Corrective Action Plans

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Finding Reference Number: Finding 2025-004: Significant Deficiency in Internal Control and Compliance over Reporting – Medicaid Cluster Corrective Action: The District submitted corrected versions of the Quarterly Financial Summaries to SBS after audit fieldwork. The District plans for the Finance D...
Finding Reference Number: Finding 2025-004: Significant Deficiency in Internal Control and Compliance over Reporting – Medicaid Cluster Corrective Action: The District submitted corrected versions of the Quarterly Financial Summaries to SBS after audit fieldwork. The District plans for the Finance Director to review Quarterly Financial Summaries and Annual Cost reports and document this review before submitting to SBS. The payroll coordinator will prepare the quarterly financial summaries and they will be reviewed by the Business Manager prior to submission to ensure accuracy. Responsible Person: Shannon Grindell, Sharon Weise Anticipated Completion Date: Ongoing
Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the ...
Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the expenditure reports against the budget items before submitting. Management Response: The District will add a verification process to reconcile the general ledger to the budget and expenditure reports before submitting. The District will consider implementing a detailed grant tracking sheet to ensure the general ledger expenditures agree to the expenses reported to ISBE by grant. Anticipated Date of Completion: June 30, 2026
Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the ...
Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the expenditure reports against the budget items before submitting. Management Response: The District will add a verification process to reconcile the general ledger to the budget and expenditure reports before submitting. The District will consider implementing a detailed grant tracking sheet to ensure the general ledger expenditures agree to the expenses reported to ISBE by grant. Anticipated Date of Completion: June 30, 2026
Condition: We noted that two of the five required expenditure reports were not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. Management Response: Mana...
Condition: We noted that two of the five required expenditure reports were not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. Management Response: Management will take the necessary steps to file all quarterly reports on time in the future. Anticipated Date of Completion: June 30, 2026
Recommendation: The University should review its policies and procedures on determining student's withdrawals and timely communication among departments to ensure timely returns of Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action...
Recommendation: The University should review its policies and procedures on determining student's withdrawals and timely communication among departments to ensure timely returns of Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University automated the process of communicating withdrawals between departments a few years ago. Unfortunately, an individual responsible for communicating withdrawals failed to use the system in that instance. When the delay in process was discovered, the offices of Student Support, Registrar, Financial Aid, and Bursar met to review communication and documentation processes. Meetings occurred in Summer 2025 to implement a cohesive process. The corrective action is that dismissals related to student conduct follow the same agreed upon process that hiatus and withdrawal follow. The responsible individual no longer works at the University, and their replacement will be fully trained and using the system in place. Name(s) of the contact person(s) responsible for corrective action: Andrew Moyer Planned completion date for corrective action plan: March 31, 2026
Condition: The Organization lacked adequate controls to ensure reviews were performed by a different individual than the one responsible for preparing monthly financial reporting, calculations of per-unit activity, and requests for reimbursement. Planned Corrective Action: 1. Standardization of Fina...
Condition: The Organization lacked adequate controls to ensure reviews were performed by a different individual than the one responsible for preparing monthly financial reporting, calculations of per-unit activity, and requests for reimbursement. Planned Corrective Action: 1. Standardization of Financial Reporting Workflow: A formal segregation of duties for all federal and pass-through reimbursement requests and financial reports has been implemented. Effective immediately, the individual responsible for accumulating cost data and calculating per-unit activity (preparer) is prohibited from being the reviewer. 2. Implementation of Approval Process: All reports must now be submitted by the preparer to the designated reviewer for approval via email prior to submission. An approval response from the reviewer is required prior to submission to the awarding agency. 3. Staff Training: All grants management and accounting personnel have been briefed on the requirements of 2 CFR 200.303, specifically regarding the necessity of documented internal controls to provide reasonable assurance of compliance. Contact person responsible for corrective action: Erin Nordmann (Controller) Chiyoko Yokota (Chief Financial Officer) Anticipated Completion Date: Fully Corrected
Condition: The Organization lacked adequate controls to ensure the SEFA was complete and accurate. Planned Corrective Action: 1. Federal Award Classification Review: Federal versus non-federal classification will be reviewed by the program manager, Director of Internal Control, and CFO based on the ...
Condition: The Organization lacked adequate controls to ensure the SEFA was complete and accurate. Planned Corrective Action: 1. Federal Award Classification Review: Federal versus non-federal classification will be reviewed by the program manager, Director of Internal Control, and CFO based on the executed agreement. Any reclassification will require documented CFO approval. 2. Annual Cross-System Reconciliation: An annual reconciliation between the contract management system and the general ledger will be performed to ensure all federal awards are captured for SEFA reporting. 3. SEFA Format Standardization: The SEFA preparation schedule will be reverted to a prior-year rollover format that retains carryforward data and enables year-over-year comparison to improve completeness review and anomaly detection. 4. General Ledger Tagging Controls: General ledger dimensional tagging has been enhanced so federally funded activity is automatically identified and included in the preliminary SEFA. 5. Independent SEFA Review: The SEFA will undergo documented independent review and approval by the CFO prior to auditor submission, consistent with 2 CFR 200.303. Contact person responsible for corrective action: Ian Kile (Director of Internal Controls and Analysis) Chiyoko Yokota (Chief Financial Officer) Anticipated Completion Date: Fully Corrected
2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report fir...
2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Direct recipients must report key data elements by registering through the FSRS and reporting subaward data through that system. Direct recipients that are awarded a federal grant are required to file a FFATA sub-award report by the end of the month following the month in which the prime awardee awards any sub-grant equal to or greater than $30,000. The City did not submit the required key data elements through the FSRS reporting system as required by the Uniform Guidance and as a result has not completed the appropriate sub-award reporting that is required for direct recipients. Auditor Recommendation: We recommend that the City review its procedures for FFATA reporting through FSRS and ensure that all key data elements are reported timely moving forward. Corrective Action: Upon discovery of the issue in November 2025, City staff corrected the noncompliance by submitting the required report to the appropriate reporting system/entity. To prevent recurrence, management has strengthened internal controls over FFATA reporting and Single Audit preparation by (1) adding review and verification steps, (2) communicating expectations with key personnel, and (3) explicitly assigning submission responsibility to a designated submitter who is independent of the individual(s) responsible for monitoring compliance. These control enhancements are expected to identify and prevent similar deficiencies and, based on implementation to date, appear to be operating effectively. Responsible Person: Jason Denton, Controller Anticipated Completion Date: June 30, 2026
FA 2025-001 Strengthen Controls over Employee Compensation Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Allowable Costs/Cost Principles Significant Defici...
FA 2025-001 Strengthen Controls over Employee Compensation Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Allowable Costs/Cost Principles Significant Deficiency Nonmaterial Noncompliance U.S. Department of Education Georgia Department of Education 84.027 - Special Education Cluster Grant to States 84.173 - Special Education Cluster Preschool Grants H027A230073 (Year: 2024), H027A240073 (Year: 2025), H173A240081 (Year: 2025) $1,283 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the employee compensation process as it relates to the Special Education Cluster. Corrective Action Plans: The District concurs with the finding and is committed to strengthening internal controls. While the identified discrepancies were isolated, we recognize the need for enhanced reconciliation during personnel transitions. The Human Resources and Finance departments will enhance our review process. This pre-payroll validation step will ensure that all salary adjustments and position changes align with Board authorized pay documentation prior to disbursement. Estimated Completion Date: 3/31/2026 Contact Person: Julie Wiley, Chief Financial Officer Telephone: 229-316-1878 Email: juliewiley@lowndes.k12.ga.us
Condition: There were no controls in place for the annual report [FAA Form 5100-126] for the fiscal year ending September 30, 2025 to ensure the report contained accurate infor-mation and was sent timely to the appropriate FAA airports office. Planned Corrective Action: A review of FAA Form 5100-126...
Condition: There were no controls in place for the annual report [FAA Form 5100-126] for the fiscal year ending September 30, 2025 to ensure the report contained accurate infor-mation and was sent timely to the appropriate FAA airports office. Planned Corrective Action: A review of FAA Form 5100-126 will be conducted with ap-propriate personnel, such as the Controller or Vice President, Treasury Management prior to submitting to the FAA. Review and timely submission will be evidenced via time-stamped DocuSign or other electronic means such as an acknowledgment via email. Contact person responsible for corrective action: Sr. Grants Manager Anticipated Completion Date: 03/31/2026
Since the prior audit period, management has taken steps to establish procedures and internal controls to ensure consistent application, billing, and reporting of indirect cost rates across all federal awards. Such steps include defining and documenting roles and responsibilities for applicable staf...
Since the prior audit period, management has taken steps to establish procedures and internal controls to ensure consistent application, billing, and reporting of indirect cost rates across all federal awards. Such steps include defining and documenting roles and responsibilities for applicable staff members during each phase of the grants management lifecycle, as well as implementing procedures and tools to ensure compliance with subrecipient monitoring requirements. These steps involve multiple levels of review for accurate and consistent application of indirect cost rates. Finance will continue implementing the corrective actions necessary to achieve effective controls over compliance with indirect cost rate requirements. Policy and procedures on allowable and allocable costs will be drafted to clearly document how direct and indirect costs will be billed to federal awards. Training will be provided to relevant staff members to ensure accurate implementation and ongoing compliance. These actions will improve our ability to manage indirect costs effectively and ensure compliance with federal requirements. The anticipated completion date remains June 30, 2026.
Since the prior audit period, management has taken steps to develop and implement a time and effort reporting system that meets federal documentation standards, such as activating the electronic timekeeping system to track actual work performed and testing adoption of reporting procedures across dep...
Since the prior audit period, management has taken steps to develop and implement a time and effort reporting system that meets federal documentation standards, such as activating the electronic timekeeping system to track actual work performed and testing adoption of reporting procedures across departments and teams. Finance will continue implementing the corrective actions necessary to establish an effective and compliant time and effort reporting system, including providing training for employees and regularly monitoring for effective system utilization. These actions will strengthen internal controls and ensure personnel costs are accurately recorded and appropriately allocated. The anticipated completion date remains June 30, 2027.
Condition: Quarterly expenditure reports for the Special Education Cluster were not filed timely. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. Managements response - The Distr...
Condition: Quarterly expenditure reports for the Special Education Cluster were not filed timely. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. Managements response - The District will take the necessary steps to file all quarterly expenditure reports on time in the future.
U.S. DEPARTMENT OF EDUCATION AND INDIANA DEPARTMENT OF EDUCATION Title I, Part A – AL #84.010 2025-002 Maintenance of Effort Significant Deficiency Recommendation: The auditor recommends the Organization develop internal controls to ensure expenses are properly reported on the Form 9 report in line ...
U.S. DEPARTMENT OF EDUCATION AND INDIANA DEPARTMENT OF EDUCATION Title I, Part A – AL #84.010 2025-002 Maintenance of Effort Significant Deficiency Recommendation: The auditor recommends the Organization develop internal controls to ensure expenses are properly reported on the Form 9 report in line with guidelines. Planned Corrective Action: The Organization has begun to use an outside vendor skilled in the preparation of Form 9 reporting and up-to-date on standards and compliance. An error in documents provided to this vendor lead to the misrepresentation of information on the report. Moving forward, all employees of the Organization are aware that any changes made that will impact the Form 9 after finalization of the period need to be conveyed to our Form 9 preparer. The Organization has provided modifications to the opening balances to the DOE in order to correct this error. Michelle Krauter, VP, Chief Financial Officer, will work with outside vendor to ensure all records are accurate. This process has already begun as of the date of this report and will be completed within the fiscal year. If the U.S. Department of Education has questions regarding this plan, please call Michelle Krauter, Vice President, Chief Financial Officer at 317.231.0010 Sincerely yours, Michelle Krauter, Vice President, Chief Financial Officer Herron High School, Inc. d/b/a Herron Classical Schools and its Wholly-Owned Subsidiaries
Finding 1176268 (2025-004)
Material Weakness 2025
Views of Responsible Officials and Planned Corrective Action FAC accepted the County’s data collection form on April 19, 2025, Report ID 2024-06-GSAFAC-0000364488. Due to the lateness of the FY 2023, this finding will be cleared in FY 2026, as it has already been filed and accepted. Finding resoluti...
Views of Responsible Officials and Planned Corrective Action FAC accepted the County’s data collection form on April 19, 2025, Report ID 2024-06-GSAFAC-0000364488. Due to the lateness of the FY 2023, this finding will be cleared in FY 2026, as it has already been filed and accepted. Finding resolution timeline: Resolved as of 04/19/2025. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager
Finding 1176249 (2025-003)
Material Weakness 2025
Views of Responsible Officials and Planned Corrective Action The County fully implemented a grant software program in FY 2026 to provide accurate and complete tracking and reporting of federal award expenditures. Finding resolution timeline: This has been resolved as of 12/4/2025. Designation of emp...
Views of Responsible Officials and Planned Corrective Action The County fully implemented a grant software program in FY 2026 to provide accurate and complete tracking and reporting of federal award expenditures. Finding resolution timeline: This has been resolved as of 12/4/2025. Designation of employee position responsible for meeting this deadline: Andrea Montoya (Deputy County Manager), Gabriella (Betty) Orosco (Assistant Finance Director) and Francine Mondello( Grant Administrator)
2025-007: Internal Control and Compliance over Special Tests – Medicaid Cluster Corrective Action: The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to C...
2025-007: Internal Control and Compliance over Special Tests – Medicaid Cluster Corrective Action: The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to CESA 10. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
2025-006: Internal Control over Reporting – Medicaid Cluster Corrective Action: The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to CESA 10. Responsible...
2025-006: Internal Control over Reporting – Medicaid Cluster Corrective Action: The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to CESA 10. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
2025-005: Internal Control over Reporting – COVID-19: Education Stabilization Fund Corrective Action: Due to its size, it is not cost effective to hire additional staff to complete necessary reporting. Reviews and checks have been put into place prior to claim submissions with existing staff members...
2025-005: Internal Control over Reporting – COVID-19: Education Stabilization Fund Corrective Action: Due to its size, it is not cost effective to hire additional staff to complete necessary reporting. Reviews and checks have been put into place prior to claim submissions with existing staff members. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
Recommendation: We recommend the District review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Action taken in response to finding: During the 2024-2025 audit, two enrollment records were reported late to NSLDS ...
Recommendation: We recommend the District review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Action taken in response to finding: During the 2024-2025 audit, two enrollment records were reported late to NSLDS in October 2024. The late reporting occurred prior to the implementation of the corrective action plan developed during the 2023–2024 audit period. The previously identified cause was timing gaps between Clearinghouse file submission and NSLDS processing. Corrective Action Taken: The corrective action plan from the 2023–2024 audit period was fully implemented as of Spring 2025 and has addressed the root cause of the late reporting. Actions implemented include: • Reviewed and documented enrollment reporting timelines from Clearinghouse submission through NSLDS posting. • Established consistent file submission schedules aligned with NSLDS reporting deadlines. • Formalized communication and escalation procedures with the Clearinghouse and NSLDS, including designated points of contact. • Updated internal policies and procedures to reflect revised reporting timelines. • Provided training to staff responsible for enrollment reporting, emphasizing timeliness and compliance requirements. • Implemented monitoring controls to track file submission, acceptance, and processing by NSLDS. The 2023-2024 audit corrective action plan was successfully implemented in Spring 2025. Since implementation, no additional late enrollment reporting instances have occurred. Moving forward, it is expected that enrollment reporting to NSLDS will be timely and compliant with federal requirements, supported by documented procedures and ongoing monitoring controls. Name of the contact person responsible for corrective action: Dr. Kristina Martinez, Acting Dean of Enrollment Services Planned completion date for corrective action plan: June 30, 2026
The District’s Director of Business Affairs conducts reviews of meal counts manually entered into the District’s point of sale system and the CRRS, and verifies the counts entered manually into the CRRS system. These review procedures are acknowledged by initials/signatures.
The District’s Director of Business Affairs conducts reviews of meal counts manually entered into the District’s point of sale system and the CRRS, and verifies the counts entered manually into the CRRS system. These review procedures are acknowledged by initials/signatures.
Corrective Action Plan for Finding 2025-001 We are in receipt of the Finding Required to be reported by the Uniform Guidance regarding the Reporting Compliance Requirement. Management agrees with the finding. The discrepancy in current-year reporting resulted from a computational oversight caused by...
Corrective Action Plan for Finding 2025-001 We are in receipt of the Finding Required to be reported by the Uniform Guidance regarding the Reporting Compliance Requirement. Management agrees with the finding. The discrepancy in current-year reporting resulted from a computational oversight caused by a formula error within the reporting templates. Where possible, we will add automated check figures to the reporting spreadsheets to validate data accuracy and strengthen internal review procedures. Jamie Moore, Accounting Manager, will be responsible for ensuring this is accomplished. The correction action plan will be implemented by September 30, 2026.
YWCA Delaware, Inc. will implement procedures and policies to enable it to identify the required reporting requirements for federal awards throughout the year and at year end and ensure all reports are filed timely and accurately.
YWCA Delaware, Inc. will implement procedures and policies to enable it to identify the required reporting requirements for federal awards throughout the year and at year end and ensure all reports are filed timely and accurately.
Schedule of Expenditures of Federal Awards (SEFA) Preparation UHMS commits to completing the SF 425/SEFA timely and accurately then providing it for audit. Person responsible: Matthew Solomon
Schedule of Expenditures of Federal Awards (SEFA) Preparation UHMS commits to completing the SF 425/SEFA timely and accurately then providing it for audit. Person responsible: Matthew Solomon
Reconciliations and Material Adjustments UMHS' acting Chief Executive Officer (CEO) was also the Chief Financial Officer (CFO) until October 2025 when a Finance Director was added. The Finance Director has an accounting degree, a master's in business administration (MBA), and is a licensed Certified...
Reconciliations and Material Adjustments UMHS' acting Chief Executive Officer (CEO) was also the Chief Financial Officer (CFO) until October 2025 when a Finance Director was added. The Finance Director has an accounting degree, a master's in business administration (MBA), and is a licensed Certified Public Accountant (CPA) with over 30 years' accounting and management experience. UMHS also retained the Payroll and Fund Accounting Manager who was on leave for 3 months in 2025. A replacement for the Fund Accounting Manager who passed away in February 2026 is also in progress. Many improvements to the Finance department have been implemented Since October 2025 including: a. Establishing department goals focusing on catching up on all required accounting activities including all reconciliations b. Removing the burdensome procurement requisition process when all the required purchase orders (POs) elements are completed and documented allowing more Finance to focus on core financial activities c. Planning for moving purchasing from the Finance department back to Operations to help focus Finance on core accounting activities d. Updating policies e. Drafting (approximately 10) formal and detailed procedures for all key/material activities f. Updating the Cost Allocation Plan g. Improving grant financial information/reports to Program Directors and Managers h. Submitting claims/draws to grantors before payroll is paid out and allocating out indirect (Admin) costs to grants allowing reimbursement through drawdowns/claims 45-60 days earlier for improved cash flow i. Several other changes for improved transparency and tracking Person responsible: Matthew Solomon
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