Corrective Action Plans

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FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting...
FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance related to the eligibility determination of a child receiving meals. The School Corporation could not provide documentation supporting the eligibility for 10 of 40 students that received free or reduced-price meals for fiscal year 2022-2023. Of the 30 students for which documentation was provided, the School Corporation could not provide documentation that the one student’s benefits were calculated properly. Due to the lack of supporting documentation we were unable to determine the School Corporation's compliance with the Eligibility compliance requirement. Contact Person Responsible for Corrective Action: Juli Windsor Contact Phone Number:765-689-9131 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: This will include all reimbursements which are submitted to the treasurer must be signed by the school cafeteria managers and the food service director. The school will also implement policies to ensure that the Verification of Free and Reduced-Price applications have an adequate internal control to ensure the validity of the free and reduced applications. This will provide for segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place. Anticipated Completion Date: April 2024
Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will now...
Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will now scan in the physical intake form that Adult ESL students self-report their eligibility status for MA DESE ACLS as well as have the student sign that form. This form will be stored electronically in addition to the information from the form being entered into the Adult ESL Access database and LACES . Name(s) of the contact person(s) responsible for corrective action: Dr. Kevin O’Connor, Claudia Castro Alves and Kate Fiore Planned completion date for corrective action plan: Effective as of 08/01/2024
Recommendation: We recommend procedures to maintain records that accurately reflect the work performed for payroll charges to the grant be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: T...
Recommendation: We recommend procedures to maintain records that accurately reflect the work performed for payroll charges to the grant be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will be collecting the Time and Effort certifications for staff on Federal grants. Name(s) of the contact person(s) responsible for corrective action: Dr. Kevin O’Connor, Claudia Castro Alves and Kate Fiore Planned completion date for corrective action plan: Effective as of 10/10/2024 so will have Time and Effort certifications for all FY25 staff on Federal grant #2340
View Audit 326124 Questioned Costs: $1
2023-003 Name of Contact Person: Matthew Roy Corrective Action: Greenheart is in the process of establishing a timecard system for all staff who work on grants and have their time allocated to a grant. In the meantime, in early 2024, the Grants Director worked directly with payroll and department le...
2023-003 Name of Contact Person: Matthew Roy Corrective Action: Greenheart is in the process of establishing a timecard system for all staff who work on grants and have their time allocated to a grant. In the meantime, in early 2024, the Grants Director worked directly with payroll and department leaders to review and update the list of personnel who are working on the grant. This was a documented process. Proposed Completion Date: Management considers this finding resolved as of August 2024.
View Audit 326064 Questioned Costs: $1
Finding 2023-001: Internal Control over Compliance Type of finding: Internal Control (material weakness) and Compliance (noncompliance) Recommendation: The Organization should strengthen its internal controls over year-end financial close and reporting with adopted policies and procedures to ensure ...
Finding 2023-001: Internal Control over Compliance Type of finding: Internal Control (material weakness) and Compliance (noncompliance) Recommendation: The Organization should strengthen its internal controls over year-end financial close and reporting with adopted policies and procedures to ensure compliance with the Report submission portion of the Uniform Administrative Requirements, Cost Principles, and Audit Requirements section. Action Taken: The Organization plans to strengthen internal controls by adopting methods that allow for better tracking of restricted versus unrestricted funding, in addition to creating internal methods of tracking income, expense, and reporting of restricted funds throughout the year. The Organization took action with a change in management and a new external bookkeeper, which will allow the above processes to be completed with oversight from both internal and external sources. If there are questions regarding this plan, please call the responsible party listed below. Thank you, Laura Cusick Executive Director Rio Grande Headwaters Land Trust Laura@Rightslv.org (719)657-0800
SafeQuest Solano will implement stronger internal controls and procedures to ensure timely submission of the DCF. This will include designating a responsible party for tracking and submitting the DCF, creating a timeline and checklist for required submissions, and conducting periodic reviews to ensu...
SafeQuest Solano will implement stronger internal controls and procedures to ensure timely submission of the DCF. This will include designating a responsible party for tracking and submitting the DCF, creating a timeline and checklist for required submissions, and conducting periodic reviews to ensure compliance with deadlines. Additionally, SafeQuest Solano will provide training to relevant staff on the importance of meeting federal compliance requirements. SafeQuest Solano has already implemented a new database system.
View Audit 325788 Questioned Costs: $1
SafeQuest Solano will revise its procedures for recording expenditures to ensure compliance with Uniform Guidance, particularly with regard to the timing of expense recognition. SafeQuest Solano will implement controls that prevent expenditure from being recorded before the related checks are cashed...
SafeQuest Solano will revise its procedures for recording expenditures to ensure compliance with Uniform Guidance, particularly with regard to the timing of expense recognition. SafeQuest Solano will implement controls that prevent expenditure from being recorded before the related checks are cashed. Accounting staff will receive additional training on these requirements and consider implementing periodic internal reviews to ensure ongoing compliance.
View Audit 325788 Questioned Costs: $1
Recommendation: We recommend that the Organization implement procedures to document and maintain the documentation to support the controls over compliance are not only properly designed but are working. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...
Recommendation: We recommend that the Organization implement procedures to document and maintain the documentation to support the controls over compliance are not only properly designed but are working. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Waldorf has established procedures that instead of a second person simply reviewing the first person’s work, that we sign off and date at the time of review. If we cannot sign off in person, we will send an email for confirmation of the review for later documentation. We had the controls in place but lacked the proper documentation. We believe with implementing these items as our procedure will resolve this finding. Name(s) of the contact person(s) responsible for corrective action: Duane Polsdofer Planned completion date for corrective action plan: Immediately
Finding 503523 (2023-004)
Significant Deficiency 2023
Recommendation: We recommend that the Organization review its procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...
Recommendation: We recommend that the Organization review its procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Waldorf experienced 100% turnover in the Business Office personnel. The new personnel established new policies and procedures while training on new financial software SageIntacct. New payroll software, Inova, and working to learn two existing ERP systems that were not synced. The Business Office help identify uncashed stipend checks in a timely manner. The new systems and new reports created will assist in the identification of these uncashed checks so they can be corrected. The Financial Aid Office and Business Office leadership are working closely together on this continuous endeavor. We believe together with new personnel this matter will be resolved. Name(s) of the contact person(s) responsible for corrective action: Duane Polsdofer Planned completion date for corrective action plan: November 1, 2024
Recommendation: We recommend that the Organization immediately start searching for a replacement controller and potentially look into outsourcing that position if necessary. There is no disagreement with the audit finding. Action taken in response to finding: Waldorf University posted, interviewed...
Recommendation: We recommend that the Organization immediately start searching for a replacement controller and potentially look into outsourcing that position if necessary. There is no disagreement with the audit finding. Action taken in response to finding: Waldorf University posted, interviewed, and hired an accountant who will begin duties on September 9, 2024. The university has also contracted with a CPA firm for additional software training, audit prep, and regulations. Name(s) of the contact person(s) responsible for corrective action: Daisy Halvorson Planned completion date for corrective action plan: September 9, 2024 and continuous.
Finding 503387 (2023-011)
Material Weakness 2023
Views of Responsible Officials and Planned Corrective Action - The County has created a documented process in the new policy and procedures manual for federal guidelines. Separation of duties has been implemented. Robert Placencio, Finance Director will be reviewing and approving these reimbursement...
Views of Responsible Officials and Planned Corrective Action - The County has created a documented process in the new policy and procedures manual for federal guidelines. Separation of duties has been implemented. Robert Placencio, Finance Director will be reviewing and approving these reimbursements moving forward. Responsible Official - Andrea Montoya, Deputy County Manager and Robert Placencio, Finance Director Timeline and Estimated Completion Date - October 10, 2024.
2023-005: U.S. Department of Agriculture - Soil and Water Conservation - Assistance Listing #10.902 Reporting: Material Weakness in Internal Control over Compliance and Material Non-Compliance Finding Summary: Due to an error with the online submission portal, Wallowa Resources was unable to submit...
2023-005: U.S. Department of Agriculture - Soil and Water Conservation - Assistance Listing #10.902 Reporting: Material Weakness in Internal Control over Compliance and Material Non-Compliance Finding Summary: Due to an error with the online submission portal, Wallowa Resources was unable to submit the required information to FSRS. Corrective Action Pan: USDA fixed the online submission portal in September 2024, and Wallowa Resources immediately submitted the required information to FSRS. Wallowa Resources will ensure that any future obligations to first-tier subrecipients will be reported via FSRS in a timely manner. Responsible Individual(s): Joni Maasdam, Finance Manager. Anticipated Completion Date: Completed September 2024.
View Audit 325232 Questioned Costs: $1
Condition: A Single Audit was not timely completed for the fiscal reporting years noted. The years ending December 31, 2023, and 2022. Planned Corrective Action: The Comstock Community Center has established internal guidelines for identifying future Single Audit requirements and will seek clarific...
Condition: A Single Audit was not timely completed for the fiscal reporting years noted. The years ending December 31, 2023, and 2022. Planned Corrective Action: The Comstock Community Center has established internal guidelines for identifying future Single Audit requirements and will seek clarification with any federal granting agencies related to filing requirements each year. Additionally, as evidenced by the filing of this report, the Comstock Community Center has performed the audit for the year ending December 31, 2023. Contact person responsible for corrective action: Mary T. Gustas, Executive Director, Michelle WhitePaster, Account Manager Anticipated Completion Date: The necessary adjustments have been made to the Community Center’s records and are appropriately presented in the financial statements. Accordingly, no further corrective action is deemed necessary.
Finding 2023-005 Accuracy of Federal Reports POF's initial and current exposure a few months later to Single Audit compliance requirements have sharpened its focus on the need to purposefully identify and maintain corroborating evidence regarding its timely submission and acceptance by each of the ...
Finding 2023-005 Accuracy of Federal Reports POF's initial and current exposure a few months later to Single Audit compliance requirements have sharpened its focus on the need to purposefully identify and maintain corroborating evidence regarding its timely submission and acceptance by each of the respective funding sources. While POF believes that all these reporting requirements were timely met and accepted by all funding sources, It did not consistently maintain either the report itself, or the related documentation such as copies of the emails sent or the associated read-receipts as evidence of these reports. Effective July 1, POF routinely and consistently accumulated and organized these documents as well as ancillary evidence of their transmission to, receipt by, and acknowledgement of acceptance by the federal agency. POF will be more diligent in its transmissions to funders. POF noted that the 2022 Closeout Report was inexplicably re-submitted instead of the correct 2023 Closeout Report. This is unacceptable, and POF will add a second set of reviews by a second person to improve quality control in this area. As necessary, POF will seek professional education and advice in implementing policies, practices, and procedures in addition to those already described herein.
Finding 2023-004 Adequate Allowable Cost Documentation As indicated in the 2022 POFCAP response to Finding 2022-003, and as reiterated herein, POF began to implement additional internal control procedures and practices effective July 1, 2024, to ensure that underlying cost documentation is adequate...
Finding 2023-004 Adequate Allowable Cost Documentation As indicated in the 2022 POFCAP response to Finding 2022-003, and as reiterated herein, POF began to implement additional internal control procedures and practices effective July 1, 2024, to ensure that underlying cost documentation is adequate, reasonable, and complete in accordance with 2 CFR Part 200 Subpart E and other regulatory requirements. More specifically, vendor invoices as of that date and related supporting documents such as weekly meeting reports and sign-in sheets are being scanned and retained electronically. As in 2022, the contact information from the 2023 weekly reports was transmitted to either Wright State University or The Ohio State University for data mining purposes. On July 22, 20224, the POF Board of Directors unanimously adopted the POF Record Retention Policy, as recommended by the auditors. The Board also unanimously adopted a Code of Conduct along with Conflict of Interest, and Whistleblower policies as further evidence of their commitment to instituting policies and procedures designed to strengthen internal controls and comply with federal regulations. Questioned Cost Totaling $19,179 Effective July 1, 2024, POF's new internal control policies, and procedures will eliminate or drastically reduce future discrepancies of this nature.
View Audit 325057 Questioned Costs: $1
Finding 502973 (2023-001)
Significant Deficiency 2023
Views of Responsible Officials and Planned Corrective Action – Grace House has created and will implement the following new controls: a) Every reimbursement request made by any employee will require approval from the Executive Director, Assistant Director, or board of directors vote where appropriat...
Views of Responsible Officials and Planned Corrective Action – Grace House has created and will implement the following new controls: a) Every reimbursement request made by any employee will require approval from the Executive Director, Assistant Director, or board of directors vote where appropriate. b) For rental invoices, the immediate supervisor must approve all rental invoices for payment processing before being submitted to the administrative office. If the immediate supervisor is absent, the invoice must be approved by the Executive Director or Assistant Director. c) When a new client invoice is submitted for approval for an existing approved landlord, the invoice along with the traditional client identifying information will be reviewed by both the immediate supervisor and the Executive Director.d) When a new client invoice is submitted for approval for a new landlord, the invoice will be reviewed by both the immediate supervisor and the Executive Director. Each invoice requires a W9 form to validate the legal name, property records verifying ownership matching the legal name on the W9, a picture ID of the individual listed on the W9, and a copy of the agreement if a property management company is listed on the W9 instead of an individual. e) All new clients and landlords will be researched through an investigative software to prove there is no evidence of false identity. f) Grace House has contracted an independent certified fraud investigator to conduct periodic reviews for compliance with fraud prevention policies at least semiannually but beginning quarterly through 2025
MATERIAL WEAKNESS 2023-002 Segregation of Duties and Control Documentation Recommendation: The University should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including number of internal staff), to determine whether addition...
MATERIAL WEAKNESS 2023-002 Segregation of Duties and Control Documentation Recommendation: The University should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including number of internal staff), to determine whether additional processes and controls over the financial records of the University are complete, accurate, and retained to support the University’s financial statement prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged an external consultant in June 2023, hired a new staff accountant in September 2023 and a CFO in November 2023. The University has begun to restructure all accounting and reconciliation functions, including implementation of new accounting software. The University is implementing financial internal controls to improve the financial statements preparation and preparation of the schedule of expenditures and federal awards. Name of the contact person responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024
MATERIAL WEAKNESS 2023-001 Financial Statement Preparation Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that ...
MATERIAL WEAKNESS 2023-001 Financial Statement Preparation Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that financial statement line items are properly stated and classified. Internally prepared financial statements should also be thoroughly reviewed by members of the board and management outside the finance department on a periodic (monthly or quarterly). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged an external consultant in June 2023, hired a new staff accountant in September 2023 and a CFO in November 2023. The University has begun to restructure all accounting and reconciliation functions, including implementation of new accounting software. The University is implementing financial internal controls to improve the financial statements preparation and preparation of the schedule of expenditures and federal awards. Name of the contact person responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024
Finding 2023-001 Federal Program Funds Utilized for Non-Federal Programs Recommendation: The Authority should locate additional sources of non-federal funds or reduce costs sufficiently so that the program can have enough cash to cover ongoing operations. Explanation of disagreement with audit findi...
Finding 2023-001 Federal Program Funds Utilized for Non-Federal Programs Recommendation: The Authority should locate additional sources of non-federal funds or reduce costs sufficiently so that the program can have enough cash to cover ongoing operations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has reevaluated its cost allocation plan, and restructured various department to better align staffing. This process helps ensure the COCC and funds are being properly charged for actual costs incurred. The Authority is also redeveloping its entire portfolio. This process had been and will continue to bring in developer and management fees to the COCC to help reduce the due to/due from activity. Name(s) of the contact person(s) responsible for corrective action: Cia Cook, Deputy Executive Director & CFO Planned completion date for corrective action plan: June 30, 2025
View Audit 324736 Questioned Costs: $1
Finding 2023-003 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Planned Corrective Actions: The Finance Department is continuing its efforts in establishing and enforcing internal deadlines to ensure the financial statements ar...
Finding 2023-003 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Planned Corrective Actions: The Finance Department is continuing its efforts in establishing and enforcing internal deadlines to ensure the financial statements are audited within the appropriate reporting deadlines. The department has shifted staff duties to ensure the FY24 financial statements will be completed within the appropriate reporting deadlines. Individual(s) Responsible for Corrective Action Plan Elizabeth Fischer (Finance Director) Jenna deLumeau (Controller) Anticipated Completion Date: The department has developed internal deadlines to ensure the FY24 financial statements will be completed within the appropriate reporting deadlines. This has been completed.
Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industr...
Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Winter 2025
View Audit 324609 Questioned Costs: $1
Action taken in response to finding: 1. Create a grant matrix to track employee grant allocations in one file: Complete 2. Utilize the matrix to apply allocation to each employee on every payroll occurrence: In Progress 3. Review the matrix with grant project managers monthly to ensure accuracy and ...
Action taken in response to finding: 1. Create a grant matrix to track employee grant allocations in one file: Complete 2. Utilize the matrix to apply allocation to each employee on every payroll occurrence: In Progress 3. Review the matrix with grant project managers monthly to ensure accuracy and capture changes: In Progress 4. Maintain records of for each payroll of grant matrix application: In progress Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024
View Audit 324609 Questioned Costs: $1
Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SOR program. Additio...
Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SOR program. Additionally, the OBHC team is currently working with the HCA in restructuring the rate schedule to incorporate the payroll costs into the direct service rates for the SOR/SABG grants. This effectively removes this issue going forward in FY25 once approved by the HCA. Name(s) of the contact person(s) responsible for corrective action: Patty Brandt Planned completion date for corrective action plan: Feb 2024 & Sep 2024
Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SABG program. Additi...
Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SABG program. Additionally, the OBHC team is currently working with the HCA in restructuring the rate schedule to incorporate the payroll costs into the direct service rates for the SOR/SABG grants. This effectively removes this issue going forward in FY25 once approved by the HCA. Name(s) of the contact person(s) responsible for corrective action: Patty Brandt Planned completion date for corrective action plan: Feb 2024 & Sep 2024
Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted...
Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted in an overhaul of the processes in place to properly develop the volunteer checklists and assure all records for staff and volunteers are now compliant. Our Quality and Compliance and Finance team worked closely with the new Program Manager to assure that we will be fully compliant and remain so.
View Audit 324497 Questioned Costs: $1
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