Corrective Action Plans

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Neighborhood Medical Center does have a formal process in place to ensure that the amount requested for payroll complies with the annual salary limitations required by HRSA. We were in the middle of moving from Quick Books to Work Force Go payroll system during this time. It appears that the perce...
Neighborhood Medical Center does have a formal process in place to ensure that the amount requested for payroll complies with the annual salary limitations required by HRSA. We were in the middle of moving from Quick Books to Work Force Go payroll system during this time. It appears that the percentage used to help us ensure this does not occur was omitted. It has been reviewd, and the information is in place to ensure the error will not occur again.
View Audit 358122 Questioned Costs: $1
Taylor Regional Hospital, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2022. The finding from the March 31, 2022 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule...
Taylor Regional Hospital, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2022. The finding from the March 31, 2022 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAM AUDIT FINDING Material Weakness (2022-001) Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure accuracy and completion of the Hospital's Schedule. Planned Corrective Action: The 2022 Schedule was restated to reflect the two federal grants that were originally omitted. The Hospital will design and implement controls over financial reporting to ensure all grants are properly included on the Schedule in accordance with reporting requirements. Jonathon L. Green Chief Executive Officer
Finding No. 2022-008: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time to the related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and mai...
Finding No. 2022-008: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time to the related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and maintained in the shared file for immediate availability and reference.
View Audit 357068 Questioned Costs: $1
Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...
Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% Federal poverty level (FPL) with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the FPL. Patients whose incomes are above 100% or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of nondiscrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.
View Audit 357068 Questioned Costs: $1
Finding No. 2022-006: Inadequate System to Ensure Timely Filing and Review of Required Reports As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas the timely filing and review of required reports (e.g., Federal F...
Finding No. 2022-006: Inadequate System to Ensure Timely Filing and Review of Required Reports As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas the timely filing and review of required reports (e.g., Federal Financial Report (FFRs)) are now expected to be filed according to the prescribed deadline(s).
Finding 2022-005: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically des...
Finding 2022-005: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically designated to cover payroll costs, this process now includes the following: • A drawdown allocation schedule for the employee’s making up the amount requested • A budget breakdown by department for the amounts making up the drawdown request • A supporting schedule and related invoices for amounts to be reimbursed (e.g., malpractice insurance, etc.) • A completed Standard Form (SF) 270 that tracks the applicable grant amounts previously drawdown that also specifies the amount to be currently drawn.
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: The Council will develop FFATA reporting policies and procedures to submit subaward information through FSRS to ensure compliance with FFATA requirements. Proposed Completion Date: June 30, 2025
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: The Council will develop FFATA reporting policies and procedures to submit subaward information through FSRS to ensure compliance with FFATA requirements. Proposed Completion Date: June 30, 2025
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments have been filled to ensure that the Council follows internal control policies over grant reporting. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments have been filled to ensure that the Council follows internal control policies over grant reporting. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to miscommunication and turnover of accounting personnel, a misunderstanding arose regarding the collateralization of the Council’s general checking account to which federal awards are deposited. The financial institution...
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to miscommunication and turnover of accounting personnel, a misunderstanding arose regarding the collateralization of the Council’s general checking account to which federal awards are deposited. The financial institution utilizes a repurchase agreement by which the daily remaining collected balance in the checking account is invested by the bank, acting as agent of the Council. Securities purchased are exclusively obligations of the U.S. government and/or its agencies, or municipal bonds rated A or better. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies over payroll transactions. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies over payroll transactions. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies over cash disbursements. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies over cash disbursements. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies relating to timely and accurate reporting. Proposed Completion Date: Complete as of J...
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies relating to timely and accurate reporting. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council is in compliance with Uniform Guidance Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council is in compliance with Uniform Guidance Proposed Completion Date: Complete as of June 30, 2024
Federal Agency Name: Department of Agriculture Federal Assistance Listing #10.766 Program Name: Community Facilities Loan and Grants Cluster Finding Summary: The Medical Center does not have an internal control system designed to identify the reports that need to be filed with the USDA. In addition,...
Federal Agency Name: Department of Agriculture Federal Assistance Listing #10.766 Program Name: Community Facilities Loan and Grants Cluster Finding Summary: The Medical Center does not have an internal control system designed to identify the reports that need to be filed with the USDA. In addition, there is not a mechanism to ensure various reports are filed timely. Corrective Action Plan: Internal controls will be updated to have a formalized process established that identifies the three reports that need to be filed and the required due dates. We will have these reports reviewed and approved by the Board of Directors prior to submission. Responsible Individuals: Judy Monson, CFO; Nikki Lindsey, CEO Anticipated Completion Date: June 30, 2025
Finding 2022-003 Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name: Community Facilities Loan and Grants Cluster Federal Agency Name: Department of Treasury Federal Assistance Listing #21.027 Program Name: COVID 19 Coronavirus State and Local Fiscal Recove...
Finding 2022-003 Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name: Community Facilities Loan and Grants Cluster Federal Agency Name: Department of Treasury Federal Assistance Listing #21.027 Program Name: COVID 19 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for a complete and accurate schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the schedule of expenditures. We have designated a member of management to review the drafted schedule of expenditures. Responsible Individuals: Judy Monson, CFO; Nikki Lindsey, CEO Anticipated Completion Date: Ongoing
PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks Condition/Cause The Authority did not properly report program inc...
PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks Condition/Cause The Authority did not properly report program income in IDIS during the year, and therefore could not support that program income was applied prior to drawing down entitlement funding. In some instances, program income received was not reported in IDIS, and one receipt was entered into IDIS twice. When received, program income is reported in a separate general ledger account in the financial reporting software. The Fiscal Officer then enters the program income into IDIS on a regular basis. No control exists to ensure completeness or accuracy of information entered into IDIS related to program income. Recommendation We recommend the Authority develop a procedure/internal control to ensure program income is entered accurately and completely within IDIS. This will allow for documentation to support that program income is being utilized prior to drawing down entitlement funding. This will also ensure compliance with reporting requirements for reports generated within IDIS on an annual basis. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval.
View Audit 355767 Questioned Costs: $1
Finding 556195 (2022-003)
Material Weakness 2022
Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploa...
Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploading the required reporting templates and we now has multiple people with access to the reporting portal and in the event of staff turnover we can continue to submit required reports. The Human Services Manager and the Budget and Finance Analyst have created reminders on their calendars to ensure reporting is completed on time and with accurate data.
Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal cost principals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...
Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal cost principals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: VSS agrees with CLA and has updated our financial policies to include electronic approval of expenditures through Bill.com. Timesheets and supplements will be reviewed and approved by staff supervisors biweekly to ensure proper allocation of hours worked. Credit Card Expense reports will require Description of item purchased, as well as the funder and class allocation. Name(s) of the contact person(s) responsible for corrective action: Jessica Franco, Director of Finance Planned completion date for corrective action plan: 3/1/2023
View Audit 353736 Questioned Costs: $1
RECOMMENDATION: Create a property management system and adopted written policies and procedures. These procedures should be reviewed and updated to, at a minimum, adhere to the newest federal guidelines under OMB Uniform Guidance. Physical inventories should be performed periodically and reconciled ...
RECOMMENDATION: Create a property management system and adopted written policies and procedures. These procedures should be reviewed and updated to, at a minimum, adhere to the newest federal guidelines under OMB Uniform Guidance. Physical inventories should be performed periodically and reconciled to the property management records. Property management records should also include copies of the original asset purchase documentation. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.
RECOMMENDATION: Develop and adopt a new policy over bank reconciliations.Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.
RECOMMENDATION: Develop and adopt a new policy over bank reconciliations.Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.
RECOMMENDATION: Proper completion of the timesheet or development of a timesheet which requires the coding. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.
RECOMMENDATION: Proper completion of the timesheet or development of a timesheet which requires the coding. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.
RECOMMENDATION: Auditors recommend the governing board require proper documentation on all types of expenditures. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.
RECOMMENDATION: Auditors recommend the governing board require proper documentation on all types of expenditures. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.
1. RSNEO will finalize engagement with external auditors no later than six months prior to the audit submission deadline. This will allow adequate time for planning, fieldwork, internal review, and final report preparation, ensuring a timely and thorough audit process. 2. A dedicated compliance o...
1. RSNEO will finalize engagement with external auditors no later than six months prior to the audit submission deadline. This will allow adequate time for planning, fieldwork, internal review, and final report preparation, ensuring a timely and thorough audit process. 2. A dedicated compliance officer will be assigned to oversee the Single Audit process. This individual will be responsible for tracking critical deadlines, coordinating with internal departments, and serving as the main point of contact with external auditors to ensure seamless communication and adherence to timelines. 3. We will establish a comprehensive audit timeline outlining all key milestones, including fieldwork initiation, internal review periods, and draft/final report submission dates. Regular check-ins will be scheduled to monitor progress, address issues promptly, and ensure the audit stays on track. 4. A document submission schedule will be implemented to ensure timely provision of required records to the auditors. Internal departments will be informed of their roles and responsibilities in advance, including specific deadlines for document submission, to enhance coordination and preparedness 5. An escalation process will be developed to manage unforeseen delays or complications during the audit. This will include steps for reallocating resources, providing additional support for internal review, and identifying alternative solutions to ensure timely resolution of outstanding items
Align Reimbursement Requests with the General Ledger Ensure that all reimbursement requests are directly tied to actual expenditures recorded in the general ledger, minimizing reliance on manual tracking. 1. 2022-005: We will ensure that all reimbursement requests are accurately aligned with t...
Align Reimbursement Requests with the General Ledger Ensure that all reimbursement requests are directly tied to actual expenditures recorded in the general ledger, minimizing reliance on manual tracking. 1. 2022-005: We will ensure that all reimbursement requests are accurately aligned with the general ledger by basing them solely on actual, recorded expenditures. This will reduce reliance on manual tracking methods and promote transparency, accuracy, and compliance in grant reporting. Implement a Systematic Reconciliation Process Establish a structured reconciliation process that links each reimbursement request to paid expenses, with supporting documentation readily available for review. 2. A formal reconciliation process will be implemented to connect each reimbursement request to the corresponding paid expenses. Supporting documentation will be organized and readily accessible for internal review and external audits, ensuring a complete and accurate audit trail. Strengthen Real-Time Grant Cash Flow Tracking Utilize existing accounting software to have a real-time tracking system for grant-related cash flow to ensure compliance with reimbursement-based grant requirements. 3. We will utilize our existing accounting software to enable real-time tracking of grant-related cash inflows and outflows. This will improve our ability to monitor available funds, ensure timely reimbursement submissions, and remain compliant with reimbursement-based grant requirements. Assign a Grant Compliance Lead Designate a finance or administrative team member to oversee cash management compliance, ensuring consistency and acting as the primary point of contact for grant related financial matters. 4. A dedicated member of the finance or administrative team will be assigned as the Grant Compliance Lead. This individual will oversee all aspects of grant cash management compliance, maintain documentation standards, and serve as the primary point of contact for grant-related financial matters. Conduct Monthly Reconciliation Meetings Facilitate monthly reconciliation meetings between finance and program teams to align financial records with program expenditures and address any discrepancies proactively. 5. Monthly reconciliation meetings will be held between the finance and program teams to review financial records, align them with program expenditures, and proactively address any discrepancies. This collaboration will support accurate reporting and effective grant management.
View Audit 353523 Questioned Costs: $1
Recommendation: Strengthen controls over compliance, reporting, and cost allocation. Action Plan: - Immediate Actions (Q2 2024): - Review and document grant compliance requirements. - Implement a structured approval process for financial reports. - Long-Term Actions: - Conduct quarterly compliance t...
Recommendation: Strengthen controls over compliance, reporting, and cost allocation. Action Plan: - Immediate Actions (Q2 2024): - Review and document grant compliance requirements. - Implement a structured approval process for financial reports. - Long-Term Actions: - Conduct quarterly compliance training for grant managers (Q3 2024). - Engage an external consultant for a mid-year compliance review (Q4 2024). Responsible: John Opalinski Completion Date: Within 3 months of CAP issuance.
View Audit 353270 Questioned Costs: $1
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