Corrective Action Plans

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Corrective Action Plan for Finding 2024-004 Community Care agrees with this finding. There are four bullets in this finding. We will be making a formal request to have the HMIS 72 hour data entry removed from our contract. The HMIS system does not have the capability to measure data entry timefram...
Corrective Action Plan for Finding 2024-004 Community Care agrees with this finding. There are four bullets in this finding. We will be making a formal request to have the HMIS 72 hour data entry removed from our contract. The HMIS system does not have the capability to measure data entry timeframes because of this we would need to design a data entry tracking process to track the timeframes. If our request is denied, we will create an entry tracking process. Bullets 2-4 are results of providing services in from the perspective of a low barrier service. Our priority is to have youth come to a safe place that is warm and where they are provided with a place to sleep, food, healthcare, and services to aid them. Staying in the program is not contingent on completing assessments or engaging in a service planning process. Each time a youth is in a program they are provided with the opportunity to participate in an assessment and are offered an organized service plan. Most participate but some do not. We will continue to offer the same level of support and opportunity for assessments and service planning to each youth. • There was no auditable evidence to test whether the participants were entered into HMIS within 72 hours. • Four participants did not have a service plan developed within 30 days. • The client was unable to provide the NavSEA for three participants. • The service plan for one participant did not have documented review. Responsible Official: David McCluskey, Executive Director Date of Corrective Action: Systems are in place and efforts will continue to encourage youth to participate in assessments and service planning practices. Regarding the HMIS data entry request will be made Friday the 21st March, 2025. If denied we will build a tracking process within 30 days.
2024-002 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: Region III will establish cle...
2024-002 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: Region III will establish clear documentation checklist with requirements for each report to ensure completeness and accuracy. Assign specific roles and responsibilities for report preparation, review and approval before submission to ensure that multiple levels of review are in place.
View Audit 350052 Questioned Costs: $1
Finding 2024-003 – Capital Fund Grant Reconciliations – Special Tests – Significant Deficiency Capital Fund Program – ALN #14.872 Corrective Action Plan: The Housing Authority has brough forward all schedules related to Capital Fund Grant as of March 2025. Person Responsible: Sheila Crisp, Executi...
Finding 2024-003 – Capital Fund Grant Reconciliations – Special Tests – Significant Deficiency Capital Fund Program – ALN #14.872 Corrective Action Plan: The Housing Authority has brough forward all schedules related to Capital Fund Grant as of March 2025. Person Responsible: Sheila Crisp, Executive Director Anticipated Completion Date: June 2025
Finding 539480 (2024-010)
Significant Deficiency 2024
Cash Management – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit...
Cash Management – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Director will ensure that when processes are completed, they are verifiable through documentation. Credit Balance refunds as well as drawdowns will be tracked for proper compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539478 (2024-009)
Significant Deficiency 2024
Special Tests and Provisions Direct Loan Reconciliation – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding:...
Special Tests and Provisions Direct Loan Reconciliation – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid director will institute a documented review of the Direct Loan reconciliations prepared by Campus Ivy or future third-party processors. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
Finding 539474 (2024-007)
Significant Deficiency 2024
Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
Eligibility – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office will be implementing an SOP which will document a review process of work done by the third-party processor, to include COD reporting, and Verification procedures. We will also be implementing a process to review students who need to complete their exit counseling. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Finding 539472 (2024-006)
Significant Deficiency 2024
Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: Ther...
Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT department continues to improve its processes; an annual review of the WISP has been started and will continue. The Financial Aid Office will work with IT to make sure that the WISP is improved to include and provide secure disposal of customer information and make sure the review is documented. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025
View Audit 350009 Questioned Costs: $1
Finding 539468 (2024-004)
Significant Deficiency 2024
Special Tests and Provisions Enrollment Reporting – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit find...
Special Tests and Provisions Enrollment Reporting – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College provide additional resources to ensure all compliance requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A new Standard Operating Procedure (SOP) is being created, which will address enrollment reporting concerns. The Financial Aid office will work with the Registrar to increase communication between offices and eliminate enrollment reporting errors. The Financial Aid office will also improve reporting to the third-party processor, so that timely and accurate information is uploaded to NSLDS. Furthermore, a recurring review of the third-party’s reporting to NSLDS will be instituted. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 6/30/2025
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs...
While the audit notes improvements in this area, we continued to face some challenges in properly allocating indirect costs and fringe benefits to individual contracts. We will close the remaining gap between the costs properly billed to individual contracts and the process of reflecting these costs in our accounting system by refining our cost allocation plan. This revision will include consistent rules for allocating indirect and fringe plus a quarterly review by accounting staff and management. We will also use newly formatted grant worksheets shared with us by Whittlesey to help us identify and correct any allocation issues before closing out our accounting records for this fiscal year.
AAA will create a worksheet to show unpaid balances and will create A/P transactions for those to be reported on monthly financials. Completion date March 31 st, 2025 by fiscal dept
AAA will create a worksheet to show unpaid balances and will create A/P transactions for those to be reported on monthly financials. Completion date March 31 st, 2025 by fiscal dept
Analysis is provided on a monthly basis by the Chief Financial Officer and the Accounting department. Balance Sheet, Profit & Loss, Cash Flow and A/P Agings are reviewed and provided to the CEO, the BOD Finance Committee and then to all BOD Members. Also provided is an organization dashboard present...
Analysis is provided on a monthly basis by the Chief Financial Officer and the Accounting department. Balance Sheet, Profit & Loss, Cash Flow and A/P Agings are reviewed and provided to the CEO, the BOD Finance Committee and then to all BOD Members. Also provided is an organization dashboard presentation with 12-14 Key Performance Indicators monthly.
Condition: Of the 40 students selected for enrollment reporting testing, 1 student did not have their program-level status change updated appropriately and another student was not updated from less than half time to withdrawn by the University's third party administrator. Planned Corrective Action: ...
Condition: Of the 40 students selected for enrollment reporting testing, 1 student did not have their program-level status change updated appropriately and another student was not updated from less than half time to withdrawn by the University's third party administrator. Planned Corrective Action: Clearinghouse reporting process has been reassessed, and error reporting will be completed weekly. Training will be done for registrar staff on process, and how to verify information has successfully been accepted by NSLDS. The Registrar's office will work closely with Financial Aid to verify enrollment updates and complete error resolution. Contact person responsible for corrective action: Callie Zake, Senior Director Student Financial Services Anticipated Completion Date: June 30, 2025
Recommendation: CLA recommends the University implements a process place to ensure the required reporting is completed in the timeline allowed by the granting agency and to complete any missed or late reporting as required. Explanation of disagreement with audit finding: There is no disagreement wit...
Recommendation: CLA recommends the University implements a process place to ensure the required reporting is completed in the timeline allowed by the granting agency and to complete any missed or late reporting as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: St. Thomas identified the applicable FFATA reporting requirements and assigned responsibility to the appropriate party. Name(s) of the contact person(s) responsible for corrective action: Sarah Ervin, sarah.ervin@stthomas.edu Planned completion date for corrective action plan: The additional reporting requirement has been added to the accounting department’s list of responsibilities beginning in January 2025.
Recommendation: CLA recommends the University review its reporting procedures to ensure the students' statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to fin...
Recommendation: CLA recommends the University review its reporting procedures to ensure the students' statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: By reviewing the ordering of internal processes and procedures St. Thomas determined two internal processes ran out of order causing incorrect reporting. Procedural documentation has been updated and training provided to ensure this error is not repeated. Name(s) of the contact person(s) responsible for corrective action: Yuko Kachinsky: yuko.kachinsky@stthomas.edu Planned completion date for corrective action plan: A process error was identified and corrected in August 2024.
Edit Check Worksheets will be matched to requests for State of NJ Division of Agriculture reimbursement on a monthly basis for accuracy.
Edit Check Worksheets will be matched to requests for State of NJ Division of Agriculture reimbursement on a monthly basis for accuracy.
BREF will ensure that the data collection form and the Single Audit package are filed the earlier of nine (9) months after year end or thirty (30) days after delivery of the financial statements.
BREF will ensure that the data collection form and the Single Audit package are filed the earlier of nine (9) months after year end or thirty (30) days after delivery of the financial statements.
Contact Person: Travis Mickey, Registrar Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College will collaborate with NSC to evaluate the errors in the file transmissions and to develop procedures to minimize further errors in ...
Contact Person: Travis Mickey, Registrar Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College will collaborate with NSC to evaluate the errors in the file transmissions and to develop procedures to minimize further errors in the future. More specifically, the College will review the reporting procedures for withdrawn and graduating students to ensure the correct information is transmitted to NSLDS. Anticipated Completion Date: 6/30/2025
Finding 539367 (2024-001)
Significant Deficiency 2024
Incorrect Return of Title IV (R2T4) Funds Calculations and Untimely Returns Planned Corrective Action: When this was identified last year, the Director of Financial Aid Office spent the next year working with the Department of Education as they conducted two separate reviews. The first review was c...
Incorrect Return of Title IV (R2T4) Funds Calculations and Untimely Returns Planned Corrective Action: When this was identified last year, the Director of Financial Aid Office spent the next year working with the Department of Education as they conducted two separate reviews. The first review was completed and we were notified that everything was good. The second review recently concluded via an exit interview where we were notified that a final report would be sent to us within the next two months. Additionally, the Director of Financial Aid has been working with the IT department, the Registrar’s Office, and our Academic Technology department to streamline the identification of students who need a R2T4 completed. This has been an ongoing process in the midst of the program reviews and getting clarification and guidance from the Department of Education, coupled with the FAFSA issues, continued to cause further delays with R2T4 calculations. Person Responsible for Corrective Action Plan: Andrea Ruth, Director of Financial Aid Anticipated Date of Completion: 3/22/2025
View Audit 349900 Questioned Costs: $1
Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates are reported to NSLDS within 60 days of an enrollment status change and that enrollment is being properly certified every 60 ...
Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates are reported to NSLDS within 60 days of an enrollment status change and that enrollment is being properly certified every 60 days. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action in Response to Finding: Portland State University relies on a third party, National Student Clearinghouse, to report student enrollment status changes to the NSLDS. Fall 2023 and Winter 2024 enrollment certification files were provided to NSC for relay to NSLDS. Despite this, these enrollment files were never provided to NSLDS and as such the students status change, effective September 26, 2023, was not certified within the NSLDS until May 3, 2024. We are researching why these enrollment certification files were never provided to the NSLDS. Name of the Contact Person Responsible for Corrective Action: Nicolle DuPont, Associate Registrar Planned Completion Date for Corrective Action Plan: April 2025
Finding 539258 (2024-710)
Significant Deficiency 2024
Planned Corrective Action: The financial aid office will report enrollment of unofficial withdrawals/last date of attendance on NSLDS upon completion of the Return to Title IV calculations and when unofficial withdrawals are reviewed at the end of each term. The Registrar's Office will review NSC G ...
Planned Corrective Action: The financial aid office will report enrollment of unofficial withdrawals/last date of attendance on NSLDS upon completion of the Return to Title IV calculations and when unofficial withdrawals are reviewed at the end of each term. The Registrar's Office will review NSC G (graduated) not applied reports after submitting degree verify files and corrections will be made, if needed, within 30 day period after submission. Anticipated completion date: financial aid has already acted on this beginning Fall 2024. Registrar's office will begin review of "G Not Applied" reportsbeginning Spring 2025. Person responsiblef or correctiveaction: Financial aid MIchelle Lamb, lamb@uwosh.edu, Alison Casady, casadya@uwosh.edu, Julia Bodette, bodettej@uwosh.edu
Finding 539257 (2024-709)
Significant Deficiency 2024
Planned Corrective Action: As soon as UW-Milwaukee was notified during the LAB review process that enrollment status effective dates were being reported incorrectly, we took action to correct this issue. While a permanent fix to the extract process from PeopleSoft is dependent on Oracle providing a ...
Planned Corrective Action: As soon as UW-Milwaukee was notified during the LAB review process that enrollment status effective dates were being reported incorrectly, we took action to correct this issue. While a permanent fix to the extract process from PeopleSoft is dependent on Oracle providing a reliable solution to the issue or UW-Milwaukee Information Technology rewriting a custom process and therefore outside of the immediate control of the Registrar’s Office, the Registrar’s Office did immediately start using the “mass correction” feature for the 1800 series warnings provided by the NSC. This will result in enrollment status effective dates which fulfil the Department of Education’s requirements. Since utilizing the “mass correction” option increases the amount of time needed to work through NSC error and warning reports, the Registrar’s Office is hopeful that a more permanent reliable solution on the SIS level will be coming in the future. In the meantime, we will continue to utilize the mass correction option to ensure that enrollment status effective dates are only changed if a student’s enrollment status changes, per the Department of Education’s requirements. UW-Milwaukee Registrar’s Office staff reviewed the records of the five individuals that LAB indicated did not have accurate data reported to the NSLDS. We discovered that the data was reported accurately for enrollment status changes, which would result in a change in effective date. However, it appears that the NSLDS roster request schedule differs from UW-Milwaukee’s enrollment reporting schedule to the NSC. UWMilwaukee reports enrollment information to the NSC on the third Tuesday of each month. It looks like the NSLDS does a roster request at the beginning of the third week of each month. We will investigate if it is possible to adjust our NSC submission schedule to move up by one week, so new data should be available for the mid-month NSLDS roster request. Anticipated Completion Date: May 1, 2025 Person responsible for corrective action: Emily Bach, Records Coordinator UW-Milwaukee Registrar’s Office ecbach@uwm.edu
Finding 539256 (2024-708)
Significant Deficiency 2024
Planned Corrective Action: UW-Madison’s Office of Student Financial Aid (OSFA) and Registrar’s Office (RO) reviewed the enrollment reporting recommendations cited in Finding 2024-708 and corrected error reports as appropriate. UW-Madison will review procedures to report all changes in student enroll...
Planned Corrective Action: UW-Madison’s Office of Student Financial Aid (OSFA) and Registrar’s Office (RO) reviewed the enrollment reporting recommendations cited in Finding 2024-708 and corrected error reports as appropriate. UW-Madison will review procedures to report all changes in student enrollment accurately, completely, and in a timely manner for all instances that require reporting. OSFA and RO will review and update internal procedures to ensure that the date that a student is unofficially withdrawn is communicated and reported consistently between the National Student Loan Data System (NSLDS) and the National Student Clearinghouse (NSC) as appropriate. Prior to the LAB’s review, UW-Madison discovered and corrected issues relating to program enrollment status in NSC and NSLDS. As of November 2024, updates were made for all retroactive instances using appropriate conferral dates and accurate “G - Graduated” statuses. The long-term solution includes the creation of a “Graduates Only Enrollment” file which includes all students who have been reported as enrolled, not withdrawn in a given term and who have earned their degree in each of UW-Madison’s three degree conferral dates. This enrollment file will trigger an enrollment status update that occurs outside of the automatic NSC process. UW-Madison has updated procedures and now uses the NSC extract process to comply with the NSLDS and NSC reporting procedures for program-level enrollment status effective dates. For the beginning of the Fall 2025 term, UW-Madison will update procedures and extract logic from the student information system to ensure accuracy in the reporting of program begin dates. In the meantime, the RO team has reviewed, tested, and updated the process to ensure previously inaccurate program begin dates are corrected. Anticipated Completion Date: September 30, 2025 Person responsible for corrective action: Beth Warner Registrar Office – Division of Enrollment Mangement beth.warner@wisc.edu
Finding 539250 (2024-700)
Significant Deficiency 2024
Planned Corrective Action: Financial Aid will continue to reconcile Direct Loans and the Federal Pell Grant programs with the Department of Education through the Common Origination and Disbursement system. The loan coordinator and Pell Grant manager will confirm SIS amounts reconcile with WISER mont...
Planned Corrective Action: Financial Aid will continue to reconcile Direct Loans and the Federal Pell Grant programs with the Department of Education through the Common Origination and Disbursement system. The loan coordinator and Pell Grant manager will confirm SIS amounts reconcile with WISER monthly, at minimum. If there are any discrepancies, the Controller will be contacted to assist with internal reconciliation of funds. Anticipated Completion Date: Will begin corrective action Spring 2025 Person responsible for corrective action: Alison Casady, Director of Financial Aid; casadya@uwosh.edu In conjunction with Direct Loan coordinator: Ashley Hass; hassa@uwosh.edu Pell Grant program manager: Elizabeth Bloedow; bloedowe@uwosh.edu Controller: Mai Lee; Financial Services; leemai@uwosh.edu
Finding 539230 (2024-303)
Significant Deficiency 2024
Wisconsin Department of Health Services Planned Corrective Action: This finding is a continuation of a prior year finding. The current finding does not include any new recommendations. The prior year finding continued into SFY 2023-24 because we didn’t receive the finding until the final quarter of ...
Wisconsin Department of Health Services Planned Corrective Action: This finding is a continuation of a prior year finding. The current finding does not include any new recommendations. The prior year finding continued into SFY 2023-24 because we didn’t receive the finding until the final quarter of SFY 2023-24, and the federal website would not accommodate the solution we implemented immediately upon receipt of the finding. DHS adjusted its corrective action plan and successfully submitted all the SFY 2023-24 awards to the federal website in July 2024. This represents timely reporting for obligations occurring in June 2024, though technically after the audit period. No further corrective actions are needed for this finding. Anticipated Completion Date: July 2024 Person responsible for corrective action: Vanessa Salata, Section Chief Expenditure Accounting, Bureau of Fiscal Services, Division of Enterprise Services vanessaa.salata@dhs.wisconsin.govRebuttal from the Wisconsin Legislative Audit Bureau In its corrective action plan on page 349, the Department of Health Services noted that it had adjusted its prior year corrective action plan and successfully submitted all the FY 2023-24 Social Services Block Grant (SSBG) awards to the federal website in July 2024. To assist the reader in understanding the corrective action plan, we offer the following clarification: The July 2024 submission was not timely for amounts awarded under SSBG that were obligated through agreements signed in fall 2023.
Finding 539229 (2024-302)
Significant Deficiency 2024
Wisconsin Department of Health Services Planned Corrective Action: After the SFY 2022-23 audit finding was received, DHS immediately began corrective actions. No new concerns were identified by LAB during their SFY 2023-24 audit. DHS corrected the assistance listing number (ALN) of TANF funds transf...
Wisconsin Department of Health Services Planned Corrective Action: After the SFY 2022-23 audit finding was received, DHS immediately began corrective actions. No new concerns were identified by LAB during their SFY 2023-24 audit. DHS corrected the assistance listing number (ALN) of TANF funds transferred to the SSBG on the DHS website (https://www.dhs.wisconsin.gov/gears/index.htm) for the calendar year 2023 and 2024 Basic County Allocation on March 20, 2024. DHS changed the ALN for TANF funds transferred to the SSBG on the calendar year 2025 Basic County Allocation contracts that started January 1, 2025. Anticipated Completion Date: January 1, 2025 Person responsible for corrective action: Rebecca Mogensen, Section Chief Managerial Accounting, Bureau of Fiscal Services, Division of Enterprise Services rebeccaj.mogensen@dhs.wisconsin.gov
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