Corrective Action Plans

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2024-005 – Reporting Contact Person Terry Hanson Corrective Action Plan Management recognizes the delayed submission of the 2024 audit to the Federal Audit Clearinghouse. To prevent recurrence, management is developing a compliance calendar and assigning responsibility for federal filing deadlines t...
2024-005 – Reporting Contact Person Terry Hanson Corrective Action Plan Management recognizes the delayed submission of the 2024 audit to the Federal Audit Clearinghouse. To prevent recurrence, management is developing a compliance calendar and assigning responsibility for federal filing deadlines to the Director of Finance. Regular progress reviews will ensure all audit deliverables are completed and submitted within the required ninemonth period. This corrective measure will improve accountability and ensure timely compliance with federal reporting standards. Planned Completion Date for CAP Immediately
2024-004 – Reserve for Replacement Contact Person Terry Hanson Corrective Action Plan Management will request a waiver from HUD to cease deposits to the RFR Account until such time that the account falls below the HUD recommended minimum required deposit, per 4350.1. If waiver is not forthcoming, ma...
2024-004 – Reserve for Replacement Contact Person Terry Hanson Corrective Action Plan Management will request a waiver from HUD to cease deposits to the RFR Account until such time that the account falls below the HUD recommended minimum required deposit, per 4350.1. If waiver is not forthcoming, management will request that owner provide funding to RFR, until such time that the operating account balance reflects a positive balance and the property is able to deposit to RFR. Planned Completion Date for CAP Immediately
Finding Number: 2024-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Pla...
Finding Number: 2024-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality controls specific to the Medicaid program, will be reviewed and updated. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether documentation is sufficient, along with examples of acceptable support. At a minimum, required documentation will include: • Documentation verifying citizenship. • Examples of properly completed applications. • Reconciliation of the income verification in MAXIS and the documentation in the case file. • Reconciliation of the asset verification in MAXIS and the documentation in the case file. The Quality Assurance review process and Corrective Action Plan have been documented and communicated to provide guidance for new staff, serve as refresher training for existing staff, and ensure that appropriate actions are consistently followed. This documentation will be reviewed and revised as necessary to maintain compliance and consistency across the department. Supervisory review has been implemented for new hires. When issues are identified with current staff, enhanced review strategies and procedures will be applied to ensure required documentation is properly reviewed prior to case approval. Supervisors will conduct periodic reviews of case files to ensure that all required documentation is on file. If errors are identified and overpayments occur, the Department will follow established protocols of the Minnesota Department of Human Services regarding the identification, reporting, and recovery of overpayments. Anticipated Completion Date: 06/10/2026
Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently f...
Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2024, the Hospital should have USDA debt reserves at least equal to $459,326. Responsible Individuals: Doug B. Lewis, Chief Financial Officer Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.
Corrective Action Plan • Policies and Procedures Reinforcement – Review and reinforce procurement policies to ensure all purchases are supported by approved requisitions and required quotations. • Documentation Retention Controls - Implement controls to ensure all procurement documentation is proper...
Corrective Action Plan • Policies and Procedures Reinforcement – Review and reinforce procurement policies to ensure all purchases are supported by approved requisitions and required quotations. • Documentation Retention Controls - Implement controls to ensure all procurement documentation is properly filed and retrievable. • Staff Training and Development – Provide training on procurement requirements under uniform guidance. This training will focus on compliance with policies and procedures and emphasize the importance of require documentation for each process and best practices. • Monitoring and Compliance Review - Establish periodic internal review procedures to ensure adherence to procurement policies. Name of the contact person responsible for corrective action plan Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date June 30, 2025
The Town has implemented a process whereas the Town Manager and Board of Trustees review all federal or state grant agreements to verify whether the grant agreement outlines a CFDA number in determining whether the funds are related to federal awards.
The Town has implemented a process whereas the Town Manager and Board of Trustees review all federal or state grant agreements to verify whether the grant agreement outlines a CFDA number in determining whether the funds are related to federal awards.
H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that the Corpora...
H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that the Corporation works with the funding agency to remedy the period of performance noncompliance. In addition, we recommend that the Corporation reassess the design of its period of performance controls to identify where enhancement or additional controls are needed over liquidation of financial obligations subsequent to the end of a grant award. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue to educate all grant managers on (1) the reporting capabilities within the system that can be utilized in the execution of monitoring payment status on individual invoices that have been submitted to granting agencies for reimbursement, and (2) the requirement to use their grant specific general ledger coding when orders are placed with vendors that are set up under the Corporation’s group purchasing process. For the specific vendor noted in Finding 2024-003, a grant number input field has been added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants and the monitoring of payment of those expenditures. The use of the accurate grant general ledger coding by grant managers when orders are placed will reduce the time between placement of order and payment of the invoice. The grant manager responsible for oversight of BHSB grants will work with BHSB to remedy the period of performance noncompliance noted in Finding 2024-003. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recogniti...
Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recognition criteria for various revenue streams. IHS will continue to review and refine its accounting policies and procedures as it transitions some of its financial reporting and audit support functions to a new outside CPA firm specializing in nonprofit services beginning July 1, 2025.
Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In ad...
Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In addition to hiring a grant manager to oversee compliance, the City has purchased OpenGov grant software to ensure compliance, monitoring and the insurance of timely submissions in accordance with the grant. This system is designed to send notifications of reporting requirements prior to the due date.
Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on t...
Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Action taken: All elements required for the sliding fee discount are being properly maintained. All employees have been properly trained in software.
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2023 – September 30, 2...
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2023 – September 30, 2024 The findings from the September 30, 2024 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2024-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Heather King, Director of Finance, 507-473-1066 Anticipated Completion Date: Ongoing
Audit Finding Reference: 2024-004 Improve Internal Controls Over Reporting Planned Corrective Action: The Town will establish and implement formal procedures to ensure quarterly reports submitted to the federal agency are reconciled to the general ledger, subject to a documented independent review, ...
Audit Finding Reference: 2024-004 Improve Internal Controls Over Reporting Planned Corrective Action: The Town will establish and implement formal procedures to ensure quarterly reports submitted to the federal agency are reconciled to the general ledger, subject to a documented independent review, and support by retained source documentation. Planned Implementation Date of Corrective Action: The revenue loss calculation was corrected on April 23, 2025, effective with the Quarter 1, 2025 (January–March) reporting period. The independent review process will begin on January 30, 2026.
This is a reiteration of Finding 2024-002. Please refer to corrective action plan under Finding 2024-002. Management will review procedures and adopt a system to adequately document and retain approval of disbursements.
This is a reiteration of Finding 2024-002. Please refer to corrective action plan under Finding 2024-002. Management will review procedures and adopt a system to adequately document and retain approval of disbursements.
We concur with the recommendation. The City of Angoon has diligently worked to meet the Uniform Guidance requirement of submitting the reporting package within the earlier of 30 days after the receipt of the audit report, or the nine (9) months after the end of the audit period. The Fiscal year endi...
We concur with the recommendation. The City of Angoon has diligently worked to meet the Uniform Guidance requirement of submitting the reporting package within the earlier of 30 days after the receipt of the audit report, or the nine (9) months after the end of the audit period. The Fiscal year ending 06/25/2025 will be submitted timely, as well as all future audits. An external accountant was hired to help train and oversee the city accounting staff which has allowed the accounting records to easily be prepared for future audits.
TOFMHS concurs with the finding. There was turnover in the finance department, moving forward TOFMHS will implement adequate and sufficient internal controls to ensure that approvals charged to the grant are reviewed and approved by authorized members of TOFMHS. Responsible Person: Fiscal Officer/Pr...
TOFMHS concurs with the finding. There was turnover in the finance department, moving forward TOFMHS will implement adequate and sufficient internal controls to ensure that approvals charged to the grant are reviewed and approved by authorized members of TOFMHS. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
TOFMHS concurs with the finding. The agency retained new auditors for the June 30,2024 fiscal year, subsequent to the due date for submission of the data collection reports. Corrective Action to be Taken: The Agency will take all reasonable measures to work with the new auditors to complete the audi...
TOFMHS concurs with the finding. The agency retained new auditors for the June 30,2024 fiscal year, subsequent to the due date for submission of the data collection reports. Corrective Action to be Taken: The Agency will take all reasonable measures to work with the new auditors to complete the audit process and submit the data collection report within the required time period. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
Finding 2024-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Charise Colsen, Finance Director Corrective Action Plan: A timeline will be established for year-end closing and preparation for the annual audits in a manner that accommodates meeting the nine-month audit...
Finding 2024-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Charise Colsen, Finance Director Corrective Action Plan: A timeline will be established for year-end closing and preparation for the annual audits in a manner that accommodates meeting the nine-month audit submission requirement. Proposed Completion Date: Month XX, 2026
The district will create an SOP for the reporting process, including reviewing procedures to ensure accuracy of reporting periods. The district will also create and maintain an SOP for maintaining supporting documentation in the reporting package for all amounts and keeping staff trained on these SO...
The district will create an SOP for the reporting process, including reviewing procedures to ensure accuracy of reporting periods. The district will also create and maintain an SOP for maintaining supporting documentation in the reporting package for all amounts and keeping staff trained on these SOPs.
The Board of Directors for the district will be monitoring all filing to be able to account for documentation available within the district. Also, there will be implementing document control procedures for all costs and invoices within the district.
The Board of Directors for the district will be monitoring all filing to be able to account for documentation available within the district. Also, there will be implementing document control procedures for all costs and invoices within the district.
U.S. Department of Treasury • Material Weakness in Internal Control over Compliance Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During audit testing of financial reporting for the Coronavirus State and Local Fiscal Recovery Funds program, the Organiza...
U.S. Department of Treasury • Material Weakness in Internal Control over Compliance Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During audit testing of financial reporting for the Coronavirus State and Local Fiscal Recovery Funds program, the Organization was unable to locate three of ten financial reports requested for review. As a result, auditors were unable to verify the accuracy, completeness, or timeliness of the reported financial information for those reporting periods. Recommendation: The Organization should strengthen internal controls over financial reporting and record retention by establishing clear procedures to ensure that all required reports are accurately prepared, timely submitted, and retained in accordance with federal requirements. Management should designate responsible personnel and implement monitoring procedures to verify compliance with reporting and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will require that all supporting documentation related to financial reporting—including reports, source data, approvals, and correspondence—be retained electronically within Sage Intacct using standardized attachment and naming conventions. Management will implement periodic monitoring procedures, including supervisory review and internal spot checks, to verify that reports are timely submitted and that documentation is properly retained in Sage Intacct in accordance with applicable federal record-retention requirements. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
U.S. Department of Health and Human Services • Material Weakness in Internal Control over Compliance Community Service Block Grant – Assistance Listing No. 93.569 Condition: During our testing, we noted there were several salary expenditures charged to the grant based on the payroll period ending da...
U.S. Department of Health and Human Services • Material Weakness in Internal Control over Compliance Community Service Block Grant – Assistance Listing No. 93.569 Condition: During our testing, we noted there were several salary expenditures charged to the grant based on the payroll period ending date, however the costs were incurred for the period 12/23/23 - 1/5/24, which the first nine days were prior to the start of the period of performance. Recommendation: The Organization should work with the federal agency to provide additional documentation or justification for the expenses, or to adjust the budget or funding limits to ensure that all expenses are within the approved period of performance. It is important to address any period of performance findings as soon as possible to avoid potential penalties or repayment obligations. The Organization should also review its process of entering invoices and payroll related expenses into the accounting software to ensure the correct period is used for federal expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will strengthen internal controls over the recording of grant-related invoices and payroll expenditures by requiring expenses to be recorded based on the actual date services are incurred rather than invoice date or payroll period end date. Finance staff will be retrained on period-of-performance requirements for federal programs, and a secondary review will be implemented for all federal grant postings to verify proper timing prior to submission for reimbursement or drawdown. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
Management agrees with the finding and has implemented corrective actions to improve documentation, grant tracking, and compliance processes. Grant transactions are now recorded and tracked within Sage Intacct using appropriate invoice dates and general ledger posting dates to ensure that expenses a...
Management agrees with the finding and has implemented corrective actions to improve documentation, grant tracking, and compliance processes. Grant transactions are now recorded and tracked within Sage Intacct using appropriate invoice dates and general ledger posting dates to ensure that expenses are recorded within the correct period of performance for each grant. Sage Intacct provides detailed grant reporting capabilities, allowing the organization to generate transaction‐level reports for individual grants. Documentation procedures have also been strengthened. Supporting documentation for expense transactions is attached directly to transactions within Sage Intacct and is also stored in organized files on Porchlight’s internal server to ensure documentation is readily available for review and audit purposes. Procurement approvals and related documentation are retained within Sage Intacct on a transactional level, archived email records, and internal file storage, ensuring that approvals are documented and accessible. The Financial Director is currently responsible for preparing and submitting grant performance reports. Porchlight is also in the process of recruiting a staff Grants Manager to further strengthen grant management, monitoring, and reporting responsibilities. Porchlight maintains a grant reporting calendar and tracking system, which is maintained electronically on the organization's internal server to ensure that all reporting deadlines are monitored and met. Grant documentation is now maintained in centralized and organized compliance files on the internal server, allowing staff and auditors to easily access grant documentation and supporting records. Management will continue to monitor grant compliance processes and documentation procedures to ensure ongoing compliance with funding requirements and reporting obligations. Person(s) Responsible: Halle Pollay Timing for Implementation: In process
Management agrees with the finding and has implemented several corrective actions to strengthen internal controls and financial reporting processes. Porchlight implemented new accounting software in 2025, Sage Intacct, which includes a grants dimension that allows the organization to track financial...
Management agrees with the finding and has implemented several corrective actions to strengthen internal controls and financial reporting processes. Porchlight implemented new accounting software in 2025, Sage Intacct, which includes a grants dimension that allows the organization to track financial activity by individual grant and sub‐grant at the transaction level. This system enables the preparation of detailed grant‐level financial reports, including profit and loss statements for individual grants. Internal accounting working papers further document detailed line‐item tracking instructions of grant revenues and expenditures. These processes provide improved transparency and audit support for grant expenditures. Indirect costs are now allocated using a nights‐of‐shelter allocation methodology, which is consistent with guidance provided by Porchlight’s government partner organizations. This methodology has been documented and is applied consistently across applicable programs. Monthly reconciliations of significant general ledger accounts are now performed and documented on a regular basis. These reconciliations are reviewed by the Executive Director, who is currently completing additional training in our new accounting processes to further support this oversight function. Management will continue monitoring the reconciliation process to ensure it is completed in a timely and consistent manner. Journal entries will be reviewed on a monthly basis during scheduled meetings between the Executive Director and the Finance Director to ensure proper documentation and approval. Cash disbursement controls have also been strengthened. Accounts Payable staff prepare a weekly payment list, which is reviewed and approved by the Finance Director. The Executive Director then performs a secondary review and signs checks or approves payments. ACH transactions are submitted to the bank by the AP accountant, and require final authorization through the bank’s online system by either the Executive Director, or the Finance Director when the Executive Director is unavailable. These procedures provide documented authorization of cash disbursements. Consistent financial reporting to the Board is in the final processes. The reporting component of the Sage Intacct implementation has required additional refinement, and we are working with outside consultants who are familiar with our specific system setup to ensure reporting processes operate effectively. Financial reports will be presented to the Board of Directors Finance Committee, which meets with the Executive Director and Finance Director every two months to review financial performance and discuss financial results. Financial statements will be prepared internally prior to the audit, which improves management oversight and reduces the need for audit adjustments. Additionally, Porchlight has significantly strengthened its finance department staffing. A new Finance Director began full‐time employment in June 2024. New Accounts Payable and Accounts Receivable accountants, as well as accounting assistants, have been hired and trained on Porchlight’s financial procedures and Sage Intacct. External accounting consultants have also been engaged to assist with audit preparation, reconciliations, and other accounting functions when additional capacity is needed. Management will continue to evaluate internal controls and financial reporting processes to ensure compliance with applicable financial reporting and grant requirements. Person(s) Responsible: Halle Pollay Timing for Implementation: In Process
As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final a...
As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final agreement, the budgeted requested salaries were not updated. The Assistance Agreement has been modified to remove any such limitation prospectively beginning with Modification 0015 in April 2024. Implementation Date – April 2025
As is touched upon in the Cause, the Organization was unaware of audit requirements which resulted in delays for both the audit of the period ending December 31, 2023 and the audit of the year ending December 31, 2024. The Organization has engaged our current auditors to perform the 2025 audit, and ...
As is touched upon in the Cause, the Organization was unaware of audit requirements which resulted in delays for both the audit of the period ending December 31, 2023 and the audit of the year ending December 31, 2024. The Organization has engaged our current auditors to perform the 2025 audit, and it is expected to be completed by the September 30, 2026 deadline. Implementation Date – January 2026
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