Corrective Action Plans

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2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale...
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: October 2025
Clinic management team acknowledges that from the audit selection made of 60 patients, 14 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. The ...
Clinic management team acknowledges that from the audit selection made of 60 patients, 14 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. The corrective action plan as developed for CY 2023 will be continued to be reinforced and followed. The plan did result in lower findings than in prior years. A new bullet was added in the fourth quarter of 2024 to further assist in meeting the compliance guidance. The addition is the last bullet listed below. • Revamped the job titles and description to encourage better return on recruitment efforts of medical case manager positions. • A position of Certified Case Counselor (CCC) – Lead, was created and filled to provide direct oversight over the medical case managers that perform the bi-annual certifications, and other daily tasks. • Added a quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. • Data Analyst(s) generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Lead is directly accountable to review the progress of the re-certification, and the process is monitored by the Assistant Manager of the clinic. The CCC-Lead and Assistant Manager monitor retention of all patients required supporting documentation in the patients’ medical records. • Patients that do not provide the required supporting documentation showing compliance with program eligibility as outlined in the grant agreement or are otherwise not able to be recertified six months after certification will be classified as inactive in the database used to submit invoices to the Ryan White HIV/AIDS Program. • CCC-Lead has been assigned to preview charts on the daily appointment book in EPIC and sending a list of the documentation required via email to case management staff as they meet with the patients. Contact Person: Mark Brown, Office Manager, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2025
Communities In Schools of Georgia acknowledges the audit recommendation regarding enhancing internal controls over payroll allocation by establishing a formalized process for accurate completion and review of employee timesheets and integrating the timesheet functionality within our payroll platform...
Communities In Schools of Georgia acknowledges the audit recommendation regarding enhancing internal controls over payroll allocation by establishing a formalized process for accurate completion and review of employee timesheets and integrating the timesheet functionality within our payroll platform with our accounting system to facilitate accurate and efficient allocation of payroll costs to grants. Under the leadership of our newly hired CFO, we are improving our internal controls over the allocation of payroll costs and reporting by implementing the following measures: Establishing a Formalized Process for Accurate Completion and Approval of Timesheets Reconciling Timesheet Data in the Payroll Platform to the Salary Costs Captured in the General Ledger Training and Capacity Building During fiscal year 2025, we took the following actions to improve internal controls over the allocation of payroll costs and reporting processes: Engaged Senior Finance Contractor Completed a Search for Permanent full-time CFO Initiated and Completed a Search for an Accounting Manager
View Audit 365140 Questioned Costs: $1
Finding 2024‐002: Allowable Costs/Cost Principles (Material Weakness and Noncompliance) Condition: For individuals charged to this program who also have time charged to other programs there were no timesheets or other evidence to support the allocation to the program was based on actual time incurre...
Finding 2024‐002: Allowable Costs/Cost Principles (Material Weakness and Noncompliance) Condition: For individuals charged to this program who also have time charged to other programs there were no timesheets or other evidence to support the allocation to the program was based on actual time incurred to the program but was instead based on the budgeted amounts for those individuals. Corrective Action Planned: -All individuals assigned to multiple contracts will keep time logs of hours workedon each, with a monthly review that the hours align with the budgeted amounts. -In the event hours diverge, workload will be adjusted or a budget adjustment will be requested. Anticipated Completion Date: February 1, 2025 Name of Contact Person Responsible for the Plan: Kimberly Atwood Lepse, Divisional Director of Finance
Contact persons responsible for corrective action: Chief School Finance Officer Recommendation: The Board should review its current policies and procedures to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Auditee response: The Board...
Contact persons responsible for corrective action: Chief School Finance Officer Recommendation: The Board should review its current policies and procedures to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Auditee response: The Board agrees with the finding. Corrective action planned: The Chief School Finance Officer will ensure that all accounting policies and procedures are followed to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Anticipated completion date: September 30, 2025
Identification of the federal program: Federal Agency: U.S. Department of Homeland Security (DHS) Assistance Listing: 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Th...
Identification of the federal program: Federal Agency: U.S. Department of Homeland Security (DHS) Assistance Listing: 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Through Award Number: 4494-DR-MI Pass-Through Award Period: 7/1/2022-4/30/2023 Summary of Finding: The Personal Protective Equipment (PPE) and other COVID related supplies were not used within the period of performance outlined within the project worksheet. There were three FEMA obligations during FY 2024. An overstatement of expenditures in one of the projects (project 10) was identified with an obligation amount of $6,732,507. The period of performance as specified within the project 10 application is July 2, 2022 to April 30, 2023 and $1,077,759 of costs were not used by April 30, 2023. The overstatement represents approximately 16% of the amounts reported in the project 10 application and 14% of the total FEMA obligations in FY 2024. The total federal expenditures for FEMA for FY 2024 were $7,795,530. Corrective Action Plan: Management agrees that a thorough review of the claim was not completed prior to submitting the Request for Reimbursement to the State of Michigan, thus causing a control deficiency. In the future management will perform, document, and sign off on a thorough claim review to validate that all final adjustments have been submitted prior to submitting the Request for Reimbursement to the State. Individuals responsible for corrective action: Brittany Kruse, Vice President Finance and Assistant Controller Cindy Brink, Director, System Accounting and Reporting. Timing of corrective action: September 1, 2025 and going forward.
View Audit 365058 Questioned Costs: $1
Management has consulted with HUD's account executive regarding the use of the reserves as collateral for financing. As of this date, management is still waiting for HUD's response since they are analyzing the transaction. Banco Popular de Puerto Rico, the mortgage, will be notified about HUD final ...
Management has consulted with HUD's account executive regarding the use of the reserves as collateral for financing. As of this date, management is still waiting for HUD's response since they are analyzing the transaction. Banco Popular de Puerto Rico, the mortgage, will be notified about HUD final notification to ensure the correct collateral requirements are met. Evidence of resolution will be sent to HUD. The reposible person for the corrective action plan is Carmen G Rivera, Blanco's Vice President. The estimated completion date for the finding is June 30, 2025
Corrective Action Planned: The Authority will make the required deposits to their reserve for replacement account as cash flow allows.
Corrective Action Planned: The Authority will make the required deposits to their reserve for replacement account as cash flow allows.
2024-002 – Written Policies and Procedures Required by the Uniform Guidance Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): o City ...
2024-002 – Written Policies and Procedures Required by the Uniform Guidance Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): o City Council o City Manager o City Finance Director Anticipated Completion Date: June 18, 2025
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be c...
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be combined to identify students who were awarded the subsidized loan in error. These reports will be reviewed after each add/drop period. Management has made a request to our vendor to create a special report that will capture this data in a more time efficient manner. Person Responsible for Corrective Action Plan: Darla Hopper, VP of Enrollment Management Anticipated Date of Completion: 09/30/2025
Finding 574638 (2024-005)
Material Weakness 2024
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will ha...
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor start signing off on all reports to verify the dates are correct for the reporting period. Anticipated Completion Date: August 30, 2025
Finding 574636 (2024-003)
Material Weakness 2024
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Depa...
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Department head will review and document their review for all Federal Grant disbursements for applicable grant requirements and Federal regulations. Anticipated Completion Date: August 30, 2025
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur wi...
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will collect dual signatures on all submissions for reporting requirements. The Auditor’s Office will also have additional employees verify submissions to ledgers for accuracy. Anticipated Completion Date: Completion is anticipated for all reports due after 12-31-2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan:...
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan: The required monthly balance and the actual monthly reserve fund account balance will be presented to the board on a monthly basis for review and approval. Previously only the actual balance and a YES/NO were provided. Starting in August 2025, monthly board packets for approval will now include the required vs actual comparison with a YES/NO of meeting the requirement. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Anticipated Completion Date: August 2025
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Su...
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Supportive Services for Veterans Families: CFDA 64.033 b. Criteria: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as tracking administrative expenses charged to the program outside of the general ledger and in other matters noted in licensing reviews. c. Condition: The Organization has failed to comply with grant requirements due to lack of proper tracking of administrative expenses, limited compliance policies including approval over supplemental pay wages, and lack of proper training over verification and documentation processes. d. Response: The organization has been successfully running the SSVF program for 11+ years and tracking/calculating administrative costs utilizing offline Excel spreadsheets since inception which provided a low cost and flexible solution for our accounting team. However, as an outcome of our last SSVF audit and due to the size and scope of our SSVF operations, the VA is requiring Adjoin to cease maintaining offline spreadsheets and ensure that all SSVF grant costs are logged in the general ledger. We're partnering with JMT Consulting (our Sage Intacct solution provider) for their assistance in implementing a new Dynamic Allocation Module to our Sage platform allowing click thru capabilities to all of the administrative costs that hit the grant (not to exceed 10%). We're committed to rolling out this functionality and are excited about the efficiencies it will bring to the team along with ensuring compliance with VA requirements. 2. Prior Year Finding 2023-001 None noted. Contact person responsible for corrective action: Pat Phelan, CFO Completion date: August 31, 2025 If you have any questions regarding this plan, please contact Pat Phelan, CFO, 858- 292-2030, pat.phelan@adjoin.org. Sincerely, Pat Phelan CFO Adjoin
View Audit 364796 Questioned Costs: $1
Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees...
Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees to the program who were transferred internally. A correction was made to the April 2025 claim to adjust for the amount overclaimed. Indiana University Health strengthened claim review controls to ensure such changes go through additional review before claim submission. Contact Person(s) Responsible for Corrective Action: Christine Smith Completion Date: July 31, 2025
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A
Management agrees with the finding and recommendation.
Management agrees with the finding and recommendation.
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025
Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025
Finding 574022 (2024-004)
Significant Deficiency 2024
During our testing, we found that the Organization provided documentation showing that the vendors used in the federal program were not listed as suspended or debarred according to the Sam.gov website, in line with their internal control procedures. However, there was no documentation indicating tha...
During our testing, we found that the Organization provided documentation showing that the vendors used in the federal program were not listed as suspended or debarred according to the Sam.gov website, in line with their internal control procedures. However, there was no documentation indicating that the verification was performed prior to entering the transactions. Recommendation: The Organization should establish and enforce controls to verify that vendors are not suspended or debarred prior to entering any transactions and maintain this documentation. This measure ensures the integrity of the procurement process and mitigates risks associated with engaging disqualified vendors. In 2024, the threshold amount for suspension and debarment checks was $25,000. Transactions equal to or exceeding this amount required verification to confirm that the entity involved was not debarred or suspended. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement a process to screen vendors to ensure compliance with applicable regulations. Planned completion date for corrective action plan: the planned corrective action will be completed by August 2025. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance If the oversight agency has questions regarding this plan, please call Regine Metellus, Vice President of Finance at 215-575-0444 ext. 163.
Finding 574021 (2024-002)
Significant Deficiency 2024
During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort ...
During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement processes and tools to ensure that all employee time and effort charged to federal grants is appropriately documented. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by October 2025.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD guidelines require Project cash to be maintained in financial institutions, which meet minimum GNMA ratings, when balances exceed federal insurance limits. Condition: The Organization maintains cash balances in excess of federally insured limits in a financial institution that does not meet HUD guidelines. Questioned costs: None Context: The cash balance as of December 31, 2024 was approximately $740,000, held in two financial institutions, which exceeded federal insurance limits by approximately $470,000. Cause: As the Organization is a community based non-profit organization, management considers supporting a local bank to be a worthwhile endeavor. Effect: No negative effect was discovered during the audit. Repeat Finding: No. Recommendation: The Organization should transfer all funds to a financial institution that meets HUD guidelines. Action Taken: Nevins moved to this financial institution with the first HUD loan in 2015. This is a local bank that actively supports Nevins mission in the community. Given Nevins current financial struggles, the balance in the bank seldom exceeds the $250,000.00 threshold.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD requires the Organization to make mortgage payments on a timely basis. Condition: Mortgage payments for February, March, April and May 2024 were not received by the mortgage company promptly. Questioned costs: None Context: February, March, April and May 2024 mortgage payments were received by the mortgage company subsequent to the 15th of the following month, which is considered late per HUD guidelines. Cause: Mortgage payments were being funded with approved withdrawals from reserve accounts which delayed timing of payment. Effect: Late charges were assessed to the Project. Repeat Finding: No. Recommendation: Mortgage payments should be made by the due date. Action Taken: Nevins was in touch with HUD monthly and developed a repayment plan but could not follow through. Nevins engaged with Alliance Healthcare for Accounts Receivable assistance in the fall of 2024 and then entered into a Management agreement with Alliance Healthcare in June of 2025.
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