Corrective Action Plans

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Management's Response: Management concurs with the above finding and all documentation for annual reports will be held and kept as required moving forward. This will be implemented with the 2025 annual report.
Management's Response: Management concurs with the above finding and all documentation for annual reports will be held and kept as required moving forward. This will be implemented with the 2025 annual report.
Management's Response: Management concurs with the audit finding above. The Director of Admissions & Records has worked with the Audit Resource team at NSC to work through a process to ensure that unofficial withdrawals are accurately captured from Banner and reported in a timely manner. The NSC spe...
Management's Response: Management concurs with the audit finding above. The Director of Admissions & Records has worked with the Audit Resource team at NSC to work through a process to ensure that unofficial withdrawals are accurately captured from Banner and reported in a timely manner. The NSC specialist helped the college set up an additional "subsequent of term" submission roughly 30 days after the end of the semester but prior to the first upload of the following semester. As a nonattendance taking institution, this timeframe will allow the college a chance to make withdrawal determinations for students who did not officially withdraw but stopped attending at some point in the semester and code them appropriately in Banner. This action has occurred, been tested and implemented as of January 2025.
2024-004 Contact Person David Klein, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP June 30, 2025
2024-004 Contact Person David Klein, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP June 30, 2025
Finding # 2024-005 Condition: The District did not meet its financial covenants required under the program during the year, and we, as the auditors, were unable to properly calculate the required financial covenants because of potential missing or misstated financial statement information due to th...
Finding # 2024-005 Condition: The District did not meet its financial covenants required under the program during the year, and we, as the auditors, were unable to properly calculate the required financial covenants because of potential missing or misstated financial statement information due to the adverse opinion on the 2022 financial statements and related disclaimer of opinion included in our accompanying 2023 Independent Auditor's Report Response: The hospital has financial covenants including: Maintaining 35 days cash on hand. We are currently at 26 Days Cash on Hand. The hospital has been as low as 6 Days Cash on Hand. To increase our Cash on Hand, we have brought all Revenue Cycle efforts in house, trained new staff, formed cross functional teams with the clinical documentation staff, set goals and work weekly with our teams to gently resolve challenges and move forward. These efforts have rewarded the hospital with increased Days Cash on Hand and improved quality processes in Revenue Cycle. One covenant requires that we maintain strong internal controls. Since the new administration have begun, each month, new internal controls are being established throughout the hospital, Finance department, Materials Management and the Revenue Cycle. On covenant requires a positive bottom line. The hospital has been losing money primarily due to the change in administration, lack of routine processes, recruitment challenges, lack of accuracy in our accounting and revenue cycle. Throughout the hospital and RHC’s, improvement teams are working to both improve quality processes, reduce costs, establish a culture to allow recruitment and improve our bottom line. The hospital has been transparent with the agency and our Board of Directors throughout our change process. More work continues. Responsible Party: Meagan Weber, CEO, Brent Peirick, COO, Carolyn Davies, CFO Estimated Completion Date: 12/31/2026
Condition: The District did not meet its financial reporting obligations under the grant during the year. The District did not complete the 2022 audit and file the Data Collection Form (SFSAC) by the due date of March 31, 2024 Response: The financial statement audit for FY 2022 is complete and we ar...
Condition: The District did not meet its financial reporting obligations under the grant during the year. The District did not complete the 2022 audit and file the Data Collection Form (SFSAC) by the due date of March 31, 2024 Response: The financial statement audit for FY 2022 is complete and we are awaiting issuance of the single audit for FY 2022. We anticipate the single audit stand-alone report will be issued prior to the end of 2025. The 2022 Report on Internal Control Over Financial Reporting and On Compliance and Other Matters Based on an Audit of Financial Statements Performed In Accordance with Government Auditing Standards has not been issued. We are currently working with our grantors and lenders to determine the appropriate course of action for not having this report. The hospital’s plan is to maintain timely completion of the financial audits in future years. Responsible Party: Meagan Weber, CEO, Brent Peirick, COO, Carolyn Davies, CFO Estimated Completion Date: 12/31/2025
Planned Corrective Action: I acknowledge the identified instance where supervisory approval was not obtained for a documented personnel expense. We have taken immediate steps to address this issue by implementing a more robust process to ensure that all personnel expense documentation is reviewed an...
Planned Corrective Action: I acknowledge the identified instance where supervisory approval was not obtained for a documented personnel expense. We have taken immediate steps to address this issue by implementing a more robust process to ensure that all personnel expense documentation is reviewed and approved by a supervisory-level employee before submission. Additionally, we will reinforce this practice through staff training and remind supervisors of their responsibility to approve all personnel expense reports. We are committed to maintaining strong internal controls, and we will monitor the implementation of this process to ensure compliance and reduce the risk of unallowable costs in the future. Anticipated Completion Date: Immediately Responsible Contact Person: Danielle Devoll
Finding Number: 2024-001 Planned Corrective Action: Towpath Trail High School will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 2/14/2025 Responsible Contact Person: Dave Massa, Treasurer
Finding Number: 2024-001 Planned Corrective Action: Towpath Trail High School will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 2/14/2025 Responsible Contact Person: Dave Massa, Treasurer
Airport Improvement Program – 20.106 Recommendation: Procedures should be put in place to ensure the data collection form is submitted to the FAC timely. Action Taken: Airport management will ensure the data collection form is submitted to the FAC timely.
Airport Improvement Program – 20.106 Recommendation: Procedures should be put in place to ensure the data collection form is submitted to the FAC timely. Action Taken: Airport management will ensure the data collection form is submitted to the FAC timely.
Finding 519712 (2024-003)
Significant Deficiency 2024
Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: Southwestern now has an internal review in place to ensure that all calculations are done within the time allotment for the R2T4. We are also working very closely with the Registrar’s Office to ensure that all withdrawals are su...
Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: Southwestern now has an internal review in place to ensure that all calculations are done within the time allotment for the R2T4. We are also working very closely with the Registrar’s Office to ensure that all withdrawals are submitted to our office timely. Person Responsible for Corrective Action Plan: Brenda Hicks, Associate Vice President of Student Financial Planning and Director of Financial Aid Anticipated Date of Completion: Ongoing, process began in October, 2024.
Third Party Servicer Reporting Recommendation: We recommend the College review its reporting procedures surrounding their third party servicer to ensure reporting is accurate and complete. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken i...
Third Party Servicer Reporting Recommendation: We recommend the College review its reporting procedures surrounding their third party servicer to ensure reporting is accurate and complete. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Based upon previous year finding, the College updated the third party servicer in one federal system and on the College’s website. There was a second system that was not updated. The third party servicer will be updated in the second system immediately. Name(s) of the contact person(s) responsible for corrective action: Michele Peterson Planned completion date for corrective action plan: 12/31/2024
National Student Loan Database System (NSLDS) Enrollment Reporting Recommendation: We recommend the College reevaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure timely and accurate reporting. Explanation of disagreement with audit finding: There is ...
National Student Loan Database System (NSLDS) Enrollment Reporting Recommendation: We recommend the College reevaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure timely and accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar will re-evaluate policies, procedures and training materials to ensure timely and accurate reporting. Name(s) of the contact person(s) responsible for corrective action: Michele Peterson Planned completion date for corrective action plan: 03/31/2024
Finding Number: 2024-004 Condition: The College does not have a written cash management policy related to federal awards. Planned Corrective Action: In accordance with 2 CFR 200.302(b)(6), the College will establish a written cash management policy, including written procedures related to fed...
Finding Number: 2024-004 Condition: The College does not have a written cash management policy related to federal awards. Planned Corrective Action: In accordance with 2 CFR 200.302(b)(6), the College will establish a written cash management policy, including written procedures related to federal payments/awards in order to implement the requirements of 200.305. Contact person responsible for corrective action: David Cummins, Vice President for Administrative Services and College Treasurer Anticipated Completion Date: As soon as possible moving forward starting December 18, 2024.
Processes will be implemented to review, update and verify data captured by NSLDS and ensure such data has been accurately reported in a timely manner.
Processes will be implemented to review, update and verify data captured by NSLDS and ensure such data has been accurately reported in a timely manner.
We have implemented the following protocol to ensure the accuracy of the Form 801A State Attendance Reporting: The site supervisor prepares a Monthly Attendance Form from the daily Attendance Sign-in Sheets and submits it to the ECE Director of Programs, with a copy to the Enrollment Coordinator. ...
We have implemented the following protocol to ensure the accuracy of the Form 801A State Attendance Reporting: The site supervisor prepares a Monthly Attendance Form from the daily Attendance Sign-in Sheets and submits it to the ECE Director of Programs, with a copy to the Enrollment Coordinator. The Enrollment Coordinator reviews the accuracy of the report based on a re-comparison to source sign-in/sign-out sheets, as well as other source information, and submits the report, corrected as necessary, to the ECE Director of Programs. The ECE Director of Programs will review and approve to submit for reporting and invoicing. Once approved, the monthly forms are submitted to the finance department by the site supervisor. GFS’s finance team will complete one more review of the totals before submitting to the CDE and CDSS.
Management concurs with the finding. Beginning in fiscal 2025, management will open an interest bearing account insured by the Federal Deposit Insurance Corporation (“FDIC”) and transfer funds to the account to comply with HUD requirements. Our policies and procedures manual will be updated to mor...
Management concurs with the finding. Beginning in fiscal 2025, management will open an interest bearing account insured by the Federal Deposit Insurance Corporation (“FDIC”) and transfer funds to the account to comply with HUD requirements. Our policies and procedures manual will be updated to more clearly specify this HUD compliance requirement. We will continuously monitor HUD’s overall requirements, in order to maintain compliance on an ongoing basis.
Finding 519612 (2024-002)
Significant Deficiency 2024
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A new Registrar was hired in late May of 2024. A new process was implemented for the Fall semester of 2024 to ensure timely and accurate processing of official and unofficial withdrawals. Outcom...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A new Registrar was hired in late May of 2024. A new process was implemented for the Fall semester of 2024 to ensure timely and accurate processing of official and unofficial withdrawals. Outcome: All student withdrawal requests both official and unofficial are processed daily and tracked in a shared workbook. This allows information about each individual withdrawal request to be captured and available for both the Business Office and Financial Aid. Date of Determination, Last Date of Attendance, Processed Date, withdrawal type, withdrawal reason, and credits impacted are all captured in the workbook to aid with R2T4 calculations. This workbook also serves as a document that can be audited in real-time to ensure accuracy of each student’s record. A Standard Operating Procedure was developed and used to train the team members effective on 8/12/2024. Person Responsible for Corrective Action Plan: Tonya Troka, University Registrar & Assistant Provost Anticipated Date of Completion: Completed and implemented for Fall 2024 Semester
Title III – Assistance Listing No. 84.364 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time an...
Title III – Assistance Listing No. 84.364 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Multilingual Achievement will ensure that Time and Effort Statements are completed two times each year. These documents will be completed and signed on January 6 and July 6 of each year. Name of the contact person responsible for corrective action: Sonja Bloetner, Director of Multilingual Achievement Planned completion date for corrective action plan: For immediate implementation and ongoing.
View Audit 338700 Questioned Costs: $1
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board continue with established policies and procedures implemented in October 2023 to ensure that it obtains documentation to support student withdrawals and that this documentation is available for audit purposes. Explan...
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board continue with established policies and procedures implemented in October 2023 to ensure that it obtains documentation to support student withdrawals and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. A year-long induction and support program has been established for office professionals including those who serve as records secretaries and liaisons. All office professionals—regardless of job title and specific responsibilities— are strongly encouraged to participate in the induction and support program. Making the training available to all office professionals serves several purposes: a. addresses gaps in learning to maintain student records; b. corrects misunderstandings of enrollment and withdrawal practices and procedures; and c. supports integration of appropriate processes for the withdrawal practices and procedures (addition to training program 2025). Immediately following the training, the presentation, print materials, and video snippets will be made available to reinforce the learning outcomes and to be used throughout the year. 2. A procedural manual for records secretaries and liaisons will be developed, shared during training, and uploaded to Schoology for future reference. 3. Policy and Rule 5130 and 5150 will be shared with principals to support the processes for student withdrawal and the student record verification process. 4. Student Record Reviews will continue to take place. Student Record Reviews are conducted to ensure that students’ cumulative folders include the documentation required by MSDE and Policy/Rule 5150. 5. Policy and Rule 5150 will be reviewed with PPWs, residency investigators and principals to ensure that they are aware of the required documents necessary to approve an initial shared domicile application and renew a shared domicile application. Name of the contact person responsible for corrective action: Patricia Mustipher, Director of Department of Student Support Services Planned completion date for corrective action plan: Various dates beginning in October 2023 through March 2025.
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and ...
Title I – Assistance Listing No. 84.010 Recommendation: We recommend that the Board reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Board should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Weekly payroll runs will be cross-referenced with Title I position logs. Any discrepancies will be investigated promptly. • Unauthorized Employees: Employees not listed on Title I position logs will be removed from payroll to ensure only sponsored employees are attributed to the grant. • Missing Sponsored Employees: Sponsored employees not appearing on payroll reports will be investigated to determine the cause and appropriate corrective actions will be taken. Names of the contact persons responsible for corrective action: Michele Stansbury, Director of Title I Deanna Ashenfelter, Accounting Manager Brent Harry, Fiscal Supervisor III Planned completion date for corrective action plan: Implemented September 17, 2024
View Audit 338700 Questioned Costs: $1
While reviewing the follow up questions along regarding enrollment reporting, a discovery was made that there could have been issues with the query that was used to create the lists to be sent to National Student Clearinghouse. A new version of the query was created mid-July 2023. This query was lac...
While reviewing the follow up questions along regarding enrollment reporting, a discovery was made that there could have been issues with the query that was used to create the lists to be sent to National Student Clearinghouse. A new version of the query was created mid-July 2023. This query was lacking 3 current student statuses that would have prevented them from picked up transmitted/uploaded to National Student Clearinghouse. The original query was missing a status that was introduced in 2023, which was around summer/spring 2023, which is why the second query was created to pull that new status. Moving forward, we will create a new query for all future reports that use all current statuses.
Finding: 2024-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with condu...
Finding: 2024-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2025
McSherrystown Interfaith Housing Corporation 40 E. High Street, Gettysburg, PA 17325 Phone (717) 334-1518 • Fax (717) 334-8326 TDD/TTY Relay Service: 1-800-654-5984 www.adamscha.org CORRECTIVE ACTION PLAN JANUARY 8, 2025 McSherrystown Interfaith Housing Corporation respectfully submits the followin...
McSherrystown Interfaith Housing Corporation 40 E. High Street, Gettysburg, PA 17325 Phone (717) 334-1518 • Fax (717) 334-8326 TDD/TTY Relay Service: 1-800-654-5984 www.adamscha.org CORRECTIVE ACTION PLAN JANUARY 8, 2025 McSherrystown Interfaith Housing Corporation respectfully submits the following corrective action plan for the year ended September 30, 2024. Cognizant or Oversight Agency for Audit: Mortgage Insurance Rental Housing, ALN #14.134 Name and address of independent public accounting firm: Hamilton & Musser, PC 176 Cumberland Parkway Mechanicsburg, PA 17055 Audit Period: October 1, 2023 - September 30, 2024 The finding from the September 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Findings and Questioned Costs - Major Federal Award Programs Audit: #2024-002 - Significant Deficiency-Reconciliation of Escrow Accounts Mortgage Insurance Rental Housing, ALN #14.134 Recommendation We recommend that McSherrystown Interfaith Housing Corporation request a revised PUPM rate from HUD as the management fee expensed has not reached the maximum of 6.04% outlined in the management agreement with the management agent, but is capped below this level due to the original PUPM rate agreed upon. View of responsible officials and planned corrective action We agree that this compliance requirement is listed in the compliance supplement. We will work with HUD to increase the PUPM rate going forward and implement controls to ensure the management fees stay within the agreed upon limits. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call McSherrystown Interfaith Housing Corporation Executive Director, Stephanie McIIwee at (717) 334-1518.
Finding 519532 (2024-001)
Significant Deficiency 2024
Catholic Charities respectfully submits the following corrective action plan for the year ended June 30, 2024. Name & address of public accounting firm: Kernutt Stokes 1600 Executive Parkway, Suite 110 Eugene OR 97401 Audit Period: June 30, 2024 Major Federal Award Findings: Finding R...
Catholic Charities respectfully submits the following corrective action plan for the year ended June 30, 2024. Name & address of public accounting firm: Kernutt Stokes 1600 Executive Parkway, Suite 110 Eugene OR 97401 Audit Period: June 30, 2024 Major Federal Award Findings: Finding Reference #: 2024-001 Significant deficiency Recommendation: We recommend management design and implement internal controls over compliance to ensure tenant recertification is performed within the timeframe specified by HUD. Corrective Action: Renaissance Court has contracted with a new property management company, effective April 1, 2024. Due to the transition, certain tenant recertifications were completed late. Management will work with Guardian Management to improve the procedures and ensure tenant recertifications are completed in a timely manner, as specified by HUD. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.
The audit identified that inaccurate program start dates were recorded due to poor report programming and the absence of clear internal policies governing the program date. The root cause of this issue appears to be poor report programming practices, compounded by a lack of a well-defined internal ...
The audit identified that inaccurate program start dates were recorded due to poor report programming and the absence of clear internal policies governing the program date. The root cause of this issue appears to be poor report programming practices, compounded by a lack of a well-defined internal policy to guide the accurate reporting of program start dates. In response to the finding, the NSC enrollment report has been rewritten with improved programming and internal quality control measures. A more robust process is being implemented to ensure data accuracy moving forward. The new report will be in place for Spring 2025. By addressing both the technical and procedural gaps, Palomar College will enhance the accuracy of program start dates and ensure better alignment with NSC reporting requirements.
As of the Spring 2025 semester all R2T4 calculations performed will then go through a secondary review by either the Assistant Director of Financial Aid or the Director of Financial Aid. This will ensure that R2T4 calculations have the correct Determination dates and that the correct amounts have be...
As of the Spring 2025 semester all R2T4 calculations performed will then go through a secondary review by either the Assistant Director of Financial Aid or the Director of Financial Aid. This will ensure that R2T4 calculations have the correct Determination dates and that the correct amounts have been returned In COD for both the Institutional and Student portion owed.
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