Corrective Action Plans

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2024-001 Housing Voucher Cluster – Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in a...
2024-001 Housing Voucher Cluster – Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Our internal audits take place monthly. The HCV department leadership pulls the list of recertifications, interims, and new admissions and samples 10% of each to ensure they have been done correctly, with all information documented. This internal audit includes checking the rent calculation, utilities, verification documents, and tenant/landlord notification. The agency has been completing this internal practice consistently since February 2024. Name(s) of the contact person(s) responsible for corrective action: Morgan Gower Planned completion date for corrective action plan: In progress as of February 2024 and is ongoing.
View Audit 323421 Questioned Costs: $1
Finding 500421 (2024-001)
Significant Deficiency 2024
The Corporation will designate an individual in management to document financial statement preparation processes to ensure timely submission of the Single Audit Reporting Package. The 2023 Single Audit Reporting Package was filed in July 2024.
The Corporation will designate an individual in management to document financial statement preparation processes to ensure timely submission of the Single Audit Reporting Package. The 2023 Single Audit Reporting Package was filed in July 2024.
Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the...
Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program and there was no formal review of the balance in comparison to the required minimum reserve balance. Responsible Individual: Mandy Robinson, Administrator Corrective Action Plan: We will implement additional control processes to ensure a formal review over the reserve fund reconciliation and a formal review of the balance in comparison to the required minimum reserve balance is completed by staff separate from the preparer. Anticipated Completion Date: 12/31/2024
2024-008 Cash Management Corrective action planned: Federal draws will be made with approval of the Director of Financial Operations or their designee for expenditures that have been incurred and recorded in the general ledger. Electronic documentation will be organized by draw to ensure proper d...
2024-008 Cash Management Corrective action planned: Federal draws will be made with approval of the Director of Financial Operations or their designee for expenditures that have been incurred and recorded in the general ledger. Electronic documentation will be organized by draw to ensure proper documentation is maintained. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Cathy Liles, Director of Fiscal Operations
View Audit 322303 Questioned Costs: $1
2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. ...
2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. Internal auditing has already been implemented to ensure compliance with reporting requirements. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Richard Bruce, Chief Operating Officer
Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FA...
Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FAFSA after a term will be reviewed to determine how much Title IV aid they are eligible to have disbursed. The R2T4 calculation will be processed to learn the percentage earned. Exception to the R2T4 will be if student completed the module/term successfully. Person Responsible for Corrective Action Plan: Karen LaQuey, Director of Student Financial Aid Anticipated Date of Completion: Immediately
View Audit 320424 Questioned Costs: $1
2024-001 – Tri-Partite Board Composition Condition: At times during the year, less than 1/3 of the members of the board of directors of Community Action for Improvement, Inc. were representative of the low-income individuals and families served by the Organization. This is a repeat of prior year a...
2024-001 – Tri-Partite Board Composition Condition: At times during the year, less than 1/3 of the members of the board of directors of Community Action for Improvement, Inc. were representative of the low-income individuals and families served by the Organization. This is a repeat of prior year audit findings 2021-001, 2022-002 and 2023-001. Recommendation: We recommend that Community Action for Improvement, Inc. establish procedures to ensure the composition of the members of its board of directors meets this requirement. Corrective Action Plan: The Board of Directors for CAFI has a Membership Committee. Their role is to guide the recruitment and retention of Board members. At the time of this plan (8/16/24) all Board seats are filled. The Committee embarked on a Board Development Plan, lowered their Board seats, and worked hard to ensure a full Board. Person(s) Responsible: Board of Directors / Jennifer Corcione Timing for Implementation: Implemented by 9/01/2024.
Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of...
Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.
We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. Th...
We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. These include the hiring of a new compliance manager and the cross-collaboration of three property accountants, with a master trial balance shared to support teammates when they are on vacation or turnover occurs. We will work to re/file these forms immediately and begin tracking their status to prevent inaccurate/untimely filing.
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.
Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to e...
Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was immediately increased from $1,135,927 to $1,182,615 to be above the minimum required threshold of $1,164,177 when identified. The new process implemented will assess potential organizational revenue growth ahead of insurance renewal to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Planned completion date for corrective action plan: 8/12/2024
Finding 485172 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation
Finding 479547 (2024-002)
Significant Deficiency 2024
Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing...
Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application. The supervisor will also review the application to ensure that all signatures and demographic data has been included. o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
The Board of Directors will designate an individual to document financial statement preparation processes which ensure timely submission of the Single Audit Reporting Package.
The Board of Directors will designate an individual to document financial statement preparation processes which ensure timely submission of the Single Audit Reporting Package.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.
2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; ...
2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Coronavirus State and Local Fiscal Recovery ALN 21.027; passed through the Commonwealth of Pennsylvania Department of Community and Economic Development. Condition The Authority did not submit the Single Audit reporting package and Data Collection Form to the Federal Audit Clearinghouse within the required timeframe of nine months after the end of the audit period. The 2022 reporting package was submitted on May 7, 2025, which was after the one month due date of September 30, 2023. In addition, the 2023 reporting package was not submitted by the September 30, 2024 due date. Recommendation We recommend that the Authority continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse. Management Response The Authority will continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse.
2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on f...
2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on file for the following reasons: (I) clerical errors, (2) duplicate payments due to multiple staff working on the same file, or (3) failure to request or maintain support before payment was made. Known questioned costs associated with the 23 exceptions noted in our testing were $9,867. Based on the projection of the sampling results to the remaining population, we project additional likely questioned costs of approximately $173,400. The Authority did not have controls in place to detect the noncompliance prior to issuing payments. We recommend the Authority revisit and strengthen internal controls over tracking individual payments for transactions entered as batches, particularly when related to federal awards. We encourage the Authority to continue working to identify the individual transactions making up the remainder of the federal expenditures under this program. We also recommend the Authority revisit and strengthen internal controls over allowable activities and allowable costs related to grant programs. Management Response The Authority launched the Emergency Rental Assistance Program (ERAP) with little administrative guidance from the U.S. Treasury. The Authority contracted with the Berks Coalition to End Homelessness (BCEH) to undertake various aspects of the Emergency Rental Assistance Program and in the late fall of 2021, the Authority began reviewing all case documentation provided by BCEH. This review eliminated the vast majority of the errors noted. The Authority also updated case documentation checklists as well as provided training for staff involved with ERAP. Current Status of Corrective Action Plan The Authority has resolved this finding. An additional review was added at the close of each case.
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.
Finding 1166097 (2023-006)
Material Weakness 2023
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address thi...
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address this finding as learning experience. We cannot rely on a vendor to submit expenditure information without proper city sign off. This finding has been addressed moving forward. Our ARP A compliance office has been on board since this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T .. Spencer, City Comptroller December 31, 2025
Finding 1166069 (2023-002)
Material Weakness 2023
Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site whi...
Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site which could of lead to this finding, I strongly feel that we are improving on this finding as we progress in stressing internal controls. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T. Spencer, City Comptroller December 31, 2025
Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionall...
Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionally, reasonably and in a timely manner to secure our 2022 audit within the required timeline. Despite our diligence, the previous auditing company and their representatives were grossly non-responsive and ultimately, we had to dispute our payment that was made in full for not receiving the 2022 audit services in a timely manner. This impacted our 2023 audit not being completed as indicated in the finding. Corrective Action: The Organization chose a new audit company that is responsive, professional and highly experienced in non-profit audits. The Organization continues to have a process in place to ensure that required audits are completed in accordance with established guidelines. In advance, we seek at least three bids from reputable audit companies; our finance team provides documentation in a timely manner; we utilize a designated person to ensure the audit process is not delayed including conducting routine follow-ups or check-ins and ensuring any issues are resolved quickly; and we pay our bills on time. Our corrective action plan is in place to ensure timely audits in the future as applicable.Name of Contact Person Sophia Nash – HR-Business Manager; 229-854-3660; hr.fwocga@gmail.com Projected Completion Date: December 31, 2025
Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as iden...
Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as identified. In addition, any project associated with outside funding has gone through or will go through a reconciliation process to evaluate its current standing, including all related receivables and payables, and will continue to do so monthly. The City is working to ensure all invoices are paid within a timely manner of the related award advances and according to application of Federal and State regulations.
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