Corrective Action Plans

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Out of over 182 compliance records requested, the organization was unable to provide 3 health assessments, all other requested documentation was provided. The missing health assessments were for high school students, who are not required to provide them to attend school and often do not have access ...
Out of over 182 compliance records requested, the organization was unable to provide 3 health assessments, all other requested documentation was provided. The missing health assessments were for high school students, who are not required to provide them to attend school and often do not have access to updated health assessments. We have been directed by the funding agency never to exclude these youth from participation for an inability to obtain a health assessment. BGCP has already taken steps to address these issues. The funding agency, PHMC has begun sending monthly compliance reports. Over the last three months, we have collected 42% of missing health assessments organization wide. Additionally, on our recent FY24 Admin review from PHMC, which included a full compliance report, all of our sites received overall scores of above 95%. We will continue to monitor compliance and follow-up with youth and families to complete needed items.
View Audit 305611 Questioned Costs: $1
THE COLLEGE HAS PROVIDED TRAINING TO EMPLOYEES AND IMPLEMENTED REVIEW PROCEDURES TO ENSURE ACCURACY OF REPORTING STUDENT STATUS FOR THE NEXT FISCAL YEAR.
THE COLLEGE HAS PROVIDED TRAINING TO EMPLOYEES AND IMPLEMENTED REVIEW PROCEDURES TO ENSURE ACCURACY OF REPORTING STUDENT STATUS FOR THE NEXT FISCAL YEAR.
We recently completed the transition and onboarding of departmental staff which would allow the University to fully enact its plan to ensure both the financial aid and the Registrar's office will perform prompt review of processing University withdrawals. The Registrar's office will develop process ...
We recently completed the transition and onboarding of departmental staff which would allow the University to fully enact its plan to ensure both the financial aid and the Registrar's office will perform prompt review of processing University withdrawals. The Registrar's office will develop process and procedures documentation as an internal control measuring tool to ensure that Administrative Withdrawals (AW) and Withdrawals for lack of attendance (WA) that affect student emollment are identified immediately. Staff in the Financial Aid and the Registrar's office will actively take part in training workshops and webinars provided by the Depatiment of Education and NASF AA for continuing education to stay abreast of new developments and best practices in the industry.
View Audit 305536 Questioned Costs: $1
Corrective Action Plan: Management will ensure controls are in place for timely reporting. Anticipated Completion Date: Fiscal Year 2024.
Corrective Action Plan: Management will ensure controls are in place for timely reporting. Anticipated Completion Date: Fiscal Year 2024.
2023-01 1: Administrative Expense 10% Earmarking Requirements Late program year changes to staff time allocation due to a need to increased emphasis on the youth program caused a change in overall cost allocation percentages. This change occurred too late in the year to offset and caused the issue....
2023-01 1: Administrative Expense 10% Earmarking Requirements Late program year changes to staff time allocation due to a need to increased emphasis on the youth program caused a change in overall cost allocation percentages. This change occurred too late in the year to offset and caused the issue. CSC staff will closely monitor the administrative costs as we move forward and work to prevent late program changes that shift costs.
Finding 2023-004 – Federal Assistance Listing Number 14.239 Statement of Condition: During the period of affordability (i.e., the period for which the nonfederal entity must maintain subsidized housing) for HOME assisted rental housing, the participating jurisdiction must perform on-site inspecti...
Finding 2023-004 – Federal Assistance Listing Number 14.239 Statement of Condition: During the period of affordability (i.e., the period for which the nonfederal entity must maintain subsidized housing) for HOME assisted rental housing, the participating jurisdiction must perform on-site inspections to determine compliance with property standards and verify the information submitted by the owners no less than every year for projects containing 26 or more units. The participating jurisdiction must perform on-site inspections of rental housing occupied by tenants receiving HOME/HOME-ARP-assisted tenant-based rental assistance to determine compliance with housing quality standards (24 CFR sections 92.209(i), 92.251(f), and 92.504(d)). Corrective Action: REACH has policies in place to ensure that HQS inspections are done in a timely manner. Staffing shortages at the property had an impact on the completion of HQS inspections in 2023. As new staff are brought onboard training is provided and additional training will be provided to on-site staff to ensure that the inspections are being completed and properties are in compliance.
Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by...
Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by individual general ledger. Each revenue and expenses account are supported with documentation. Classes within QuickBooks are available within the platform. However, using classes is optional and with the purchase of the more advance version of QuickBooks “QuickBooks Enterprise Platinum” it’s the intent of the organization to move to enhanced detail general ledger accounts (which will provide detail data relating to each individual transaction). As it relates to Assistance Listing No 93.185 National Urban League Vaccine Equity 2021-22 in the amount of $40,000 and Assistance Listing no. 10-551 in the amount of $52,129 is not affiliated with Head Start from a program perspective. No staff time or expenses of the two grants are related to the Head Start Program. Each of the reference programs are stand-alone funded through a third-party pass through grantee and not a direct grant from a federal agency. However, the organization will establish separate classes within QuickBooks Enterprise Platinum for each federal and state contract. The implementation of the vertical classes within the QuickBooks Enterprise Platinum platform will consist of the reconciliation of cost reimbursements with a separate and dedicated “in kind” calculation of 25% within the class where applicable as per grantee requirement. Implementation Date: July 1, 2024
View Audit 305459 Questioned Costs: $1
Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has r...
Finding 2023-101 Allowable Costs/Cost Principle and Reporting (Material Weakness Compliance Finding) Repeat Finding Responsible Individuals: William Bridgeman Chief Fiscal Officer Natalie Alvarez- Chief Operating Officer Head Start Director Corrective Action Plan: Greater Phoenix Urban League has received great support from our community partners by providing in-kind space in 4 school districts and the abundance of parent volunteer support for our Head Start program, however, the program struggles to identify the in-kind match during the turn to full on campus instruction. COVID19 has had a considerable impact on the programs ’s ability to meet the non-federal share obligation as families and community volunteers are not allowed fully back onto Head Start Campuses and enrollment has declined. The program was unable to open several classrooms due to lack of qualified staff and low enrollment. In the past, Greater Phoenix Urban League Head Start has relied heavily on in-kind Space as the main source of program match and with the closing of classrooms in-kind was very difficult to collect. We believe we have worked towards meeting the challenge of program in-kind match. We have used ARPA funds to develop “A grow your own program.” Greater Phoenix Urban League Head Start has recruited parents and the community to participant in a workforce development program to train and hire new Head Start staff as classroom aides and teacher assistances. We also have contracted with an organization to provided contracted instructional support to open up temporarily closed classrooms. The program will continue to identify non-federal share to meet the obligations of the grant award. COVID will continue to have an impact on the programs ’s ability to meet non-federal share but it certainly opens new channels of identifying non-federal share. The following steps are in progress of being implemented in fiscal year 23-24 within the grantee: • An internal control process has been developed to review the current system to document the resources for non-federal share. A Data Assistant will review and analyze at our process in collecting in kind. • Revised Policies and procedures will be developed to assisted instructional staff to collect parent volunteer hours. • Parent Policy Committee will be trained on the non-federal share in-kind as it relates to their important role within the Head Start Program. • Greater Phoenix Urban League Head Start will continue to review the internal control process annually to ensure compliance with the Head Start Program Performance Standards, federal regulations, and City of Phoenix Grantee regulations. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • Greater Phoenix Urban League will continue their efforts to identify citywide partners that can provide non-federal share to the Head Start Program. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • All third-party appraisals will be conducted in May 2024 to reflect the current market value of space and real property. • The activities mentioned above will assist the Greater Phoenix Urban League-Head Start Program in meeting its obligations in the coming years. Anticipated Completion Date: Ongoing throughout the contract period on an annualized basis. May 1, 2024
View Audit 305459 Questioned Costs: $1
Finding 395808 (2023-001)
Significant Deficiency 2023
Person responsible for corrective action Emily Allen, SVP Programs Corrective Action The Foundation concurs with this finding. We have worked with the U.S. Department of Labor and the matter is now closed. In February 2024, the Foundation repaid the $435,289 identified in this finding, and a mod...
Person responsible for corrective action Emily Allen, SVP Programs Corrective Action The Foundation concurs with this finding. We have worked with the U.S. Department of Labor and the matter is now closed. In February 2024, the Foundation repaid the $435,289 identified in this finding, and a modified final report has been filed. The Foundation will design and implement additional processes to ensure that earmarking requirements are monitored on a continuous basis by SCSEP staff. In the meantime, the Foundation has implemented additional controls to address the risks of noncompliance with earmarking requirements. Beginning with the March 2024 quarterly report (which was filed on April 9, 2024), all such reports will be reviewed by the Group Controller and Assistant National Director, SCSEP, with specific reference to the earmarking requirements. In the event of any report identifying a risk of noncompliance with the earmarking requirements, the Foundation will immediately raise the matter with our colleagues at the U.S. Department of Labor. Anticipated Completion Date Initial implementation completed, with further control enhancements to be in place by June 30, 2024
View Audit 305433 Questioned Costs: $1
CORRECTIVE ACTION PLAN Federal Award Findings and Questioned Costs Finding 2023-001 Student Financial Aid Cluster: Assistance Listing #84.007 Federal Supplemental Educational Opportunity Grants Assistance Listing #84.033 Federal Work-Study Program Assistance Listing #84.063 Federal Pell Grant Progra...
CORRECTIVE ACTION PLAN Federal Award Findings and Questioned Costs Finding 2023-001 Student Financial Aid Cluster: Assistance Listing #84.007 Federal Supplemental Educational Opportunity Grants Assistance Listing #84.033 Federal Work-Study Program Assistance Listing #84.063 Federal Pell Grant Program Assistance Listing #84.268 Federal Direct Student Loans Assistance Listing #93.364 Nursing Student Loans Federal agency – U.S. Department of Education Grant Period – Year ended August 31, 2023 Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Public Law 106-102) (GLBA) requires the College, on an annual basis, to identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of customer (student) information that could result in the unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information, and assess the sufficiency of any safeguards in place to control these risks. At a minimum, the GLBA risk assessment should include consideration of risk in each relevant area of operations, including: Employee training and management. Information systems, including network and software design, as well as information processing, storage, transmission, and disposal. Detecting, preventing, and responding to attacks, intrusions, or other system failures. Condition: During our testing, we noted the following: While the IT Systems Team is the assigned resource for information security matters, the College communicated that it does not have a single qualified individual designated with the responsibility for implementing and enforcing the College’s information security program. An annual IT risk assessment was not performed. A vendor management program is not in place. Mobile device management is not in place. Backup media is not encrypted. A full set of policies and procedures is not in place. Cause: The expected documentation supporting the required controls to adequately confirm compliance with GLBA safeguards was not complete. Effect: Without demonstrable, documented controls supporting compliance with the GLBA standards for safeguarding the protected data, compliance with the law and the requirements in the federal PPA may not be assured. Context: Inquiry and observation of the information received from the College related to compliance with GLBA. Recommendation: The College should review the GLBA safeguarding rules and as soon as practical implement and document the controls necessary for compliance with the rule, focusing on the completion of a documented, thorough, and standardized risk assessment and management reporting framework. The College should perform comprehensive risk assessments on a regular basis, which is suggested to be at least annually, and at any significant change in infrastructure or business process. Contact Person Responsible for Corrective Action Plan: Donna Rocap, Associate Vice President of Administration Corrective Action Plan: The College agrees with the findings and is in process of developing a corrective action plan to address. In addition, the College has made it a top priority to hire both a Chief Information Officer and a Chief Information Security Officer but has experienced difficulty getting a qualified pool of candidates. Timing of Planned Corrective Action: The College expects to resolve this finding during its August 31, 2024 fiscal year.
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report ...
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report filing. Anticipated Completion Date: June 30, 2024
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report ...
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report filing. Anticipated Completion Date: June 30, 2024
Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.
Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.
Finding 395578 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as...
Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as $13,011,879, rather than $12,930,176. Total lost revenues available to be used in this reporting period based on the adjusted amount was $7,142,168 on payments in the period of $7,142,168. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management increased the level of review over the lost revenue calculations for future reporting periods. Management did not believe that further corrections to the Period 4 report were necessary as the remaining available lost revenues after adjusting for the error were equal to the payments received in the period and there was no further submissions necessary for Robert Parker Hospital. Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: September 30, 2023
Finding 395577 (2023-001)
Significant Deficiency 2023
Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have inc...
Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have increased the allowable costs eligible for reimbursement under the Federal award by $671. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management implemented an enhanced review process to validate all amounts reported on the PRF Reporting Portal Submission, and to ensure compliance with existing policies and terms and conditions of the Provider Relief Funds. Further action was not considered necessary as the errors would result in increased costs eligible for reimbursement under the Federal award and no further funding is available. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: This was corrected as of June 30, 2023, and the pay for event program was phased-out after the final Provider Relief Funds were released.
Institutional Comments on Findings and Recommendations: The institution agrees with the auditor on this finding in that there were (3) three cases where the enrollment status was not reported correctly. Although as was observed by the auditor, the enrollment status for the three students in questio...
Institutional Comments on Findings and Recommendations: The institution agrees with the auditor on this finding in that there were (3) three cases where the enrollment status was not reported correctly. Although as was observed by the auditor, the enrollment status for the three students in question were corrected in the next enrollment report that was submitted. During the audit period, the institution was unable to update, submit or complete in a timely manner Enrollment reports for the period of July through December 2022. This was mainly due to problems with the implementation of a new format for enrollment reporting through the NSLDS Modernized Website. The institution has on file, multiple inquiries to the NSLDS Customer Support Center in relation to this issue. The Department of Education also posted various Electronic Announcements updating and giving continued guidance to institutions on this issue. The auditors were provided with copies of all of ED’s posting and updates as related to this issue. Nevertheless, during the subsequent months from January 2023 to June 2023 covered in this audit period, the institution was able to complete and report the current enrollment status of students to the NSLDS platform. Actions Taken or Planned: The matter as related to this finding has already been discussed with the Registrar who is responsible for the completion and submission of the Enrollment Reports to the Department of Education To continue to improve on the reporting to student’s enrollment status, the institution would continue to submit its Enrollment Reports monthly instead of every two months as schedule. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the stud...
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the students withdrew within fourteen (14) days after the student’s last day of attendance. In one (1) of the two (2) cases the Date of Determination was twenty-two (22) days after the Last Day of Attendance and in the second case, the Date of Determination was Three (3) days after the Last Day of Attendance. All funds due to the Department, (for the first case $682.00 of Unsub. Direct Loan funds and in the second case $974.22 of Federal Pell Grant funds), were returned within the forty-five (45) days required timeframe as of the Date of Determination of each case. This process was evidenced to the auditors for their records. Actions Taken or Planned: The institution is fully aware of the Return of Title IV funds (R2T4) reporting requirements and deadlines. The issue related to this finding was identified as a lack in some Faculty notifying student absences within the fourteen (14) day timeframe to process an R2T4 in a timely manner as required. Although this issue was already discussed with them by the Dean of Academic Affairs, an additional follow up meeting would be held to remind them of the importance in monitoring student attendance and notifying student absences to the Registrar office within the required timeframes to fully comply with the R2T4 reporting requirements. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.
View Audit 305178 Questioned Costs: $1
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's policy. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Direct...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid, Chief Financial Officer & V.P. of Academic Affairs Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Regist...
Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Registrar Effective: Immediately and ongoing
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal regulations as it relates to resolving credit balances. The College will resolve credit balances timely and within the 14-day period as defined in the Federal guid...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal regulations as it relates to resolving credit balances. The College will resolve credit balances timely and within the 14-day period as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
Management concurs with this finding. The College will ensure the accuracy of the data that is input into the COD system and the College will work to apply funds appropriately to students' accounts. The College will review and adhere to its practices, policies, and procedures along with federal gu...
Management concurs with this finding. The College will ensure the accuracy of the data that is input into the COD system and the College will work to apply funds appropriately to students' accounts. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to managing the COD system. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
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