Corrective Action Plans

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Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Acco...
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Account) were reconciled on a timely basis. This increases the possibility that errors related to the USDA Accounts and other accounts impacted by the USDA Accounts, including construction in progress, are not properly stated in the financial statements. In addition, there could be amounts expended from the USDA Accounts that do not meet the requirements and those expenditures would not be identified in a timely manner. Corrective Action Plan Internal controls will be updated to have a formalized process established to ensure timely reconciliation of the USDA Accounts as well as a review process of those reconciliations each month Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO; Jasen Walker, Controller Anticipated Completion Date Complete.
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Cli...
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Clinics Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.301 Program Name COVID 19 Small Rural Hospital Improvement Grants Finding Summary Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Corrective Action Plan It is not cost effective to have an internal control system designed to provide for a complete and accurate schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the schedule of expenditures. We have designated a member of management to review the drafted schedule of expenditures. Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO Anticipated Completion Date Ongoing
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current ...
Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current staff has completed HUD training modules on monitoring to ensure that monitoring that takes place will follow all guidelines. With the updated catalogue of all HOME loans, the division of housing and community development can have an accurate list of properties that are in the period of affordability and subject to monitoring. Staff will refer to monitoring files from previous years to create documents and letters to be sent to homeowners. Proposed Completion Date: 6/30/26
Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The depar...
Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program Compliance Officer after thorough review. Written agreement documentation will be revised to include the requirements from the new compliance manual. The City of Woonsocket plans to procure grant management software which will streamline the application process and allow for improved recordkeeping to ensure compliance with all policies and procedures. Proposed Completion Date: 6/30/26
Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued ...
Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26
Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is ...
Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is both complete and accurate. This will include establishing a formal process for reconciling all reported federal expenditures with supporting documentation such as the general ledger and grant reports. Additionally, the SEFA will undergo a documented review by a qualified individual who was not involved in its preparation prior to finalization and submission. Proposed Completion Date: 3/31/26
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.
The new VIP processing system and accompanying spreadsheet is now used to complete a more thorough list for the Board for approval.
The new VIP processing system and accompanying spreadsheet is now used to complete a more thorough list for the Board for approval.
Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be ret...
Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be returned to the department director and will not be processed until signed.
The department will adopt written policies with the Uniform Guidance for Federally Funded Grant Programs accepted by the department.
The department will adopt written policies with the Uniform Guidance for Federally Funded Grant Programs accepted by the department.
RMIPA will strictly enforce contractors to submit wage-rate compliance documentation as a condition for invoice payment. This reporting requirement will be formally integrated into contract oversight practices.
RMIPA will strictly enforce contractors to submit wage-rate compliance documentation as a condition for invoice payment. This reporting requirement will be formally integrated into contract oversight practices.
RMIPA will update its processes to better track obligations alongside expenses for more accurate financial reporting and compliance. This includes obtaining additional Microix modules to enhance internal tracking and compliance.
RMIPA will update its processes to better track obligations alongside expenses for more accurate financial reporting and compliance. This includes obtaining additional Microix modules to enhance internal tracking and compliance.
2023 – 008: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008, 2021-007 and 2022-009) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Constru...
2023 – 008: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008, 2021-007 and 2022-009) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Construction ALN 93.575 Child Care and Development Block Grant Condition: During compliance requirement testing for Activities Allowed and Unallowed, Allowable Costs and Period of Performance for the above noted major programs, the auditors selected 120 transactions for testing from each major program. The following number of transactions were not provided for review during the audit: ALN 93.441 – Indian Self Determination – 18 transactions ALN 20.205 – Highway Planning and Construction – 16 transactions ALN 93.575 – Child Care and Development Block Grant – 7 transactions Corrective Action Plan: The Finance Department will become familiar with the requirements of 2 CFR, Part §200.313(a) and establish appropriate internal control policies and procedures to ensure compliance with the requirements of Uniform Guidance and each major program. In addition, all staff will be trained on those policies and procedures, so they are familiar with the requirements. The Finance Department will not process payment for disbursements that does not contain sufficient, appropriate supporting documentation and necessary approvals. The Finance Department will implement and execute an internal audit, by pulling random vouchers packets to test for compliance mid-year. An internal audit process is being developed and personnel assigned. Forms will be developed to assist with the internal audit process to ensure a timely and consistent process will be followed.
Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive ...
Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive adequate training on the procurement policy and the required methods of procurement to be made when making procurements with federal awards. Responsible Person(s): CHC President, Rob Dibble as Primary; CHC Vice President Betsy Gordon as Backup Corrective Action Plan Dates: Schedule implementation starts: February 1, 2026; Staff training starts: March 1, 2026; Review process in effect starts: April 1, 2026
VITEMA concurs with this finding. This information is documented in BSIR as part of the submittal process and does not allow for the submittal of reporting if not verified to meet this requirement. VITEMA will also document this information when preparing the SF 425 report by including this informat...
VITEMA concurs with this finding. This information is documented in BSIR as part of the submittal process and does not allow for the submittal of reporting if not verified to meet this requirement. VITEMA will also document this information when preparing the SF 425 report by including this information in the notes section of this report. This will be conducted on a quarterly basis.
In accordance with 2CFR #200.303 federal recipients VITEMA/ODR must create internal controls that provide reasonable assurance that FFATA reporting requirements are met. Currently, internal controls have been established to ensure compliance with the Federal Funding Accountability and Transparency A...
In accordance with 2CFR #200.303 federal recipients VITEMA/ODR must create internal controls that provide reasonable assurance that FFATA reporting requirements are met. Currently, internal controls have been established to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA). On a monthly basis, the Disaster Program Administrative Assistant in responsible for obtaining the P5 report from the Grants Manager and entering all project with obligated funds exceeding $30,000 into the SAM.gov database, formerly FSRS.gov. The report must be submitted by the end of the following month. Once the data is entered, the Territorial Public Assistance Officer reviews the submission and, upon the verification, certifies that the information has been accurately reported in the federal database. The reports and associated certifications will be placed in a centralized database.
The ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a Direct...
The ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a Director of Audit and Compliance has been onboarded. Once the audit team is developed, support and compliance monitoring will be provided to ensure compliance.
Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibil...
Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibility of reviewing completed case files.
DHS is committed to strengthening internal controls and addressing the auditors’ concern related to the reconciliation process and the importance of clear, auditable reconciliation processes that fully support the preparation of the Schedule of Expenditures of Federal Awards (SEFA) and demonstrate c...
DHS is committed to strengthening internal controls and addressing the auditors’ concern related to the reconciliation process and the importance of clear, auditable reconciliation processes that fully support the preparation of the Schedule of Expenditures of Federal Awards (SEFA) and demonstrate compliance with internal control requirements. DHS will continue to collaborate closely with the auditors and other stakeholders in the reconciliation process and SEFA preparation to ensure all affected parties confirm receipt of required documentation so determination of compliance can be readily identified, confirming DHS’s commitment to federal funds stewardship. To achieve this, DHS will streamline communication between all parties through a designated point of contact, the Director of Audit & Compliance who onboarded in August 2025, to make certain that necessary documentation is distributed to all stakeholders involved.
As part of the close-out process, all open purchase orders are now submitted to the Department of Finance for closure. The grant close-out process has been shifted to the OMB to ensure the grant is no longer available for transaction entries or liquidations. Additionally, a dedicated Fiscal Analyst ...
As part of the close-out process, all open purchase orders are now submitted to the Department of Finance for closure. The grant close-out process has been shifted to the OMB to ensure the grant is no longer available for transaction entries or liquidations. Additionally, a dedicated Fiscal Analyst is being integrated into the workflow to ensure compliance.
The Department of Human Services (DHS) adopted the electronic Timeforce (STATS) system for payroll, replacing manual processes. Time and attendance are approved through management levels, with payroll based on Notice of Personnel Action (NOPA) cost centers. Financial Analysts reconcile payroll, and ...
The Department of Human Services (DHS) adopted the electronic Timeforce (STATS) system for payroll, replacing manual processes. Time and attendance are approved through management levels, with payroll based on Notice of Personnel Action (NOPA) cost centers. Financial Analysts reconcile payroll, and a workflow ensures accurate NOPA listings for payroll purposes. Additionally, in order to ensure that Notice’s of Personnel Actions are updated on a timely basis, ensuring that salaries are charged to the respective account, DHS has implemented the following process: (1) Provisional Payroll Codes are requested prior to the close of the Fiscal Year by the Department of Finance through the Office of Management and Budget through the established process. (2) Once the codes are received, the Division of Human Resources will update the most current Personnel Distribution Sheets to reflect active employees. (3) The sheets will be submitted to Fiscal certification by the CFO, (4) NOPAS are updated with the provisional codes.
An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, in...
An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, internal audits will be conducted to ensure alignment with the Federal mandates in addition to ensuring overall compliance.
An internal programmatic audit process is actively utilized, involving the exchange of caseloads between workers. Eligibility and subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing a...
An internal programmatic audit process is actively utilized, involving the exchange of caseloads between workers. Eligibility and subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, internal audits will be conducted to ensure alignment with the Federal mandates in addition to ensuring overall compliance.
DHS remains in compliance with this finding from previous audit years, the untimely submission led to the issue in current year. To address this, a shared file will be established to ensure that the necessary information for each year is readily available for audit purposes.
DHS remains in compliance with this finding from previous audit years, the untimely submission led to the issue in current year. To address this, a shared file will be established to ensure that the necessary information for each year is readily available for audit purposes.
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