Corrective Action Plans

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Finding 12236 (2022-001)
Significant Deficiency 2022
Finding 2021-001 Federal program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing 93.498 Statement of Condition During our testing over reporting, we observed management did not have effective internal controls in place to ensure lost revenues reported in th...
Finding 2021-001 Federal program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing 93.498 Statement of Condition During our testing over reporting, we observed management did not have effective internal controls in place to ensure lost revenues reported in the Portal were not duplicated between a subsidiary entity and the parent entity, resulting in an overstatement of lost revenues reported in the Portal. Lost revenues attributable to Coronavirus in the amount of $2,382,081 were reported in both the parent entity?s PRF reports for the general distribution report for Period 2 and for Ashland Community Healthcare Services and Asante Three Rivers, subsidiary entities, targeted distribution reports for Period 2 (i.e., lost revenues were duplicated). Actions Taken and Status As noted within the portal filing summary for the general reporting Period 2, the Corporation?s consolidated lost revenue totaled $113,690,616. Payments from the PRF for Period 1 and 2 totaled $25,713,324 for the consolidated parent, $5,571,616 for Ashland Community Healthcare Services, and $1,810,465 for Asante Three Rivers per Period 2 targeted reports. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the ?condition found? section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions. Person responsible for the implementation of the corrective action plan: Heather Rowenhorst, Chief Financial Officer Asante Health System
Condition: During compliance testing of the District's accounting records to the expenditure reports filed with the Illinois State Board of Education, we noted the District claimed one expenditure of which was not allowable per the budget detail function code, resulting in questioned costs of $279. ...
Condition: During compliance testing of the District's accounting records to the expenditure reports filed with the Illinois State Board of Education, we noted the District claimed one expenditure of which was not allowable per the budget detail function code, resulting in questioned costs of $279. Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Anticipated Date of Completion: 6/30/23. Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools. Management Response: While this grant program was already finalized, the District will consider amending future budgets with ISBE prior to the grant end date.
View Audit 16420 Questioned Costs: $1
Finding Number: 2022-002 Finding Title: Procurement Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Kevin Venenga Corrective Action Planned: The first step of our planned action is to rev...
Finding Number: 2022-002 Finding Title: Procurement Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Kevin Venenga Corrective Action Planned: The first step of our planned action is to review and update our policy to ensure that all current criteria for procurement are appropriately addressed. The second step will we be establishing a documentation procedure for the type of transactions and vendors used for our multi-year equipment replacement procurement items. Anticipated Completion Date: December 31, 2023
Finding Number: 2022-001 Finding Title: Procurement Policy Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Kevin Venenga Corrective Action Planned: A review of our current policy is under...
Finding Number: 2022-001 Finding Title: Procurement Policy Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Kevin Venenga Corrective Action Planned: A review of our current policy is underway, and it will be updated appropriately to meet all federal requirements. Anticipated Completion Date: 12/31/2023
Finding 12225 (2022-002)
Significant Deficiency 2022
FINDINGS?FINANCIAL STATEMENT AUDIT SIGNIFICANT DEFICIENCY 2022-001 Preparation of Annual Financial Report Recommendation: CLA recommends the County continue reviewing the annual financial report. Such review procedures should be performed by an individual possessing a thorough understanding of accou...
FINDINGS?FINANCIAL STATEMENT AUDIT SIGNIFICANT DEFICIENCY 2022-001 Preparation of Annual Financial Report Recommendation: CLA recommends the County continue reviewing the annual financial report. Such review procedures should be performed by an individual possessing a thorough understanding of accounting principles generally accepted in the United States of America and knowledge of the System?s activities and operations. While it may not be cost beneficial to train additional staff to completely prepare the report, a thorough review of this information by appropriate staff of the County is necessary to obtain a complete and adequate understanding of the County?s annual financial report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management believes the cost for additional staff time and training to prepare year-end closing entries and reports outweigh the benefits to be received. Management has reviewed and approved the annual financial report prior to issuance. Name of the contact person responsible for corrective action: Lynnette Lorenz, Administrator Planned completion date for corrective action plan: December 31, 2023
Recommendation: Southwell Obligated Group should continue to improve its understanding of the reporting requirements as specified in the USDA loan documents and create a process to ensure reports are submitted in a timely manner. Planned Corrective Action: Southwell Obligated Group will establish a ...
Recommendation: Southwell Obligated Group should continue to improve its understanding of the reporting requirements as specified in the USDA loan documents and create a process to ensure reports are submitted in a timely manner. Planned Corrective Action: Southwell Obligated Group will establish a calendar schedule of key dates and required reports by July 31, 2023. This Calendar will be managed by the Controller and reviewed by the Senior Vice President ? Chief Financial Officer. Reports not previously submitted timely have now been submitted.
View Audit 16400 Questioned Costs: $1
Department of Housing and Urban Development Federal Financial Assistance Listing #14.871 Section 8 Housing Choice Vouchers Program Special Tests and Provisions: Housing Quality Standards Failed Inspections Material Weakness Finding Summary: Metro West Housing Solutions did not perform re-inspection...
Department of Housing and Urban Development Federal Financial Assistance Listing #14.871 Section 8 Housing Choice Vouchers Program Special Tests and Provisions: Housing Quality Standards Failed Inspections Material Weakness Finding Summary: Metro West Housing Solutions did not perform re-inspections of 6 failed inspections within the prescribed 30-day HAP requirement during 2022. Responsible Individuals: Tillie Wright, HCV Administrator Corrective Action Plan: It was decided that adding back the position of in-house full-time inspector and an additional Section 8 Housing Specialist was the step needed to better keep on top of inspections. The inspector was hired on 6/22/2023 and started work on 07/10/2023. He has passed his HQS training test. In addition, he, and HCV Administrator both did a short training on the Inspection Module through Yardi. He is currently shadowing the former in-house inspector who is employed at MWHS in a different position. Once the new inspector is fully trained, the HCV Administrator plans to shift some responsibilities over to him, including scheduling and coordination of inspections both in house and 3rd party, insuring all the PIC submissions are entered, and monitoring all failed inspections. The Section 8 team was short staffed most of 2022. They will be fully staffed including the additional team member on 8/13/2023 when two new hires start. Anticipated Completion Date: We anticipate the inspector will be fully trained by mid-August 2023 and after training will slowly start taking over duties from the HCV Administrator over the next 30 days. The two new Specialists should be trained by the end of September and staff case loads will be redistributed in the next few months following that.
Finding 12195 (2022-002)
Significant Deficiency 2022
Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023...
Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan This issue is a result of no manual or system controls in place to prevent disbursement of financial aid to a student?s account if a student?s federal financial aid award notification was not yet communicated. This issue was corrected as soon as it was identified by changing our procedures to require Pell notification letters be sent as soon as funds are awarded and before funds are disbursed to a student?s account. As an additional precaution, Pell notification letters will be added to the nightly batch process in PeopleSoft to ensure letters are sent timely. Financial aid staff will also receive additional training in this area. Timing Procedures will be changed in May 2023 by Riley Niemand, Manager of Financial Aid, to require Pell notification letters be sent as soon as funds are awarded and prior to funds being disbursed to a student?s account. During May 2023, Riley Niemand will also provide additional training to financial aid staff in this area. Additionally, Riley Niemand started working with a consultant to add Pell notification letters to the daily batch process. This work is expected to be complete by June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109
Finding 12194 (2022-001)
Significant Deficiency 2022
Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Pr...
Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan The prior year corrective action plans were successful in addressing the issues identified in previous audits in enrollment reporting. These additional steps will be taken to address the new issues found during the 2022 audit within enrollment reporting, which resulted in a repeat finding of 2021-001. Grayson Layton, Registrar, will review the College?s policies and procedures surrounding student enrollment and enrollment reporting, starting in May 2023 specifically as it relates to students that have withdrawn that are expected to return in the subsequent semester but fail to reenroll. Any changes in the College?s policies and procedures will be appropriately documented and communicated to the individuals involved in updating student enrollment information in the system. Additionally, Enrollment Services will work with a PeopleSoft consultant and technical staff to customize our Student Information System to allow for the correct reporting of student status to the National Student Clearinghouse (NSC). Technical staff and a consultant will be engaged to perform an evaluation of all systems and practices related to enrollment reporting. The Enrollment Services and Financial Aid and Scholarships Offices will use various NSC and National Student Loan Data System (NSLDS) error reports to ensure student enrollment information, including program level information, is reported in an accurate and timely manner. Timing Grayson Layton, Registrar, will work with consultants and technical staff starting in May 2023 to begin making necessary adjustments to the Student Information System to allow for accurate reporting of student enrollment information and to evaluate systems and practices related to enrollment reporting. They will meet monthly throughout the year to monitor their progress with an expected completion in December 2023. Grayson and Riley Niemand, Manager of Financial Aid, will coordinate the use of NSC and NSLDS error reports to identify students with reporting errors. This process will be complete in June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109
Contact Person Jolene Palme, Finance Manager Corrective Action Plan We are in the process of updating the Center?s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2023
Contact Person Jolene Palme, Finance Manager Corrective Action Plan We are in the process of updating the Center?s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2023
Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID 19 HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund Management agrees with this find...
Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID 19 HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund Management agrees with this finding and performed a review of claims submitted to the HRSA COVID 19 Uninsured Program identifying payments for ineligible services and refunded the entire overpayment amount. In March 2022, HRSA announced the discontinuance of the HRSA COVID 19 Uninsured Program, and therefore, remediation of internal controls is no longer applicable. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.
View Audit 16159 Questioned Costs: $1
Federal Grantor: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution All expenditures included by VUMC Management (Management) in its sub...
Federal Grantor: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution All expenditures included by VUMC Management (Management) in its submissions in the Department of Health and Human Services (HHS) portal were verified against HHS guidance to ensure allowability. Management understands that additional audit evidence must be retained at a detailed enough level to allow the auditor to meet their reperformance standard. Management believes that our control risk is mitigated by the fact that our lost revenues far exceed any provider relief funding received. However, should management need to report any future eligible expenses in the HHS portal, we will retain additional audit evidence to enable auditor reperformance of the controls regarding allowability of expenditures. Management also established appropriate review and approval controls surrounding the performance and review of the lost revenue analytic and the subsequent reporting of lost revenue in the HHS portal. Management retained documentation to support execution of this control; however, Management understands that additional audit evidence supporting the reviews was not available to the auditor to evidence execution of this control. Management will retain additional audit evidence to allow the auditor to reperform execution of this control for future HHS portal submissions. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.
Grady’s corrective action plan: Grady Memorial Hospital Corporation will implement the control and process of completing an attestation assuring compliance with the review of the PRF data in the HRSA portal prior to submission. The review was completed online at the time of the submission but was no...
Grady’s corrective action plan: Grady Memorial Hospital Corporation will implement the control and process of completing an attestation assuring compliance with the review of the PRF data in the HRSA portal prior to submission. The review was completed online at the time of the submission but was not formally documented. This will be done and retained by Grady as support going forward
Finding 11724 (2022-001)
Significant Deficiency 2022
This finding was disclosed in Fall 2023. Upon disclosure, new procedures were implemented for payroll review. Upon completion of payroll by ABC Accounting and Bookkeeping, a review is completed by a second member of the ABC Accounting and Bookkeeping team and/or the HistoriCorps Executive Director...
This finding was disclosed in Fall 2023. Upon disclosure, new procedures were implemented for payroll review. Upon completion of payroll by ABC Accounting and Bookkeeping, a review is completed by a second member of the ABC Accounting and Bookkeeping team and/or the HistoriCorps Executive Director.
The City has identified federal grants subject to the Uniform Guidance and will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions.
The City has identified federal grants subject to the Uniform Guidance and will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions.
The City will develop written standards of conduct in that satisfy the requirements of 2 CFR § 200.318(c)(1).
The City will develop written standards of conduct in that satisfy the requirements of 2 CFR § 200.318(c)(1).
The City has identified federal grants subject to the Uniform Guidance and will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
The City has identified federal grants subject to the Uniform Guidance and will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
The City has identified federal grants subject to the Uniform Guidance and will develop written procedures to implement the requirements of 2 CFR § 200.305 Payment.
The City has identified federal grants subject to the Uniform Guidance and will develop written procedures to implement the requirements of 2 CFR § 200.305 Payment.
Future wage decisions will be submitted to Finance. Grants Department to complete monthly review to verify information.
Future wage decisions will be submitted to Finance. Grants Department to complete monthly review to verify information.
Finding 11520 (2022-001)
Significant Deficiency 2022
Corrective Action Plan for La Jolla Music Society Audit Finding 2022-001 Finding No. 2022-001 – LJMS did not have policies in place to ensure the single audit was submitted timely (See Corrective Action Plan for La Jolla Music Society) Criteria – 45 CFR 75.501 requires a non-Federal entity that expe...
Corrective Action Plan for La Jolla Music Society Audit Finding 2022-001 Finding No. 2022-001 – LJMS did not have policies in place to ensure the single audit was submitted timely (See Corrective Action Plan for La Jolla Music Society) Criteria – 45 CFR 75.501 requires a non-Federal entity that expends $750,000 or more during the non_x0002_Federal entity’s fiscal year in Federal awards must have a single or program-specific audit conducted for that year. Audits must be completed and submitted within 30 days after receipt of the auditor’s report, or 9 months after the end of the audit period, whichever is earlier. Condition/Context – LJMS did not submit a single audit in a timely manner to be in compliance with the audit requirement under 45 CFR 75.501. LJMS did not meet its reporting deadline. Cause – LJMS was unable to meet the deadline due to certain delays in becoming aware of the compliance requirement. Effect – Audit was not performed and submitted in a timely manner. LJMS has not met the reporting requirements under 45 CFR 75.501. Recommendation – We recommend that LJMS obtain a single audit for each year that it meets the audit requirement of 45 CFR 75.501. Corrective Action Plan- LJMS will identify grants with federal funding and evaluate whether or not a single audit is required. When an audit is required they will plan to complete the audit within the deadline. The September 30, 2022 audit and Data Collection Form will be filed within 30 days of issuance of the report. Contact Person: Karin Burns, Director of Finance Anticipated Completion: February 28, 2024
Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, ma...
Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, management plans to collaborate with its Payroll Service Provider to capitalize on software upgrades, aiming to enhance the accuracy of Time & Allocation to grants and reduce errors by designing straight-through-process improvements. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: April 2024
Corrective Action: Management will review all cost allocations and implement documented policies and procedures to ensure sufficient support of any allocations of costs is maintained as required by 2 CFR §200.403. In addition, Management has developed a cost allocation worksheet and framework and is...
Corrective Action: Management will review all cost allocations and implement documented policies and procedures to ensure sufficient support of any allocations of costs is maintained as required by 2 CFR §200.403. In addition, Management has developed a cost allocation worksheet and framework and is in the process of implementing a new procedure to ensure it is reviewed by accounting and grant managers to ensure accurate reporting. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: March 2024
Corrective Action: Management will enhance existing procedures within the Grant Accounting process for Request for Reimbursement, aiming to identify controls to ensure credits appropriately reduce the requested funds or that any additional funds are promptly returned in compliance with 2 CFR §200.40...
Corrective Action: Management will enhance existing procedures within the Grant Accounting process for Request for Reimbursement, aiming to identify controls to ensure credits appropriately reduce the requested funds or that any additional funds are promptly returned in compliance with 2 CFR §200.406. Additionally, the Grant Accounting team will conduct extra training sessions for accounting staff and accounts payable personnel to enhance their proficiency in recognizing refunds and credits associated with grant expenses. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: January 2024
Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, ma...
Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, management plans to collaborate with its Payroll Service Provider to capitalize on software upgrades, aiming to enhance the accuracy of Time & Allocation to grants and reduce errors by designing straight-through-process improvements. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: April 2024
View Audit 15308 Questioned Costs: $1
Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, ma...
Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, management plans to collaborate with its Payroll Service Provider to capitalize on software upgrades, aiming to enhance the accuracy of Time & Allocation to grants and reduce errors by designing straight-through-process improvements. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: April 2024
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