Corrective Action Plans

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Uniform Grant Guidance Implementation Recommendation: We recommend the County finalize the assessment of its financial management system and related internal controls over federal awards during the 2021 fiscal year. This assessment should include an evaluation of existing policies and procedures to ...
Uniform Grant Guidance Implementation Recommendation: We recommend the County finalize the assessment of its financial management system and related internal controls over federal awards during the 2021 fiscal year. This assessment should include an evaluation of existing policies and procedures to determine where additional enhancements should be made or new policies created, a plan to communicate these policies to County employees, and procedures to periodically review and update, as considered necessary. Action Planned/taken in response to the finding: Kewaunee County agrees with the finding. An assessment of all grants, requirements, and related policy and procedures is in progress and will continue to:  Evaluate existing policy and procedures for needed revisions  Document revisions to policy and procedures as necessary  Communicate any new policies to employees responsible for awards  Identify awards covered by the Uniform Guidance  Set and document a schedule for periodic review and revision Policy and procedures, as well as related documentation, are being revised as necessary to ensure compliance with the Uniform Guidance. Progress continues into 2024. The Finance Director will continue to coordinate and provide assistance and guidance to departments receiving grants subject to the Uniform Guidance. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh Planned completion date for corrective action: December 31, 2025
Review of Claim Forms and Expenditure Reconciliation Recommendation: We recommend that there is an appropriate reviewer of each grant claim and monthly reconciliation. Action planned/taken in response to the finding: Management will evaluate their current processes and procedures during staffing tra...
Review of Claim Forms and Expenditure Reconciliation Recommendation: We recommend that there is an appropriate reviewer of each grant claim and monthly reconciliation. Action planned/taken in response to the finding: Management will evaluate their current processes and procedures during staffing transitions in fiscal year 2025 to ensure that proper review of claim forms and expenditure reconciliation. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh and Brian Johnson Planned completion date for corrective action: December 31, 2025
Person responsible for corrective action: Nicole Meland, Vice President of Finance and Operations Responsible official’s response: Management is in agreement with this finding. Corrective action planned: The Chamber Foundation has subsequently requested all audit reports from all subrecipients. Addi...
Person responsible for corrective action: Nicole Meland, Vice President of Finance and Operations Responsible official’s response: Management is in agreement with this finding. Corrective action planned: The Chamber Foundation has subsequently requested all audit reports from all subrecipients. Additionally, the Chamber Foundation has changed subaward formatting to ensure that all required information is included within the award. Planned implementation date of corrective action: Ongoing
Finding 573036 (2024-001)
Material Weakness 2024
Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reve...
Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reverse invoices’ using the time tracked in Banner’s timekeeping system by contract labor resources and presents those hours/dollars to contract labor agencies for approval prior to remitting payment to those agencies. These invoices are reviewed by Banner’s staffing services team for reasonableness prior to being presented to the agencies for approval. There is an expectation that managers review and formally approve the timecards of contract labor resources in the timekeeping system, however, the reverse invoicing process moves forward even in the absence of a documented formal approval. Banner will implement a periodic monitoring process that provides a report of ‘forced sign offs’ (timecards without documented manager approval) to senior leadership in an effort to increase compliance with the timecard approval policy. Contact: Paul Nolde-Morrissey, Vice President and Corporate Controller Expected completion date: September 30, 2025
The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.
The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.
Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University D...
Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement stronger internal controls over the administration of tenant eligibility and file maintenance, inclusive of more rigorous staff training, to ensure HUD regulations are followed timely and accurately. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting, tenant file maintenance, and monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO
2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: ...
2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: 04/18/2022-12/31/24 Statistically Valid Sample: No, and not intended to be a statistically valid sample Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Condition/Context: There was no support provided for the three out of three contractor vendors with construction work noted on their purchase orders to support compliance with Davis Bacon. Corrective Action Plan: Regarding the wage tests for the Park’s grant, no information was provided to the City from the contractor of employee wages paid by the contractor. An email request and answer from the contractor was forwarded to the auditors, that the contractor was not responsible to report the wages. This in the future will be part of the Grants Coordinator position for Internal Control purposes, to ensure that any future construction contracts include the wage reporting requirements. Anticipated completion date: December 2025 Contact Person: Mr. Joel Kramer, City Manager
2024 – 008 – Reporting Federal Agency: Department of the Treasury Department of Interior Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds (ARPA) Outdoor Recreation Acquisition, Development and Planning ALN: 21.027 15.916 Pass-Through Agency: Coronavirus State and Local ...
2024 – 008 – Reporting Federal Agency: Department of the Treasury Department of Interior Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds (ARPA) Outdoor Recreation Acquisition, Development and Planning ALN: 21.027 15.916 Pass-Through Agency: Coronavirus State and Local Fiscal Recovery Funds (ARPA) N/A Outdoor Recreation Acquisition, Development and Planning Arizona State Park Trails Pass-Through Number(s): Coronavirus State and Local Fiscal Recovery Funds (ARPA) N/A Outdoor Recreation Acquisition, Development and Planning 04-007-652304 Award Number and Period: Coronavirus State and Local Fiscal Recovery Funds (ARPA) 1505-0271 3/3/2021 – 12/31/2024 Outdoor Recreation Acquisition, Development and Planning 04/18/2022-12/31/24 Statistically Valid Sample: No, and not intended to be a statistically valid sample Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Condition/Context: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) (ARPA) - Audit procedures included testing the SLFRF Compliance Report. During the testing of the Compliance report, it was noted that the report’s key line items below were not properly supported: • Current period expenditure • Cumulative expenditure Current period expenditures per the Compliance Report was $-0- and per the expenditure details provided were $907,419 creating a difference of $907,419. Cumulative expenditures per the Compliance Report was $6,714,003 and per the expenditure details provided were $4,264,421 creating a difference of $2,449,582. Outdoor Recreation Acquisition, Development and Planning - Audit procedures included selection and testing of two quarterly reports. Two out of two of the quarterly reports tested contained no separate reviewer/approver support.   FEDERAL AWARD FINDINGS (Continued) 2024 – 008 – Reporting (Continued) Corrective Action Plan: The City concurs with this finding. With the addition of the Grants Coordinator, all reporting of all departments will be filtered through this position. The City also will use an outside Grants consultant to help research, apply, and coordinate the City’s grants in entirety. Anticipated completion date: December 2025 Contact Person: Mr. Joel Kramer, City Manager
The City will work to develop a listing of report submission deadlines as well as cross training staff as appropriate.
The City will work to develop a listing of report submission deadlines as well as cross training staff as appropriate.
SEE CORRECTIVE ACTION PLAN AT PDF PAGE 32 OF THE SUBMITTED AUDITED FINANCIAL STATEMENTS
SEE CORRECTIVE ACTION PLAN AT PDF PAGE 32 OF THE SUBMITTED AUDITED FINANCIAL STATEMENTS
Item: 2024-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Reporting Criteria or Specific Requirement:...
Item: 2024-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Reporting Criteria or Specific Requirement: Per the grant agreements, award recipients are required to submit monthly reimbursement report within a set number of days after month end. Condition: Financial reimbursement reports were submitted after the required due date. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will submit required reports timely going forward.
Finding 572993 (2024-002)
Significant Deficiency 2024
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with...
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reviewed all our internal controls to ensure all approvals are documented. The procedure has been updated to include preparing the draw documentation, entering the accounts receivable invoice into the accounting system, which now requires an approval for all accounts receivable invoices. Once the accounts receivable invoices are approved in the accounting system then a draw down can be requested in the payment management system. This new process to ensure the documented approval of federal fund drawdown's was implemented mid-year 2024, after the three selections in this finding were completed.
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categori...
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization made changes to improve the process and procedure based on the 2023 audit finding, but they were not implemented until midyear 2024 based on the completion of the audit. It is expected that 100% improvement in findings would not take place with this late implementation. There was an improvement over the prior year, especially in the lack of documentation on file. The monthly audit process to spot check applications for accuracy and ensure complete documentation in the chart was also implemented mid-year in 2024.
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditure...
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.
View Audit 363843 Questioned Costs: $1
We accept this finding that we could not provide adequate verification or documented dates when an entity is being checked through the Sam.gov system prior to entering into a contract as defined in 2 CFR section 180.995. We have taken steps to correct the issue as of June 1, 2025. All new prospect...
We accept this finding that we could not provide adequate verification or documented dates when an entity is being checked through the Sam.gov system prior to entering into a contract as defined in 2 CFR section 180.995. We have taken steps to correct the issue as of June 1, 2025. All new prospective contractors will be entered into the Sam system and scanned for debarment prior to contracting with them by the Program Manager. In addition, we are in the process of updating our vendor agreements to include language so a vendor can attest they are not debarred from doing business with the federal government.
Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified i...
Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified in which the City did not use accurate financial information or retain evidence to document the individual who reviewed the Voucher Management System (VMS) reports prior to submission. Responsible Individual: Diana Steiner, Finance Director Corrective Action Plan: We agree with the auditor’s recommendation and staff will have asecond person review the reports. Anticipated Completion Date: By the completion of the ACFR for the fiscal year ending June 30, 2025.
Management plans to develop proper written policies and procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline during years in which the District incurs federal expenditures above the threshold requi...
Management plans to develop proper written policies and procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline during years in which the District incurs federal expenditures above the threshold required by Uniform Guidance.
The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. S...
The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of the WIC applicant’s proof of eligibility. Therefore, the auditors were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.
Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, D...
Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, Director of Finance. Estimated Completion Date: May 15, 2025
Corrective Action Plan: Targeted training will be implemented to ensure full compliance with the sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Au...
Corrective Action Plan: Targeted training will be implemented to ensure full compliance with the sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Audits by location will be carried out by CBO staff and financial analysts, with results shared with administrators and CARs for accountability. Clinics showing minimal improvement will receive additional training. Two mandatory sliding fee scale training sessions will be schedules for all CARs, accounts receivable staff, and administrators. Persons Responsible: Steven Hansen, President & CEO; Peral Lujan, Central Billig Office Director Estimated Completion Date: December 31, 2025
2024-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended June 30, 2024 Condition Found The City failed to submit the annual report in a timely manner. We consider this to be an instance of non-compliance relating to the Reporti...
2024-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended June 30, 2024 Condition Found The City failed to submit the annual report in a timely manner. We consider this to be an instance of non-compliance relating to the Reporting Compliance Requirement. Corrective Action Plan The employee responsible for this negligence no longer works for the City. The City will endeavor to comply with all reporting requirements for our Federal Grants and monies received. Responsible Person for Corrective Action Plan Gregory Donovan, Director of Finance (SLFRF) Tenille Rose Martin, Grants Manager (SS4A) Elliot Liebson, Director of Planning (FEMA) Gary Bainter, Asst. Fire Chief (FEMA) Implementation Date of Corrective Action Plan January 1, 2025
Finding 572650 (2024-003)
Significant Deficiency 2024
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
Action Taken: Management agrees with the finding noted above. Management will also note that as a repeated finding we do not so much offer a corrective action plan as we do a summarization of steps already taken to close this finding for fiscal 2025. A new and highly qualified Chief Financial Office...
Action Taken: Management agrees with the finding noted above. Management will also note that as a repeated finding we do not so much offer a corrective action plan as we do a summarization of steps already taken to close this finding for fiscal 2025. A new and highly qualified Chief Financial Officer with over 30 years of public housing experience was hired by the agency in April of 2024. The CFO has fully staffed the department with competent and qualified individuals including a new and fully qualified Controller and Director of Finance. All individuals hired have received targeted training from both internal and external sources. In June 2024 the new financial management team implemented a policy/procedure for the records requirement and payment timeframes for all capital fund draw downs. This policy requires the hand signing of eLOCCS forms and reconciliation of individual draws at the time of drawdown. During fiscal 2025 the entire Finance staff was trained extensively on all matters related to HUD accounting. Specific training was directed to the Capital Fund program, its eligibility standards, accounting processes, and drawdown procedures. This training was conducted by a nationally recognized HUD-specific trainer. The Authority has hired a qualified, experienced internal auditor. The internal auditor has completed a 100% testing sample on capital fund draws made in fiscal 2025. His observations were rectified, and the policy revised where needed. The sampling assured that supporting documentation was sufficient for audit, that it matched the amounts drawn, and that invoices were paid within HUD dictate s timeframes. Management feels that with this policy and enhanced testing in place the finding will not be repeated in 2025. Management expects closure of this finding, under the direction of the Chief Financial Officer, for the Fiscal 2025 audit.
View Audit 363741 Questioned Costs: $1
Action Taken: Management agrees with the finding noted above. It is the stated practice of the management of the Housing Authority of the City of Tampa to comply with all rules and regulations regarding its programs. Management feels this condition is more the result of errors than process. It is ma...
Action Taken: Management agrees with the finding noted above. It is the stated practice of the management of the Housing Authority of the City of Tampa to comply with all rules and regulations regarding its programs. Management feels this condition is more the result of errors than process. It is management's feeling that this resulted from staffing turnover, available administration funding and the sheer volume of files processed annually. There is a highly refined review and quality control process in place which will be re-evaluated and changed as needed. Staff, under the direction of the Director of Assisted Housing, remains dedicated to processing files as accurately is possible. We are hopeful to close this finding in the next fiscal audit. If the Department of Housing and Urban Development has questions regarding this plan, please contact Jerome Ryans, President/CEO at (813) 3419101 .
Finding 2024-03 - Significant Deficiency in Internal Control over Compliance with Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the d...
Finding 2024-03 - Significant Deficiency in Internal Control over Compliance with Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the due date. As of the audit report date, the Council has engaged an outside accounting firm to provide financial oversight. Action: Develop procedures to ensure required single audits are completed and submitted to the Federal Audit Clearinghouse by the 9-month due date. Due Date: 10/1/25 Staff: Carrie Castillo, Executive Director Carrie Castillo, Executive Director, is the official responsible for implementing each corrective action plan.
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