Corrective Action Plans

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U.S. Department of Health and Human Services AL No. 93.767 Children’s Health Insurance Program (CHIP) Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure...
U.S. Department of Health and Human Services AL No. 93.767 Children’s Health Insurance Program (CHIP) Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024
U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure...
U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024
U.S. Department of Health and Human Services AL No. 93.044, 93.045, 93.053 Aging Cluster Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters fo...
U.S. Department of Health and Human Services AL No. 93.044, 93.045, 93.053 Aging Cluster Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024
U.S. Department of Housing and Urban Development (HUD) AL No. 14.239 HOME Investment Partnerships Program Significant Deficiency in Internal Controls and Noncompliance over Special Tests - Housing Quality Standards Repeat Finding: No Auditee’s Corrective Action Plan: The Agency appreciates the compr...
U.S. Department of Housing and Urban Development (HUD) AL No. 14.239 HOME Investment Partnerships Program Significant Deficiency in Internal Controls and Noncompliance over Special Tests - Housing Quality Standards Repeat Finding: No Auditee’s Corrective Action Plan: The Agency appreciates the comprehensive review of this program and concurs with this finding. It is the responsibility of DHCD to perform physical inspections annually. This process includes creating and maintaining inspection review forms and correspondence with the inspected properties. We believe the oversights discovered were caused in part to an increase in the workload of the sole compliance officer performing the physical inspections. Because of this increase in workload, exacerbated by impromptu medical leave, the other compliance officers have received some cross training in HQS inspecting and are now available to assist in the record keeping process. The unit is also in the process of hiring an additional Compliance Officer to assume the physical inspection responsibilities. Additionally, all active compliance officers will review the program’s standard operating procedures for inspections. If necessary, any needed adjustments to the plan will be made at this time. We will also review all FY 24 inspections to ensure that all Inspection Findings and Corrective Measures have been issued and are available in the department’s shared drive. Contact Person: Eugene Greene, HOME Program Manager Completion Date: December 2024
Significant Deficiency and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. Although Workday is “live” as of Augu...
Significant Deficiency and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. Although Workday is “live” as of August 2022, the City is currently working to refine the software and fully utilize functionality. The Workday grants modules requires the grant funding source be defined prior to grant approval and fields are available for the AL titles and numbers and sub-recipients’ information. The implementation of the Workday grants modules centralizes much of the grant management function by requiring the agencies to upload the grant documents into Workday. Prior to the completion of the SEFA, the City instituted training sessions with the agencies to ensure that the reporting is understood by the agencies, with special emphasis on subrecipient payments being reported properly. Additionally, the City will give access to the grant report upon which the SEFA is based. The City will keep a check list to ensure that all agencies respond to the grant certification to ensure that all agencies review the grant data. Based on FY 23 training and feedback the City is expanding that training schedule to begin with agency preparation in November 2024. Additionally, the corrective actions for grants have included citywide trainings in the fourth quarter FY24 led by the Grants Management Office and BAPS on key grant accounting functions in Workday; including for example, Billing, Creating an Award, Sub Recipients with each training having between 50-70 agency grant staff attending. Contact Person: Michael Moiseyev, Chief Financial Officer, Baltimore City Completion Date: December 2024
FINDING 2023-001: SEGREGATION OF DUTIES Classes of financial transactions have been segregated to the extent possible among the existing employees. However, because of the limited number of employees involved in the accounting and bookkeeping functions, a corrective action plan to remedy the lack of...
FINDING 2023-001: SEGREGATION OF DUTIES Classes of financial transactions have been segregated to the extent possible among the existing employees. However, because of the limited number of employees involved in the accounting and bookkeeping functions, a corrective action plan to remedy the lack of segregation of duties is not cost justified. Rather, each level of management, the Board of Directors and Administrator, are aware of the concept of "segregation of duties" and are also aware of potential problems that may occur when accounting and bookkeeping duties cannot be segregated. Because there is awareness, each level of management is charged with the responsibility to follow-up on any circumstances or transactions that they perceive to be unusual. Contact person: Tim Nichols Anticipated completion date: Unknown
Corrective action planned: Effective 06/2023, One Health transitioned EDR systems to better integrate with the EMR. Intention of the new system is to automate the slide process and reduce manual entry by staff. In conjunction with the EDR transition, One Health has expanded their staffing and train...
Corrective action planned: Effective 06/2023, One Health transitioned EDR systems to better integrate with the EMR. Intention of the new system is to automate the slide process and reduce manual entry by staff. In conjunction with the EDR transition, One Health has expanded their staffing and training regarding slide applications. Patient Financial Services staff review and support slide applications, working directly with patients to obtain needed documents. Additionally, One Health has added a supervisory role within this department in order to prioritize slide application internal audits on an ongoing basis. Anticipated completion date: 12/31/2023 Contact person responsible for corrective action: Emily Faricy, Associate Vice President - Finance
2023-002: 2023-001 – Grant Project Payroll Tracking Reports Contact Person: Christian Strohmaier, cstrohmaier@chesco.org, 610-455-1370 Condition: Per review of the District’s internal payroll tracking reports, it was noted that while employees keep a detailed list of time worked each day, no specif...
2023-002: 2023-001 – Grant Project Payroll Tracking Reports Contact Person: Christian Strohmaier, cstrohmaier@chesco.org, 610-455-1370 Condition: Per review of the District’s internal payroll tracking reports, it was noted that while employees keep a detailed list of time worked each day, no specific documentation was maintained within the tracking reports of which projects relate to the ACAP grant program to support the hours being charged to the program each quarter. Corrective Action: Increased programmatic responsibilities make it necessary for all staff to accurately record their completed activities and the time spent upon them. Technical staff historically have reported this way, with activity stated, hours spent, and which program the activity relates to recorded. Each technical staff employe has an individual report maintained in Excel that is updated daily. This model will be used for administrative staff as well for their time spent in support of these programs. Proposed Completion Date: December 1, 2024
BFDI has updated its financial management processes to require written authorization by either the CFO or CEO prior to the submission of reimbursement requests in the payment management system. This approval will be performed on the Financial Status Report and maintained for independent review.
BFDI has updated its financial management processes to require written authorization by either the CFO or CEO prior to the submission of reimbursement requests in the payment management system. This approval will be performed on the Financial Status Report and maintained for independent review.
Finding 508278 (2023-002)
Significant Deficiency 2023
Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate a...
Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate an internal reviewer to continually review the casefile eligibility determinations throughout the year. Name of the contact person responsible for corrective action plan: Jill Frisell, Finance Director Planned completion date for corrective action plan: December 31, 2024
Views of Responsible Officials and Planned Corrective Actions: USTTI formalized a procurement policy be in compliance with 2 CFR 200 subsequent to December 31, 2023. USTTI management has distributed and communicated the policy with all USTTI employees. USTTI management will ensure the policy is prop...
Views of Responsible Officials and Planned Corrective Actions: USTTI formalized a procurement policy be in compliance with 2 CFR 200 subsequent to December 31, 2023. USTTI management has distributed and communicated the policy with all USTTI employees. USTTI management will ensure the policy is properly enforced and that all procurement actions are documents in writing in vendor and contractor files.
Views of Responsible Officials and Planned Corrective Actions: USTTI will prepare its SEFA on a quarterly basis, and we will reconcile the expenses reported on the SEFA with general ledger amounts. We will also review the chart of accounts coding to be sure all eligible expenses are clearly identifi...
Views of Responsible Officials and Planned Corrective Actions: USTTI will prepare its SEFA on a quarterly basis, and we will reconcile the expenses reported on the SEFA with general ledger amounts. We will also review the chart of accounts coding to be sure all eligible expenses are clearly identified.
Finding 2023 001 - Reasonable Rental Rates Auditee's Response and Planned Corrective Action Hudson River Housing's action moving forward is that the Director of Resident Services, Vinny Darrow, will ensure that each tenant file under this program contain a signed rent reasonableness determination w...
Finding 2023 001 - Reasonable Rental Rates Auditee's Response and Planned Corrective Action Hudson River Housing's action moving forward is that the Director of Resident Services, Vinny Darrow, will ensure that each tenant file under this program contain a signed rent reasonableness determination worksheet ensuring that the rent being charged does not exceed the annual HUD published Fair Market Rent for that unit. In the event that the rent does exceed FMR, the determination will document how the rent was arrived at and that it has been determined reasonable as per HUD guidelines in comparison to other rents in the area. Planned Implementation Date of Corrective Action: November 6, 2024 Person Responsible for Corrective Action: Christa Hines, CEO
Finding 508041 (2023-002)
Significant Deficiency 2023
2023-002: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): The District’s school lunch office-maintained production records and manual count sheets for the elementary school and high school instead of using the point-of-sale sys...
2023-002: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): The District’s school lunch office-maintained production records and manual count sheets for the elementary school and high school instead of using the point-of-sale system for tracking student meal counts. (Questioned Costs: None) The Town of Clinton/School Department will utilize and maintain the point-of-sale system consistently in all district school buildings to track student meals counts. Already implemented at the start of FY25 school year.
Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. The corrective action plan to address this deficiency includes the following actions: (1) Monitor all expenses to ensure Vouchers are based on accrual basis, not cash basis, at year end (...
Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. The corrective action plan to address this deficiency includes the following actions: (1) Monitor all expenses to ensure Vouchers are based on accrual basis, not cash basis, at year end (2) Reconcile expenses submitted on vouchers monthly beginning November 1, 2024 Name(s) of the contact person(s) responsible for corrective action: Mary Ann Mahon Huels, President and CEO, Hector Perez, Senior Vice President and Mary Zaleski, Consultant Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented today, October 21, 2024
2023-002 Twenty-First Century Community Learning Centers -Assistance Li st ing No. 84.287 Significant Deficiency in Internal Control Over Compliance -Appropriate Monitoring of Levels of Federal Funding Recommendation: The Auditor recommends BGCH should implement policies and procedures to periodical...
2023-002 Twenty-First Century Community Learning Centers -Assistance Li st ing No. 84.287 Significant Deficiency in Internal Control Over Compliance -Appropriate Monitoring of Levels of Federal Funding Recommendation: The Auditor recommends BGCH should implement policies and procedures to periodically monitor federal funding and expenditure levels throughout the year to ensure a level of awareness regarding whether an audit under the Uniform Guidance may be applicable for the current year. In addition, the Organization should prepare a schedule of federal expenditures (SEFA) as part of its year-end closing process, which reconciles to the general ledger. The SEFA and data used to prepare the SEFA should be reviewed by a separate individual within the Organization with knowledge of the related reporting requirements, as outlined in the Uniform Guidance, to ensure its accuracy and completeness. The schedule should be used to determine whether an audit in accordance with the provisions of the Uniform Guidance is required so that an auditor may be engaged to perform a timely audit. Planned Corrective Action: We agree with the recommendation and plan to have the corrective action implemented by December 31, 2024. Boys & Girls Club of Huntington Finance Board Subcommittee discusses this item throughout the fiscal year and is in the Board minutes, but has not put a written policy in place. A policy will be created by the Finance Board Subcommittee at the October meeting, presented to the full Board of Directors at the November Board meeting and voted on at the December 2024 Board meeting.
2023-001 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Significant Deficiency in Internal Control Over Compliance and Noncompliance - Appropriate Internal Control Structure Related to Compliance Requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cos...
2023-001 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Significant Deficiency in Internal Control Over Compliance and Noncompliance - Appropriate Internal Control Structure Related to Compliance Requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, and C. Cash Management Recommendation: The Auditor recommends the policies in accordance with §200.302 Financial Management paragraph (b)(7) be written by the Organization, approved by the Board of Directors, and included in the permanent files of BGCH. Planned Corrective Action: We agree with the recommendation and plan to have the corrective action implemented by December 31, 2024. Boys & Girls Club of Huntington has always followed the Twenty-First Century Community Learning Centers policy on activities allowed or unallowed, but had not put a written policy in place to recognize this, so will create the written policy and have it approved by the end of 2024.
Management will ensure that all grant reports submitted to federal agencies are reviewed and approved by the Tazewell County manager overseeing the grant prior to submission. The County will review and approve all necessary supporting documents including certified payrolls to verify compliance with ...
Management will ensure that all grant reports submitted to federal agencies are reviewed and approved by the Tazewell County manager overseeing the grant prior to submission. The County will review and approve all necessary supporting documents including certified payrolls to verify compliance with federal reporting requirements and guidelines. When outside consultants are engaged to aid in grant administration, the appropriate Tazewell County manager will be responsible for reviewing and approving all required reporting and supporting documentation prepared on the County’s behalf.
Moving forward, the District will ensure that all items reported to various agencies, including the California Department of Education, are supported and are retained to external review.
Moving forward, the District will ensure that all items reported to various agencies, including the California Department of Education, are supported and are retained to external review.
2023-003 Tenant File Errors Corrective Action Plan (CAP): Recommendation: We recommend, the Authority develop a process to verify that rent calculations are correctly performed and all required income verifications are maintained in tenant files. Explanation of disagreement with audit finding: There...
2023-003 Tenant File Errors Corrective Action Plan (CAP): Recommendation: We recommend, the Authority develop a process to verify that rent calculations are correctly performed and all required income verifications are maintained in tenant files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will train the individuals doing the calculations to ensure calculations are correctly performed and all required income verifications are maintained in tenant files. Name of the contact person responsible for corrective action: Georgia Crownhart Planned completion date for corrective action plan: December 31, 2024
2023-001 Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the Authority develop a process to ensure that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement wi...
2023-001 Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the Authority develop a process to ensure that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will train individuals doing the calculations to ensure calculations are done and maintained in the files and implement processes to verify rent reasonableness calculations are done. Name of the contact person responsible for corrective action: Georgia Crownhart Planned completion date for corrective action plan: December 31, 2024
Item 2023-006 Delinquent Claim Filings Significant Deficiency Recommendation: Filing claims should be incorporated into the month-end close process. Management Views: Management agrees with the finding. Action Planned: Claim filing has been incorporated into the month-end closing process as o...
Item 2023-006 Delinquent Claim Filings Significant Deficiency Recommendation: Filing claims should be incorporated into the month-end close process. Management Views: Management agrees with the finding. Action Planned: Claim filing has been incorporated into the month-end closing process as of November 2023. Anticipated Completion date: Complete Responsible Party: Karla Davis, Chief Financial Officer
Finding No. 2023-003 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-t...
Finding No. 2023-003 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-through Entity (if applicable): City of Scranton Condition: During our testing, we noted that the Organization did not provide the required monthly reports to the City of Scranton. Recommendation: We recommend that the Organization establish policies, procedures, and controls to ensure that the required information is submitted on a timely basis. Action Taken: Management has incorporated procedures into our grant compliance and administration policies and procedures to ensure that a Project Director reviews, understands and takes the necessary steps to comply with reporting requirements or other, as set forth by the client agreements. This step includes but is not limited to the Project Director completing a Grant Award File Checklist. Anticipated completion date: Immediately.
2023-002 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance This is a repeat finding of 2022-003, reported as a Materi...
2023-002 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance This is a repeat finding of 2022-003, reported as a Material Weakness from March 31, 2022 (initially occurred as Finding 2021-003, Significant Deficiency) Condition: Out of a total tenant population of approximately 1,775 tenants, 25 files were selected for testing. Exceptions were noted as follows: • 1 tenant file error for one missing 214 affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o General assistance income was included in income when it should have been excluded. Correcting this error would increase the HAP rent from $958 to $1,027. o One missing 214 affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o Two members of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificates, the two household members are U.S. citizens. o The tenant’s medical expense was misreported on the 50058. However, the error had no effect on the HAP rent. • 1 tenant file had the following errors and correcting the errors would decrease the HAP rent from $846 to $724: o Miscalculation of social security income reported on the 50058. o Miscalculation of medical expense reported on the 50058. o Miscalculation of the tenant’s annual unreimbursed childcare costs reported on the 50058. • 1 tenant file error where a member of the household over the age of 18 did not sign the 9886. • 1 tenant file had the following errors and correcting the errors would have no effect on the HAP rent: o Food assistance was included as income when it should have been excluded. o The tenant’s utility allowance was misreported on the 50058. • 1 tenant file error where the tenant’s utility allowance was misreported and correcting the error would decrease the HAP rent from $1,198 to $1,183. • 1 tenant fille error where the tenant did not sign the lease agreement. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.
RLHT will add procedures to the current financial policies document that contain oversight over the receipt and use of federal award funds.
RLHT will add procedures to the current financial policies document that contain oversight over the receipt and use of federal award funds.
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