Corrective Action Plans

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Finding: 2023-003 - Oversight over cash management compliance requirement. Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action pla...
Finding: 2023-003 - Oversight over cash management compliance requirement. Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned: In September 2023, CLR has addressed the finding that its policies and procedures over reimbursement requests for federal funds lacked proper documentation of approvals according to the Uniform Guidance for federal grants. We have added a step in the online submission process with the Substance Abuse and Mental Health Services Agency (SAMHSA) to capture a screenshot of the reimbursement form to be approved before submission. Due to the timing of the FY 2022 Single Audit completion and the ending of the CCBHC contract, we were limited in the execution of this new procedure, however it is now part of our Single Audit accounting Policies and Procedures Manual. Anticipated completion date: Completed September 2023.
Finding: 2023-002 - Written policies required by the Uniform Guidance Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned:...
Finding: 2023-002 - Written policies required by the Uniform Guidance Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned: In September 2023, CLR has implemented written policies and procedures for Single Audit accounting that comply with the Uniform Guidance for federal grant payments, procurement, allowable costs, and compensation. They will also be posted online via the company website for access by all staff. Going forward, these policies will be reviewed and updated as needed following the general CLR process for all policies and procedures. Anticipated completion date: Completed September 2023.
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-006 Special Tests and Provisions Significant Deficiency in Internal Co...
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-006 Special Tests and Provisions Significant Deficiency in Internal Control Over Compliance Finding Summary: The Organization did not request prior approval from HUD before entering into a finance lease agreement. A finance lease is identified in the Mortgage Note Insured by HUD as the incurrence of additional indebtedness which, by terms of the agreement, should be approved by HUD in advance of entering into such agreements. Responsible Individuals: Charles Roeder, Vice President Finance/CFO Corrective Action Plan: The Organization has enhanced internal control policies to ensure all lease agreements are evaluated to determine whether the lease should be accounted for as an operation or finance lease prior to entering into the lease. If the lease is concluded to be a finance lease, HUD should be notified, and the Organization should request and receive approval from HUD prior to entering into the lease agreement. Anticipated Completion Date: June 1, 2024
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-005 Special Tests and Provisions Significant Deficiency in Internal Co...
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-005 Special Tests and Provisions Significant Deficiency in Internal Control Over Compliance Finding Summary: The Organization did not retain documentation of review and approval of certain invoices or Purchase Orders. Responsible Individuals: Charles Roeder, Vice President Finance/CFO Corrective Action Plan: The Organization has enhanced internal control policies to ensure all cash disbursements are reviewed and approval is documented prior to payment to ensure that all payments are necessary and correct. Anticipated Completion Date: June 1, 2024
Finding 404842 (2023-003)
Significant Deficiency 2023
Guild
MN
Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifyin...
Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifying their payment support to show any payer-initiated adjustments. Responsible Individuals: Keith Rachey, Chief Financial Officer Anticipated Completion Date: Completed and staff trained by September 2024
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a sep...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a separate individual. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Hospital personnel will compile the initial requests for reimbursement with the help of Management to provide proof of invoices and payments. The final request for reimbursement will then be verified by Management prior to requesting reimbursement to the Communities Facilities Grant Coordinator. Anticipated Completion Date: June 30, 2024
COVID-19 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: The County should review and enhance internal controls and procedures to ensure that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no d...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: The County should review and enhance internal controls and procedures to ensure that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Grants Management requires annual reports from all SLFRF subrecipients. We will be requesting a copy of all annual audits from the subrecipients for the most recent completed year. The accountant team will review audit reports for any findings of note. We recognize that some subrecipients will not have their most recent audit completed and will allow those who need extra time to submit their audits by the fall. Name(s) of the contact person(s) responsible for corrective action: Ashley Meyer Planned completion date for corrective action plan: 6/30/2024
COVID-19 – Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: We recommend that management review their policies and make revisions where necessary to ensure that documentation is maintained to support amounts reported by the County in their quarterly grant reporting. We al...
COVID-19 – Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: We recommend that management review their policies and make revisions where necessary to ensure that documentation is maintained to support amounts reported by the County in their quarterly grant reporting. We also recommend that management review their policies and procedures and make changes necessary to ensure reports are filed timely. Explanation of disagreement with audit finding: The one instance when the County submitted its quarterly report after the due date occurred due to a technical problem with submission. The Treasury data system would not accept the County’s report on the due date. The County sent Treasury an email alerting them to the problem as soon as it was determined that the County was unable to submit. Once the issue was resolved, the County submitted a few days later with no adverse impact to the County or its use of federal ERA funding. As per the concern that audit staff could not verify key line items in the submitted quarterly report, the County completed all required line items in the reports, however, the Treasury report downloads with multiple blank items in report cells. The County cannot control this deficiency in the Treasury downloads. If any submitted report were incomplete, Treasury would have returned the incomplete report to a local jurisdiction for missing elements. No referenced reports were returned to the County for completion, thereby demonstrating that all reports were complete at the time of submission. The problem relates solely to the downloaded report from the Treasury website. Neither the County nor the audit staff were able to determine a workaround for the incomplete Treasury report downloads. Action taken in response to finding: No additional action is needed because the one late quarterly reporting problem was resolved and the report was uploaded as soon as the technical glitch was resolved. Name(s) of the contact person(s) responsible for corrective action: Colleen Mahoney Planned completion date for corrective action plan: Already Completed
View Audit 311187 Questioned Costs: $1
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the County keep records to show all tenant who had a rent increase during the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in resp...
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the County keep records to show all tenant who had a rent increase during the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reached out to our software provider to have such a report added. Name(s) of the contact person(s) responsible for corrective action: Kenneth Stratemeyer Planned completion date for corrective action plan: 7/1/2024
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the County maintain a list of all individuals at the top of the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response t...
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the County maintain a list of all individuals at the top of the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As recommended, we will seek a method to keeping, and maintaining, a list of those on top of the Wait List. Name(s) of the contact person(s) responsible for corrective action: Kenneth Stratemeyer Planned completion date for corrective action plan: 10/1/2024
CDBG Entitlement Grant Cluster – Assistance Listing No. 14.218 Recommendation: We recommend the County review and enhance their procedures to ensure that all required reports are submitted accurately and timely. We concur with the finding: Although the local HUD field office has no regulatory powe...
CDBG Entitlement Grant Cluster – Assistance Listing No. 14.218 Recommendation: We recommend the County review and enhance their procedures to ensure that all required reports are submitted accurately and timely. We concur with the finding: Although the local HUD field office has no regulatory power to grant formal CAPER extensions, HUD has routinely communicated its preference for a late CAPER over an incomplete submission because there is no sanction or adverse effect to HUD funding with the submission of a late CAPER. After significant challenges in CAPER reporting in the prior year related to the Workday conversion, the County still had some lingering issues impacting its reporting for FY23 period as well. The County communicated its plan to submit the CAPER in December 2023 and HUD provided the County with a letter confirming the CAPER would be submitted in December 2023. The County submitted late, but with communication to HUD. Action taken in response to finding: No additional action is required at this time. The County expects to submit its next CAPER in September 2024. Name(s) of the contact person(s) responsible for corrective action: Colleen Mahony Planned completion date for corrective action plan: September 2024 when the County submits its next CAPER.
Finding 2023-002: Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Recommendation: The Authority should review and enhance its policies, procedures, and internal controls to ensure the financial reporting package and audited financial statements are submitted by the r...
Finding 2023-002: Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Recommendation: The Authority should review and enhance its policies, procedures, and internal controls to ensure the financial reporting package and audited financial statements are submitted by the required due date. Explanation of disagreement with audit finding: There is no disagreement. Action taken in response to finding: The Authority will implement a year-end closing process to ensure all accounts are properly reconciled. Due to the delay in receiving the prior year audits, the Agency was unable to submit a timely and accurate current year audit. The Authority has now recently filled several accounting positions, implemented multiple internal controls, policy and procedures over financial reporting as well as changed audit firms to increase financial efficiencies and timeliness. Name of the contact person responsible for corrective action: Dontrelle Young Foster, Executive Director Planned completion date for corrective action plan: We expect to have the finding resolved by March 31, 2025.
We have recorded all transactions into the general ledger and will review all transactions in the future.
We have recorded all transactions into the general ledger and will review all transactions in the future.
The Authority had instances of missing income verification, incorrect utility allowance and incorrect payment standard. Gardner Housing Authority has established a system of internal control over the participant recertification process that meets HUD’s requirements. Seven (7) to ten (10) files will ...
The Authority had instances of missing income verification, incorrect utility allowance and incorrect payment standard. Gardner Housing Authority has established a system of internal control over the participant recertification process that meets HUD’s requirements. Seven (7) to ten (10) files will be reviewed fiscally for quality assurance.
Program: 20.507 Urbanized Area Formula Program Finding: No evidence of the review of FY2021 payroll expenditures were available at the time of the audit Recommendation: Management should ensure that they have a documented control that includes required evidence retention for reviewing and approvin...
Program: 20.507 Urbanized Area Formula Program Finding: No evidence of the review of FY2021 payroll expenditures were available at the time of the audit Recommendation: Management should ensure that they have a documented control that includes required evidence retention for reviewing and approving employee time and payroll expenditures Responsible Party: Kenneth DiLaura, CFO Corrective Action Plan: All hourly employees have an electronic access card they scan on the Time Clock when they arrive and when they leave. They also scan in and out for their lunch period. At the end of each pay period, the employee’s supervisor logs into the Time Clock website and reviews time sheets for all the employees that report to them. They approve each time sheet in the website. Salaried employees do not scan in and out but there is a time sheet in the software for each salaried employee that is approved by their supervisor. The timesheets for the President and General Manager are approved by the CFO. Once all time sheets are approved, the CFO reviews all the timecards in the time clock software and then submits the hours shown to the Costaff Payroll System. The hours are then populated in the Costaff Payroll. The CFO will log into the Costaff Payroll System, review the hours again and submit the timesheet. A CoStaff employee reviews the payroll time sheet that is entered and submits it to be approved. A CoStaff employee generates an email stating that the payroll is ready for approval. The email goes to Paul Vollmerhausen of Quatrro Business Solutions. He reviews the payroll and approves the payroll in the CoStaff Payroll System. Anticipated Completion Date: Implemented June, 2022
Finding 404698 (2023-002)
Significant Deficiency 2023
Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. I...
Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. It was also noted one out of seventy-one timesheets were not approved by the supervisor. Recommendation: Ke Ola Mamo should exercise greater care in reviewing timesheets and data entered into the payroll system to ensure that only allowable costs are charged to the program. Action Taken: Ke Ola Mamo was in the process of implementing an on-line payroll processing system during Fiscal Year 2023. The implementation was completed during Fiscal Year 2023. This process minimizes potential clerical errors as employees input the hours they work directly into the on-line payroll system, with employees’ supervisors and the Human Resources Specialist approving prior to the payroll being processed.
Finding 404551 (2023-004)
Significant Deficiency 2023
The County’s Fiscal Year 2022 Annual Comprehensive Financial Report was issued June 6, 2023. However the Fiscal Year 2022 Single Audit report was not issued until August 31, 2023. Effective immediately through this corrective action plan, County Finance Department management (Ajay Gajjar) requests t...
The County’s Fiscal Year 2022 Annual Comprehensive Financial Report was issued June 6, 2023. However the Fiscal Year 2022 Single Audit report was not issued until August 31, 2023. Effective immediately through this corrective action plan, County Finance Department management (Ajay Gajjar) requests the independent auditors to perform Single Audit interim testing during the summer in order to avoid delays in issuing the Single Audit.
Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the co...
Responsible Person: Tim Bergsma, CFO - West Michigan Partnership for Children (WMPC). Management View: Management agrees with the finding and is in the process of implementing the recommendation. Corrective Action: WMPC will create a Compensation Adjustement Policy. This policy will reference the compensation policy, connect to the budget approval process, and identify clear directions regarding the approval process for compensation adjustments. Anticipated Completion Date: August 15, 2024
Reference Number: 2023-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Federal Catalog Number: 14.871 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions HQS Enforcement Classification o...
Reference Number: 2023-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Federal Catalog Number: 14.871 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions HQS Enforcement Classification of Finding: Significant Deficiency in Internal Control over Compliance Instance of Noncompliance The Authority has made significant progress in addressing the backlog of annual inspections since outsourcing the programmatic functions of the HCV program to third-party contractors. The Authority acknowledges that more progress in this area is required and continues to work diligently with the third-party HCV contractors to ensure this occurs. The Authority uses the Emphasys Elite software to schedule, record, and enforce HQS inspections. The Authority also uses its Customer Relations Management (CRM) system to track units that have failed an HQS inspection. The HCV contractors have implemented a daily review process of units that have failed and/or no-showed two or more consecutive inspections. The inspection department will use this process to accurately review the letter generation and notification process for HQS deficiencies and notices of abatement. The inspection department will manually review and generate both letters to their respective parties (landlord/owner and tenant). In addition to the daily morning review, at the close of business day, the HCV contractors will review the emergency failed inspections and will schedule any emergency re-inspections to ensure compliance with HQS enforcement rules and regulations. Anticipated Implementation Date September 30, 2024 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractors Kendra Crawford, Director of Housing Operations
View Audit 311041 Questioned Costs: $1
Finding 2023-002: Assistance #11.307 - Economic Adjustment Assistance - Revolving Loan Fund, U.S. Department of Commerce, Economic Development Administration, Award No. 05-39-01879 (Significant Deficiency) (Repeat Finding 2022-002) Condition: Reports submitted during the year were not submitted wi...
Finding 2023-002: Assistance #11.307 - Economic Adjustment Assistance - Revolving Loan Fund, U.S. Department of Commerce, Economic Development Administration, Award No. 05-39-01879 (Significant Deficiency) (Repeat Finding 2022-002) Condition: Reports submitted during the year were not submitted within the deadline and the review process was not documented. Criteria: All Economic Development Administration (EDA) Revolving Loan Fund (RLF) recipients must submit in electronic format Form ED-209 through EDA’s Revolving Loan Fund Management System (RLFMS) semi-annually based on the entity’s fiscal year-end and submitted within 30 calendar days. Corrective Action Plan: The EDC Loan Corporation ED-209 Reports will be reviewed and submitted by the required 30 calendar days following the entity's fiscal year-end due date. EDCLC will submit the ED-209 Reports 5-10 days prior to the reporting due date, allowing for any correction response submission. Contact Person: Debra Davis Anticipated Completion Date: 11/30/2024
Management’s Response: We will establish centralized controls that include identifying all required reports and implementing effective controls over report preparation. We will also implement a monitoring function to ensure that these controls are in place and operating effectively for timely and ac...
Management’s Response: We will establish centralized controls that include identifying all required reports and implementing effective controls over report preparation. We will also implement a monitoring function to ensure that these controls are in place and operating effectively for timely and accurate report submission. In addition, we are in the process of implementing a new ERP/Accounting system that will help us with our reporting process. This new system will provide us with better tools for identifying required reports and implementing effective controls over report preparation. It will also enable us to establish more effective monitoring functions to ensure timely and accurate report submission. Anticipated Completion Date: September 30, 2024 Responsible Party: Keterah Mitchell, Accountant Tony Gutierrez, Consultant – Moss Adams
United States Department of the Treasury Programs Jackson Park Hospital (“The Hospital”) respectfully submits the following corrective action plan for the year ended March 31, 2023. Audit period: April 1, 2022 – March 31, 2023 The findings from the schedule of findings and questioned costs are disc...
United States Department of the Treasury Programs Jackson Park Hospital (“The Hospital”) respectfully submits the following corrective action plan for the year ended March 31, 2023. Audit period: April 1, 2022 – March 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Treasury 2023 – 002 Coronavirus State and Local Fiscal Recovery Funds Recommendation: We recommend the Hospital design controls to ensure that reporting is completing in accordance with U.S. Department of Treasury guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Hospital will ensure that controls are put into place to report timely on future grants. Name of the contact person responsible for corrective action: Barry Mandell, VP Special Projects. Planned completion date for corrective action plan: July 1, 2024. If the U.S. Department of Treasury has questions regarding this plan, please call Barry Mandell at 773-947-7701.
Finding 404250 (2023-003)
Significant Deficiency 2023
Finding 2023-003 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Kimber Mikulecky, Finance Director Corrective Action Plan: Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Management will al...
Finding 2023-003 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Kimber Mikulecky, Finance Director Corrective Action Plan: Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Management will also carefully review reporting requirements and ensure that requirements are adhered to. This includes the following program: National Forest Receipts- Municipal & Regional Assistance. Proposed Completion Date: Fiscal year 2024
Finding Number: 2023-002 Condition: The County did not track WIC interest income earned throughout the fiscal year, resulting in the County not refunding the Department of Health and Human Services the excess of $500 earned during the year. Planned Corrective Action: The financial analyst assigned t...
Finding Number: 2023-002 Condition: The County did not track WIC interest income earned throughout the fiscal year, resulting in the County not refunding the Department of Health and Human Services the excess of $500 earned during the year. Planned Corrective Action: The financial analyst assigned to the grant will review interest income earned throughout the fiscal year and ensure any amount exceeding $500 is returned to the Department of Health and Human Services. Contact person responsible for corrective action: Vanessa Barker Anticipated Completion Date: 06/30/2024
View Audit 310975 Questioned Costs: $1
Finding 404195 (2023-002)
Significant Deficiency 2023
A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.
A new HUD lease will be prepared, presented, and signed at the time of the annual recertification for every tenant.
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