Emerge’s funding in any manner, and reporting errors regarding this categorization has not – and cannot – result in over‐billing for service units within the contract. Nevertheless, Emerge takes its reporting obligations very seriously and strives to always provide the most complete and accurate data to funders and the community. In regard to determining a client’s eligibility for TANF Cash Assistance or other government benefits, Emerge collects information and assesses eligibility for two reasons: 1) as a means of supporting our case management services and efforts to connect clients with appropriate resources, and 2) in order to comply with ADES requests to report whether or not we serve TANF‐eligible clients. While Emerge and its employees are not trained by ADES in determining individual’s eligibility for TANF Cash Assistance or other government benefits that we do not administer, we do provide our own internal training to employees about the factors that go into determining eligibility. Historically, this information has been provided as a stand‐alone document and noted during new hire training. In researching the client files which were selected for audit, it was determined that, in some instances, clients were categorized incorrectly, or that qualifying information was not sufficiently documented as it pertains to the client’s TANF Cash Assistance eligibility. Overwhelmingly, this was a result of one or both of the following factors: (1) clients whose TANF eligibility changed during the year, but whose status was not updated in our system, and/or (2) inconsistencies in how a client’s children had been documented in our client information system (eg. clients whose children are not enrolled in Emerge’s services do not appear in this system, but staff may have marked the client eligible for TANF based on verbal information without documenting the children in their notes). Our internal inquiry into this issue also revealed that TANF income eligibility charts were not correctly updated in all areas of the client information system, which may have led to confusion among staff regarding client eligibility status changes throughout the year. To mitigate future errors, we have taken immediate steps to begin the process of updating our client information system to ensure the correct TANF eligibility charts are reflected in the appropriate areas. We also have a plan to update TANF eligibility chart updates annually, which will include a quality assurance check by the Vice President of Operations to ensure the information has been updated in all appropriate areas of the client data managements system. As of November 28, 2025, we have developed an internal performance improvement plan. This plan includes conducting an internal audit of our client information system files for 2025 to ensure accuracy, re‐training staff on TANF eligibility and documentation, and conducting monthly quality assurance checks through the end of FY26. Additionally, greater time and focus related to the details surrounding the TANF assessment process will be built into the curriculum for new hire trainings moving forward. These corrective actions, while ongoing, are expected to be fully implemented by 01.31.2026
We will continue to review our procedure and implement controls when possible
We will continue to review our procedure and implement controls when possible
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