Corrective Action Plans

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Response - Management agrees with the recommendation and will implement the necessary components of the recommendation. Accounting policies and procedures have been developed which pertain to our subrecipient reporting and monitoring and are in the process of being implemented. Also, by adding the b...
Response - Management agrees with the recommendation and will implement the necessary components of the recommendation. Accounting policies and procedures have been developed which pertain to our subrecipient reporting and monitoring and are in the process of being implemented. Also, by adding the bookkeeper in March of 2021, receipt spot checking of subrecipients on a monthly basis has been implemented to help ensure compliance.
Response - Management agrees with the recommendation and will continue to work at implementing the necessary components of the recommendation. New board members have come aboard and are working to implement changes. A finance committee has been established (independent of the CEO) and their role wil...
Response - Management agrees with the recommendation and will continue to work at implementing the necessary components of the recommendation. New board members have come aboard and are working to implement changes. A finance committee has been established (independent of the CEO) and their role will be to ensure the adoption and recommendations of the CAP to ensure transparency and accountability. A bookkeeper was added March 2021 as another tier of financial control, along with CEO handing over some financial duties to the financial advisor and bookkeeper. Regular meetings are held by bookkeeper, financial advisor, and finance committee member of the Board. Please note though, that the small size of our staff, precludes the total elimination of this weakness.
The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this tas...
The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task to the Assistant Director for Financial Compliance to ensure that reporting is completed to the FFATA Reporting System FSRS.
We agree with this finding. The Chief Financial Officer in collaboration with the Assistant Director for Finance and the Assistant Director for Financial Compliance will set a calendar at the end of the fiscal year to ensure timely closeout of the books that will allow ample time to engage and comp...
We agree with this finding. The Chief Financial Officer in collaboration with the Assistant Director for Finance and the Assistant Director for Financial Compliance will set a calendar at the end of the fiscal year to ensure timely closeout of the books that will allow ample time to engage and complete the audit prior to the deadline for the FAC filing.
The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this tas...
The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task to the Assistant Director for Financial Compliance to ensure that reporting is completed to the FFATA Reporting System FSRS.
The City is fully committed to establishing and maintaining robust internal controls to ensure compliance with federal requirements, particularly in the administration of federal grant programs. Reporting: To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will tak...
The City is fully committed to establishing and maintaining robust internal controls to ensure compliance with federal requirements, particularly in the administration of federal grant programs. Reporting: To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will take the following actions: Update training material and implement annual training for all Accounting staff and City departments managing federal grants. Update and distribute monthly email to departments to clarify the required information for FFATA filing and require responses with supporting documentation for review. Periodically review federal reporting requirements for any updates and make adjustments as needed, utilizing resources such as the State Auditor’s Office (SAO) Newsletter, conferences, and trainings. Wage Rate Requirement: To meet Davis Bacon Act reporting requirements, the City will incorporate the verbiage from 29 CFR 5.5(a) in full into specifications, as applicable, which will be incorporated into the resulting contracts.
2023-001: Internal Control Over Financial Reporting Auditor's Recommendation: We recommend SWCAP implement procedures to ensure accounts are adjusted and that provided supplementary audit information is accurately prepared. Corrective Action: SWCAP experienced significant turnover in its accounting ...
2023-001: Internal Control Over Financial Reporting Auditor's Recommendation: We recommend SWCAP implement procedures to ensure accounts are adjusted and that provided supplementary audit information is accurately prepared. Corrective Action: SWCAP experienced significant turnover in its accounting and finance team during the year. Immediate action has been taken and as of December 2024, SWCAP has identified and implemented changes with its personnel, hired an outsourced accounting firm, and implemented additional internal controls to include secondary level of review. SWCAP will make any additional changes necessary to complete the closing process and provide accurate financial information. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director). Anticipated Completion Date: Completed as of December 2024.
MATERIAL WEAKNESS 2023-002 Policies and Procedures Auditor’s Recommendation: We recommend that the Foundation adopt a formal written procurement policy in the format and with the elements required by 2 CFR Sections 200.318 to 200.327. Action Taken: • As a First Year Single Auditee, the management...
MATERIAL WEAKNESS 2023-002 Policies and Procedures Auditor’s Recommendation: We recommend that the Foundation adopt a formal written procurement policy in the format and with the elements required by 2 CFR Sections 200.318 to 200.327. Action Taken: • As a First Year Single Auditee, the management team will ensure that senior leadership team, finance and accounting team, as well as program manager/directors for federal awards receive some form of training and certify receipt of this training within six-months of these findings no later than December 31st, 2024. • As a First Year Single Auditee, the management team will ensure that specific policies are created to ensure a procurement process for goods and services expensed from federal funds is established and in alignment with UG (Uniform Guidance) standards for federal awards no later than December 31st, 2024. • As a First Year Single Auditee, the management team will have an independent audit firm review this policy to ensure they are in alignment and conformance with UG (Uniform Guidance) standards no later than December 31st, 2024.
View of Responsible Officials and Corrective Action Plan – The Academies will develop a reliable system that will lead to the timely processing of the financial records by reviewing existing procedures to identify bottlenecks and areas of improvement. Feedback will be gathered from team members invo...
View of Responsible Officials and Corrective Action Plan – The Academies will develop a reliable system that will lead to the timely processing of the financial records by reviewing existing procedures to identify bottlenecks and areas of improvement. Feedback will be gathered from team members involved in the financial record keeping process so that standard procedures can be development and implemented. Furthermore, opportunities to automate processes and use software to assist with data entry, record reconciliation, and reporting can be used. This will significantly decrease manual workload and improve accuracy and timeliness.
View of Responsible Officials and Corrective Action Plan – Management will monitor the review and approval procedures for reporting to ensure that reports are signed off to indicated and document that review and approval has been made.
View of Responsible Officials and Corrective Action Plan – Management will monitor the review and approval procedures for reporting to ensure that reports are signed off to indicated and document that review and approval has been made.
All Nations Health Center has switched EHR systems that allows for intake coordinators to suspend/pause eligibility status until all proper documentation has been obtain from the client, scanned into the system, and filed appropriately.
All Nations Health Center has switched EHR systems that allows for intake coordinators to suspend/pause eligibility status until all proper documentation has been obtain from the client, scanned into the system, and filed appropriately.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kalama School District No. 402 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Fed...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kalama School District No. 402 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: James Capen Director of Business Services 360-673-5282 Corrective action the auditee plans to take in response to the finding: The Kalama School District has taken the following steps to ensure that we are currently in compliance, and will continue to stay in compliance, with the Davis-Bacon Act; 1. All new contractors and existing contractors covered by the Davis-Bacon Act will submit certification attesting to compliance of prevailing wage requirements. 2. District staff will review the State Labor and Industries prevailing wage and certification website on a weekly basis when work is performed or collect a certified payroll record from the contractor on a weekly basis. 3. All new staff that have purchasing or financial oversight will be trained on these procedures when hired and on an ongoing basis. Anticipated date to complete the corrective action: 7-26-24
Finding 515835 (2023-008)
Material Weakness 2023
Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in ...
Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all the LCTS reports submitted by each collaborative member each quarter for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024
Finding 515833 (2023-007)
Material Weakness 2023
Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Inter...
Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024
Finding 515831 (2023-006)
Material Weakness 2023
Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Inter...
Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of the state time study listings each quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of the state time study listings each quarter. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024
Management's Response: The Housing Entity will adhere, and practice set forth in the Financial Management Policy and Procedures, 8. Finance Reporting (a) Reports to Grant Agencies. The Housing Entity will do its best to implement control for filing of financial reporting prior to the deadline(s). Es...
Management's Response: The Housing Entity will adhere, and practice set forth in the Financial Management Policy and Procedures, 8. Finance Reporting (a) Reports to Grant Agencies. The Housing Entity will do its best to implement control for filing of financial reporting prior to the deadline(s). Estimated Completion Date: The TDHE shall complete and submit all reports to Federal, State, and local grant agencies in accordance with, and in the format and timelines required by the agency. In accordance with 2 CFR Section 200.512(a), the audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor's report, or nine months after the end of the audit period, adjusted for any extensions permitted by the Office of Management and Budget. Again, the Housing Entity will do its best to implement control for filing of financial reporting prior to the deadline(s). Responsible Party: Executive Director and Bookkeeper.
Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of B...
Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS concurs with the finding and would like to note this matter was discovered through internal review of OIG recoupment documentation and filings with CMS. This matter was reviewed in detail by our financial management team and AHCCCS determined this was caused by a few factors: (1) staffing issues and employee turnover in all units involved in the process to return OIG recoupments to CMS. (2) A breakdown of inter and intra-departmental communication and collaboration. Efforts to eliminate this from occurring in the future include recently filling the related following positions that experienced turnover: Accounting Supervisor, Reporting Administrator, and 2 Accounting Specialists. In addition, AHCCCS has increased collaboration across the respective departments and divisions to ensure the federal share of all case recoupments is timely returned to CMS. Further, we have revised our standard work processes to include monthly reconciliations of case recoupments among the various departments and divisions. AHCCCS anticipates to have returned the federal share to CMS for all case recoupments identified by December 31, 2024.
View Audit 333243 Questioned Costs: $1
Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Offic...
Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Office of Inspector General; Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur AHCCCS OIG agrees with the finding as stated above. AHCCCS OIG commits to a review of the current Deferred Process and will determine areas of improvement to include; timelines for deferred case review completion, quarterly completed deferred case review reports, and required documentation for all deferred case processes.
View Audit 333243 Questioned Costs: $1
Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of B...
Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiates to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for holistic and systemwide changes. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Stop gap strategies implemented include, but may not limited to the following: · Increased scrutiny of claims based on claims volume. · Issued a moratorium on new provider registrations for impacted provider types · Prevented Reimbursement of Claims for Impossibly Rendered Services · Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment · Set thresholds for services to initiate a prepayment review. · Required claims to be billed for specific dates of service rather than ranges. · Flagged claims for services of the same style/overlapping codes. · Created a prepayment review process for providers utilizing suspicious billing practices. · Eliminated retroactive billing. · Credible Allegation of Fraud (“CAF”) suspensions include both provider entities and owners/ behavioral health (“BH”) practitioners. · Implemented ID.Me identity verification for AHCCCS Online. · Required providers to disclose any third-party billing relationships. · Behavioral Health Providers are now considered high-risk provider types for provider enrollment. · Per Diem codes have been set to only be able to be billed once per day. · Practitioners, including Behavioral Health Technicians, can no longer be patients at the same provider. · Worked with the Arizona Corporation Commission to flag suspicious registrations. · Ensured AHCCCS coding adhered to National Correct Coding Initiative (“NCCI”) standards and confirmed no edits had been turned off. · Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. Stop gap strategies in process include, but may not be limited to, the following: · Implementing eligibility integrity requirements for AIHP enrollment. · Linking BHP to BH companies they work for. · Link BH Providers to BH facilities they work at. · Conduct onsite quality of care reviews for patients in treatment longer than 90 days. · Require medical records to define specialized services. · Implement a new pre/post pay claims system. · Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements. AHCCCS continues to investigate and identify areas of concern and implement necessary system improvements until it is determined that the integrity of the AHCCCS provider network is restored.
View Audit 333243 Questioned Costs: $1
The following steps have been taken or will be taken to address Finding 2023-001: Shalom Health Care Center, Inc. has made some changes in how the draws are done with each payroll versus previously per month. Shalom has also hired new staff to help keep up with the grants and payrolls and entering d...
The following steps have been taken or will be taken to address Finding 2023-001: Shalom Health Care Center, Inc. has made some changes in how the draws are done with each payroll versus previously per month. Shalom has also hired new staff to help keep up with the grants and payrolls and entering data into the accounting system, as we had previously had turnover and were using temp services for some of the prior year. Contact Person: Michael A. Nino, Chief Financial Shalom Health Care Center, Inc. anino@shalomhealthcenter.org 317-269-7198
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
2023-004 PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has created and filled the position of Manager of Grants Management. This staff member will be responsible for the oversight and m...
2023-004 PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has created and filled the position of Manager of Grants Management. This staff member will be responsible for the oversight and management of all grants. Additionally, the School has contracted with an outside firm that specializes in State Board of Accounts compliance, as well as Federal Award Compliance in line with Uniform Guidance. The firm will assist in the development of the required manuals, policies, procedures and review processes. The current estimated completion date is February 28, 2025.
2023-003 Internal Control over Compliance Requirements. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has contracted with an outside firm that specializes in SBOA compliance, as well as Federal Award Compliance in line with Uniform Guidance. Th...
2023-003 Internal Control over Compliance Requirements. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has contracted with an outside firm that specializes in SBOA compliance, as well as Federal Award Compliance in line with Uniform Guidance. The firm will assist in the development of the required manuals, policies, procedures and review processes. The current estimated completion date is February 28, 2025.
2023-002 Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has contracted with an outside firm that specializes in SBOA compliance, as well as Federal Award Compliance in line with Uniform Guidance. The firm will assist in the development of the re...
2023-002 Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has contracted with an outside firm that specializes in SBOA compliance, as well as Federal Award Compliance in line with Uniform Guidance. The firm will assist in the development of the required manuals, policies, procedures and review processes. The current estimated completion date is February 28, 2025.
Finding Number: 2023-002: Allowable Costs – 19 out of 25 samples were not 100% charged to the grant and were not supported by a cost allocation plan for how the percentages charged to the grant were determined. Planned Corrective Action: We will review and update our existing cost allocation plan to...
Finding Number: 2023-002: Allowable Costs – 19 out of 25 samples were not 100% charged to the grant and were not supported by a cost allocation plan for how the percentages charged to the grant were determined. Planned Corrective Action: We will review and update our existing cost allocation plan to ensure it aligns with current practices. Appropriate staff will receive retraining on the updated plan, and quarterly audits will be implemented to monitor compliance. Any discrepancies will be addressed immediately to prevent future issues. Cost allocation calculations will be kept on file to document how the allocation was determined. Anticipated Completion Date: October 1, 2024 Responsible Contact Person: Tana Rice, Director of Finance
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